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Ep09: Edward Cox, Executive VP of Strategic Alliances/Global Head of Digital Medicines at Eversana

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Transcript

00:03 Eugene Borukhovich 

Welcome to Digital Therapeutics Edition of Digital Health Today, and I’m your host Eugene Borukhovich. In the last episode, I spoke with David Klein, CEO and founder of Click Therapeutics, a company that was started in 2012 as a smoking cessation app, and now with a pipeline of DTx therapies, and a 500 million deal with Boehringer Ingelheim.¬†

 

Today, I continue with Ed Cox, who is an Executive Vice President of Strategic Alliances and Global Head of Digital Medicines at Eversana. In this podcast, however, we focus on his journey through Dthera, and the many lessons learned. But before we dive in, for those of you who know Ed, he is a very memorable guy. And therefore, I am actually super surprised, I cannot even remember where we first met. What I do know is that every time I speak with Ed, I feel like I have known him my whole life. And now, we jump to my conversation with Ed Cox.

 

01:02 Eugene Borukhovich 

Ed welcome, and please tell our audience and listeners a little bit about yourself and your history and how you got to this exciting digital therapeutic space.

 

01:11 Ed Cox 

Well, Eugene, one, thank you for doing this. I look forward to when we can do one of these in person, but it’s always awesome talking to you. So for those in the audience that don’t know who I am, my name is Ed Cox, I’m presently the Executive Vice President of Strategic Alliances and Global Head of Digital Medicine in a company called Eversana. Before that, so I’ve been here a little less than a year, for the last five years, previously that I was the chief executive officer of a digital therapeutics company. And some people may have heard, which was called Dthera Sciences, we were the digital therapeutic that got FDA breakthrough status on Alzheimer’s. At least to my knowledge, we were the first digital therapeutic to ever get breakthrough status as a monotherapy. Obviously, Pear was the first to get it at all in combination with buprenorphine. And, at least to our knowledge, we were the first to get it as just as a monotherapy, a few months later. Really proud of that work. Alzheimer’s is a brutal indication, and there’s very few good solutions there. So got involved in digital therapeutics through that. And then also, I had the pleasure and honor of being the chairman of the first digital therapeutic conferences that we had in our industry, which we now call DTx East and DTx West, that was the same for DTx, Europe. And I just had the opportunity to speak in the field a lot. And, and to see some of the, some of the good and some of the bad, and, and some of the romantic and or romantically tragic so, kind of depends.

 

02:26 Eugene Borukhovich 

And actually, maybe step back just a little bit further, like, just by background, who are you as Ed, right. I mean, just kind of your professional experience prior to that, because I think as you came into Dthera and created it, just for our viewers to understand the background a bit more.

 

 02:41 Ed Cox

Yeah, no, it’s, it’s, thank you for that Eugene. Nice, insightful question. So before I became the CEO of Dthera Sciences, I was an executive officer of a NASDAQ company in San Diego. And over the, the five years there, I held, sort of a variety of roles. I ran corporate development, and then I ran business development, then I eventually ran commercial. And while we were there, we signed partnerships with a series of large pharma Takeda, an Abbott, partnership with record ATI in Europe really proud of that work. And so, that company was primarily in men’s and women’s health, and so, in experience with what it’s like to be a smaller company or micro cap company, and, and doing business development deals, and corporate film deals, and commercial. Prior to that, I was president of a small biotech company, also in San Diego, which we eventually took on the NASDAQ. Before that, I was an investment banker for a small boutique firm, and I’ve started my career as the chief operating officer of a film technology company, which turned out later to be extremely relevant.

 

03:37 Eugene Borukhovich 

I was gonna say around experiences, right for, for human beings.

 

03:41 Ed Cox 

Yeah. It did. It did. One would never have thought, in the early 2000s, that film technology and life science would have fused together. But the mechanism of action of what we’re doing at Dthera turned out to be highly relevant. And so, it’s been an interesting journey, but I, I’ve enjoyed it, most of it.

