The MX Q&A: David Rose, Vitality

It’s a safe bet that few chief executives mention Frodo Baggins and his sword, Sting, in their business presentations. As befits a visiting instructor in tangible user interfaces at the MIT Media Lab, David Rose can make The Lord of the Rings connection ring true. The CEO of Vitality Inc., a five-year-old company based in Cambridge, MA, Rose name-checks Frodo to describe the “magical” capabilities of the firm’s new medical device. Called GlowCaps, the healthcare product is a wireless-enabled cap for standard prescription bottles that glows like Frodo’s sword to remind patients it’s time to take their medication. But instead of fighting Orcs, the device is designed to help ward off hypertension, diabetes, heart disease, and other treatable maladies.

At the previous company he founded, Ambient Devices, Rose developed products such as the Ambient Orb, which changes color to track changes in stock markets, weather forecasts, and traffic. Spurred by family-related health concerns, Rose and his serial entrepreneur partner, Joshua Wachman, company president, cofounded Vitality in 2005 to address the multibillion-dollar problem of medication nonadherence through their respective backgrounds in ambient information display and machine learning. In 2008 the pair brought in a healthcare system expert, Patrick Soon-Shiong, M.D., the chairman of Abraxis BioSciences, as an investor and board member.

Vitality launched the first GlowCaps in 2008 and recently released the fourth generation of the device, which lights up and plays a pleasant ring tone to remind a person to take her medication. The device sends a wireless time-stamp to Vitality’s secure network each time the medicine bottle is opened. Reminder calls are sent to the patient or designated caregiver if the bottle isn’t opened within one to two hours of the designated time. The patient or her caregiver receives an e-mailed medication adherence summary each week. The goal is to effect behavioral change through a combination of self-motivation and social networking. The company claims that patients, physicians, payors, drug companies, and pharmacies will all benefit from improved medication adherence.

Calling them “enchanted objects,” Rose specialized at Ambient in embedding Internet information in commonplace items such as light bulbs, umbrellas, and refrigerator doors. Vitality’s first medical device to use the smart-packaging concept won the company a silver 2010 Medical Design Excellence Award in the OTC/Self-Care products category.

In addition to teaching at MIT, Rose speaks at industry conferences and corporate retreats on the topic of product innovation. He received bachelor degrees in physics and fine art from St. Olaf College (Northfield, MN) and a masters degree in education from Harvard University. In this interview with MX, Rose discusses the social dynamics of behavioral change, encouraging clinical study results, the slow rate of innovation adoption within the healthcare bureaucracy, and the therapeutic value of lifting one’s voice in song.

MX: So are GlowCaps “enchanted objects,” too?
David Rose: I do think the GlowCap represents an “enchanted object,” because it’s taking an ordinary, everyday object and adding a little bit of computation and a little bit of wireless connectivity and making it a lot more useful. It’s the same way—and this is a geeky example—that Frodo’s sword in The Lord of the Rings showed him whether he needed to use it when Orcs were nearby. It’s almost the same thing, showing that [your medication] needs to be used so you don’t forget about it.

What’s the genesis of the concept?
Most of my family has suffered from heart disease. My grandfather died of it, and my father is struggling with it. I realized for many of us it’s something we face and that we will struggle with every day for, hopefully, decades. And so, more than just being a reminder device, it was seen more as a helping hand or a coach, where if the data about my hopefully good behavior is shared with someone in my life that cares about me, I’m much more likely to do the right thing. It does remind me, but I think more importantly it offers a little visibility into my social network and allows others to celebrate my success or my interest in keeping up with my medication regime.

As we looked at the literature, we learned almost every successful example of behavioral change uses social dynamics. Whether it’s smoking cessation programs or Alcoholics Anonymous or weight-loss programs, the recipe for success is all about opening windows of connectivity between you and the people that care about you so that they can support you and try to help you change your behavior. And behavior change is incredibly hard. It doesn’t happen without that social nudge.