 

03:57 Eugene Borukhovich 

Yeah, I mean, listen, we all have some ups and downs, but as long as we’re constantly learning. So, talk to me a little bit about Dthera, was it already existing? You kind of joined in, what was, the early days of Dthera and again, you said it yourself Alzheimer space is very difficult to innovate in both molecular and non molecular.

 

04:16 Ed Cox 

Yeah, no, for sure. So, Dthera pre existed in a form before I came in. So, it was originally called Every Story, and it was founded by our CTO, Dave Keene, a brilliant technologist, really, dear friend, actually went on to become the chief executive officer of Introspect, and the head of digital at ATAI, so he stayed in life science. His background was really into video games. So, he was the senior software architect to the PlayStation Network then the chief architect over at Trion. So, he, he came from a video games background, and he invented a technology stack that could very seamlessly get content and stories, specifically stories from families, and allow them to share. And you know, if we go back, this would have been 2015, right, so maybe pared down approach release on digital therapeutics or maybe more likely Omada had, but it was beyond nascent, right. It was early days. I know that, I think David over at Click had probably said the word digital therapeutics a couple years before that, but it was not like that was something that, that was in the mind share yet. And so I, I came in, coming from a healthcare background, and looked at the original technology. And even from the very beginning, although it was a couple years before we did the name change, I posited that this could be used in Alzheimer’s. You can look at our, some of our very first presentation decks, we thought it could be this consumer use, and maybe this connectivity use that there could be this use case in Alzheimer’s. And the reason for that was there was a cognitive behavioral therapy, called reminiscence therapy, that had been around for 40 years or something, and, and four or 500 publications effectively showing that if you could get an Alzheimer’s patients to re-experience the stories of their life, it would trigger memories, which would then trigger grounding, which in symptoms like agitation depression, which many years later, we connected those dots, could be profoundly impactful. And so, we began sort of moving the focus for more consumer to what would later be called Digital Therapeutics and, and focused on medical, eventual medical claim, and eventual breakthrough.

 

06:19 Eugene Borukhovich 

And, and what was, you know, before you bring in your investment and commercial head in, what was the business hypothesis? And even in the early days, I mean, you just mentioned kind of moving from DTC, right, because this to me is fascinating in the PDT space.

 

06:33 Ed Cox 

Yeah. So, it was interesting, because again, like, if, if you think about where we were in 2015, 2016, 2017, we were, I mean, we, we still at scale, don’t pay for digital therapeutics now and it’s 2020. Right? We are en route to that. But, the idea that someone was going to pay for, what we now call, PDT, which even now that’s sort of a new phraseology because there’s some branding around digital therapeutics and DTx versus PDT’s, and you know, that that’s its own conversation.

 

07:03 Eugene Borukhovich 

It wouldn’t be healthcare, if it wasn’t acronyms, so.

 

07:05 Ed Cox 

It wouldn’t be healthcare, if it wasn’t acronyms, it wouldn’t be healthcare if there wasn’t some territorialism on what the acronyms are. But I think our original hypothesis, which made a lot of sense, we had really comprehensive market research, some, like 500 people, and we showed that people, consumers, would be glad to pay this for their parents. And the data looked like that people viewed their parents like they view their children, and that they would be glad to pay for digital consumer products. What we learned over many years of going different versions of DTC from about every angle, you could imagine, everything from Facebook ads, to Google ads, to commercials on ESPN, as many ways as you could think, partnering with long term care, memory care, assisted living, independent living, we just tested all kinds of things. And the revelation was that at least in the American culture, that’s not true, is that we do not actually pay for things for our parents, and certainly not our ailing parents.

 

08:03 Eugene Borukhovich 

So we actually don’t care about our parents in American culture? No, I’m kidding.

 

08:07 Ed Cox 

So I think, I think what it was is we have framed this idea in our mind that the social contract is Medicare. Right? And that we are a future-looking society. We are, we know that. Our view of children, our view of the youth, or view that that’s the way that we’re wired. And it was one of those things that, if you ask a 100 people, would you pay for something for your parents? 100 people say yes. If you then look at their spending patterns, they absolutely will not. And the best proxy, we learned the hard way, was long term care, Senior Living. So, 95% of senior living is paid for out of three buckets, either Medicare, long term care Insurance, which effectively means the patient paid for it in the future, or the savings of the patient. Okay, so the most useful thing for an elderly person, which would be the care of themselves, is almost never paid for by their children, right. Versus, who generally pays for a kid to go to university, or private school or ballet lessons. So in other words, is you had this very, like, we will spend all the money we have on this cohort, some of the money that we have on our own cohort, and none of the money that we have on this, but that’s okay, because Medicare will take care of it. And that’s true, if you’ve created things that fit within a Medicare framework. And I use that sort of, more broadly, but and if you look at the products that have sold successfully to the elderly or into the elderly market, it is almost always the person themselves buying it. So you remember Life Alert like ‘I’ve fallen and I can’t…’

 

09:39 Eugene Borukhovich 

Yeah, yeah.

 

09:40 Ed Cox 

So that’s the person painted for themself. In some cases, it’s you pay for it for your mom, but that’s, that’s in the minority.

 

09:46 Eugene Borukhovich 

Super surprising.

 

09:47 Ed Cox 

The products like the Jitterbug, or products like the GrandPad, that have been somewhat successful, but in many ways, excluding you know, GrandPad is probably one of the very few success stories, but mostly what you’re talking about is products in which the elderly, but not dementia person, is paying for something for themselves to stay greater connected. Then it is someone saying I really want my mom to stay connected. It leaves at scale.

 

10:13 Eugene Borukhovich 

So, when you kind of hit that, for lack of a better term, a wall, as far as the direct pay by the caregivers, I’ll just call them, is that when you decided to say, look, let’s get this as a prescription. Now was that the pivot in the model.

 

10:27 Ed Cox 

So it was two things. So we were pursuing both in parallel. And so we thought the idea that we could even get this ever paid for by, because one thing to keep in mind is we could never practically go to employers, right. So so if we think of some of our other colleagues in digital therapeutics that have been really successful, especially successful in getting employers to pay, their indication is almost always something that affects the worker, like sleep deprivation. That’s a really good example of something an employer should pay for. Even to this day, employers are maybe not reticent, but more likely naive, to pay for caregiver support for Alzheimer’s. They are much more likely to do daycare; actually, they’re infinitely more likely to provide daycare services than they are for an employer to provide resources to someone to take care of their parents. So much so, that I know this just because of some of the work I do with different associations, is most people are very reticent, and very cautious to tell their employer that they are the caregiver for an Alzheimer’s patient for fear that the perception will be that they won’t be fully committed to the job in a way that they never would with kids. I have three kids, I have to go for a kid thing; people are willing to say that. People are never willing to say, or they should be willing. So you can’t really sell to consumers, you can’t really sell to employers, then that leaves insurance. But if we think about it, the Venn diagram of Alzheimer’s patients is entirely within the larger circle of Medicare. And so when we got breakthrough status, we thought we had a path, we saw a path to eventual Medicare reimbursement.

 

12:01 Eugene Borukhovich 

And when was the breakthrough status, by the way.

 

12:03 Ed Cox 

Our breakthrough status in fall of 2018. The other component to this is when we got breakthrough status, we got a significant amount of inbound interest from pharmaceutical companies. And again, if we just go back in history through 2018, and 2019, the hypothesis around Alzheimer’s drug development had not yet cracked. There was maybe, you know, within that two-year window, about 10 drugs that all read out over that 24-month time period that all effectively went sideways. But prior to that, there was this sense that okay, you know, five to 10 of these are gonna do pretty well and at least two of these are going to get approved. Maybe more. But like, you know, no way we’re gonna go over 10. Again, I’m sort of being cavalier about the numbers, but it was in that range. Like if we, if we look back from the beginning of 2018, through the end of 2019, the number of Alzheimer’s programs that stopped, had bad readouts, were paused, were indefinitely paused or cancelled the number of companies that would that eventually pivoted out of Alzheimer’s or or related dementias, it was dramatic. But we didn’t know that yet. So we got a significant amount of interest from pharma companies saying, “Okay, look, Alzheimer’s is still really critical to us, we’re going to develop products like this, we need to stay in this lane.”