There are two types of social nudges that we’ve designed into the product. One is where you select one or more people in your social network, like a family member, in order to see the data about how you’re taking your medication on a weekly basis. And so it gives you a little calendar of which days you did or did not take your medication and how you’re tracking against a goal. And the second type is really a product for…sharing your data with a physician. There are certain personality types—people who respect their doctors and have a high respect for authority—that really respond [to this approach.]

How long did it take to develop the GlowCap?
It’s had a long developmental period. We’ve been working on the product for about three years. This is the fourth-generation product we’re launching now. The fourth-generation product connects over an AT&T cellular network. You don’t need a computer, you don’t need broadband, and you don’t need WiFi. You just need to be able to plug the nightlight in, and it creates connections to the AT&T network. Previous versions relied on a home phone line or a broadband connection. The new version is easier to install, and it’s just magical. It just connects to the Internet on its own.

I imagine that’s a plus for elderly people who may not be technologically savvy—that ease of use, wouldn’t you say?
Yes, absolutely.

Just as a follow-on to the ease-of-use point, one of the advantages in embedding technology in everyday objects like a pill [bottle] cap is it doesn’t look like technology. It’s not a computer program or a Web site or an iPhone app. It’s a dedicated, very inexpensive microprocessor just for that one app. As the cost of wireless and computation falls, I think you’ll be seeing this more and more. You can afford to create a $5 pill cap that people use every day. And that people can throw out.

Are you at liberty to tell us your start-up costs?
No.

Okay, but has it been difficult then to find investors for the device in this economic environment?
No, the problem of medication adherence is such a well-understood one that lots of people have been interested in coming and funding it. Especially if you have a product that breaks new ground in terms of simplicity, and also if you get the sort of blue-chip research evidence we’ve gotten.

Speaking of that, what’s your latest research news?
We worked with Massachusetts General Hospital, which is part of Harvard Medical School, and we did a study over the last year specifically for hypertension, which is one of the hardest things for people to solve. With hypertension you don’t feel sick and you don’t feel the medication working, so it’s very easy to not take the medication.

Half of the population used the GlowCap with all its services turned on, which were reminders, social support, doctor accountability, and refill coordination. And we gave the other half GlowCaps that just collected data. And then we looked at the difference between those two populations every day for about nine months now. The difference in the people’s medication-taking behavior is about 30% between those groups. Meaning that 70% [were not taking their medication in the second group] and 98% were in the first. The group [adherence] where we had the GlowCaps turned on, where they were doing all the things they do to take medication, was much higher than we expected.

This is a much better result than anybody else who has been working on this problem has gotten. A 30% lift [represents] about 100 days a year. The current best-of-breed on the market is [an increase of] about 10 days per year. With the current best-of-breed you send somebody a letter, and you call them if they haven’t picked up their script. Those services buy you about 10 more pills taken per year, so we’ve really done the classic type of innovation by improving the state of the art by a factor of 10.

Did you have any manufacturing or design challenges, say with overseas production, for instance?
Well, my previous company, Ambient, has been manufacturing in China for about eight years. I think the hardest part is designing a product that is polite enough that people want to live with it every day. You can’t make it [sound] like a smoke detector, because people would toss it out the window.

Your previous position involved selling consumer products. Did you face new regulatory concerns in designing a product for the healthcare market?
We passed all the standard regulatory issues. There are at least six tests we had to pass. We had to use food-safe plastic, the device had to pass the “light-and-tight” test, which means that no moisture can penetrate the bottle that can change the absorption rate of the drug. We had to pass childproof testing, and we independently had to pass AT&T FCC wireless certification.

Your previous question is really good, I think. What’s surprising is just the pace of adopting even innovations that have overwhelming evidence that shows they work. It’s still quite slow. Everybody wanted to do…their own little studies. Here we have evidence for a device that has been shown in a clinically controlled and randomized trial to change people’s behavior by an incredible amount. And other people have already written studies. There are 30,000 studies about medication adherence and the problems and the cost of medication non-adherence. People have already documented what happens with people not taking medication: getting put right into the hospital or a rise in nursing home admissions due to non-adherence or the cost of increased ER visits for diabetics who are non-adherents.

There are already thousands of studies that have documented the financial ramifications of low adherence versus high adherence, and we show we have a product that increases adherence more than any product we know of. And we have a price-point of less than $20 per month for a Blue Cross, a Blue Shield, a Humana, or self-insured employers to distribute the product. What else should we have to do?

But instead, if you talk to United Healthcare or Humana or Kaiser, they say, “this is very interesting; we want to buy a 1000 units and do a six-month trial and see if we get the same result with our population.” How is their population any different than the population recruited by Harvard?

Your point is: here’s a well-established and identified healthcare problem and here’s a solution.
I would expect a large employer or large insurance company to start with 10,000 units or with 50,000 units, not to start with 500 or 1000 units. It’s: “Let’s start slow.” They should not do these minuscule studies that take 1000 people at a time. [Laughs]. That’s my soapbox [speech.]

Does Vitality have any new medical devices in the pipeline?
We’re working on a couple other ones that we can’t talk about. They are very simple. They are wireless. They are things that create positive feedback loops for good behavior and things that you wear all the time.

What’s the timeline for introducing them?
We’re doing in-house tests over Q4. We hope to announce something in [calendar] Q1.

In developing the GlowCap, did you consult with pharmaceutical companies?
We consulted with pharmaceutical companies and with pharmacies. One of the reasons we made a cap rather than a box is because pharmacies say boxes are illegal. They can’t put medication in a box for you. They can’t use the box even if you’re on 10 meds. It would be a [problem] if the box separates the medication from its instructions, or it may cause interactions between drugs sitting next to each other. Also, it’s not childproof.

That’s why we did an incremental innovation. We just reengineered the cap. The vial is the existing Walgreens vial.

Your business model assumes that drug companies and insurers will see the financial benefit of using GlowCaps. How would you describe the acceptance rate?
Our [business] model is that it’s just given away through the pharmacy. We have an almost 100% acceptance rate. When your pharmacist gives it to you or mails it to you, it’s “oh, look, you get one of these free GlowCap things; it’ll call you if forget to take your pills.”

Right now we’re working with Express Script, which has a national footprint. They’re the second largest pharmacy benefits manager. They mail you your script. You may be mailed a script with a GlowCap. Right now our model is for people taking specific meds who have adherence challenges. Patients can also go to Vitality.net. They can put their names and medications in [the site.] If we have a program with that medication, we’ll let them know.

What’s the level of acceptance for individual patients?
The acceptance level among individuals who are given the product is nearly 100%. The acceptance level among pharmaceutical companies is faster than it is among insurers, because insurers are even larger bureaucracies that should accept innovation faster.

Of the different pricing strategies such as loss-aversion pricing and pharmaceutical reimbursement, which one appears to work best?
I’m intrigued by the idea of giving people a discount on their co-pays, for example, if their adherence rate is high. But I don’t think that’s required in order for the product to be really successful. Value-based pricing insurance plans are very interesting to me. Certainly, it helped to have a tool like GlowCaps in order to be able to calculate [adherence rates]. If your adherence is over 80% then you get a discount on your co-pay or your health savings accounts gets more money added. You can certainly do that, although I prefer not to do an extrinsic reward if an intrinsic reward [is possible].

You’d like to believe that people would change unhealthy behavior because it’s inherently a good idea.
Ideally. There are certain persons who are susceptible to a financial reward—people who are scratch-card lottery players, for example. Those people might be open to a financial reward. I don’t think it’s needed in order to get people to change.

This question is tangentially related to healthcare, but I read in your bio description that you sing in the Tanglewood Festival Chorus. I’m a former choirboy and church cantor myself. How important is it for executives to have creative outlets?
(Chuckles.) I don’t know about others, but for me it’s inherently therapeutic. Business is so engaging that I have to concentrate on it 100%. When I’m singing I can’t stress about my business or concentrate on anything else during concerts. I’m sure for many people it might be all kinds of different hobbies.

If you’re in an intense start-up situation you’ve got to do something to get out of thinking about [business] all the time. For instance, you wake up in the middle of the night and you’re making lists. You’ve got to schedule something so that you [can relax].