 

13:14 Eugene Borukhovich 

And how do we augment that experience with a digital technology to maybe enhanced some outcome.

 

13:19 Ed Cox 

For sure. So, if you could launch the Dthera product a couple years ahead of a drug company, or a drug coming to market that would be good, it would make people aware. And also, our product was on the symptoms, our label was agitation depression, so we were touching cognition. So it was a clear symptom treatment that obviously had no drug to drug interaction. So it was a very natural fit for any drug company that was going to already be in the Alzheimer’s market, our product would have been a perfect slot in. And so that became our primary commercial pathway, we saw that Medicare was possible, but probably some years off. The MCT language just came together this fall and so that would not have been viable in 2018. But the inbound interest for farming was significant. And so we thought that that was the right path to go down, and that we would, you know, partner with a pharma company, that their product would read out positively. And then and then they would continue to be in that space, and our product would launch alongside it. And I still contend that that was the right strategy. I wish that every Alzheimer’s drug on the horizon hadn’t all busted all at the same time. But I mean, even if we look at the Biogen drug, which is still in play, there was at a minimum of long period of unknown there, you know. And we’re, I’m very hopeful that new treatments come to market, but it effectively went from a good plan that gave us a clear path to market to a non-viable plan because there was not any actionable partnerships.

 

14:46 Eugene Borukhovich 

So let’s hold that thought just for a second and before I even dive into the pharma and the pharma revenue stream and the kind of the sustainability of the Dthera, take us through because I think too many individuals out there outside of, you know, the core, I’ll say DTx people, right? What is that experience for the consumer / patient? Specifically, what was it with Dthera? Right? Like, how does it help consumers interact with Dthera’s product?

 

15:13 Ed Cox 

I still feel that what we had done was created in one of the most clever ways to solve for this. So in my mind, we were a drug delivery company. Like I knew reminisce therapy worked, right. And they’re, some of these other cognitive therapies can be a little more challenging to kind of like, follow the logical leap to say, Alright, if I’m gonna really do this behavioral therapies are really going to have that kind of impact and, you know, sort of mechanism of action versus claim, but almost any person believes, okay, if I show precious stories from Alzheimer patient triggers a memory, it will help them. Almost everybody accepts that, it’s fact, right? Not the least of which is when you then show it to a patient and they go out of an agitated state into a calm state, it’s, it is self evident. So, our our challenge we found was, you needed to be able to get the content from the family, that was one. You needed to be able to display the content to the patient. And you needed to be able to tell whether or not the content was working, without effectively having someone sitting next to them and saying they you know, they did like a story they did not like this story. So we started, we started with patient and worked backwards.

 

16:19 Ed Cox 

So we thought, Okay, the first thing can we do is consumer tablets. Could we do this with iPads? We found out that that was unsuccessful, for a myriad of reasons that you would not think. Some of the more obvious was that iPads were too heavy, they were too small. So you needed a larger screen, and a lighter device. They had to be wirelessly charged, because both the patients, and frequently the caregivers, were unlikely to take a little lightning cable and put it inside. The challenge with that is, if you go with a larger screen, it consumes more energy than most inductive charging can actually create. So we had to find a way to wirelessly charge a large tablet that was extremely light that could be charged by almost anybody once a week. 

 

17:06 Eugene Borukhovich 

Very easy. 

 

17:07 Ed Cox 

Well, I mean, it was really, we manufactured 5000 tablets. So this was, it wasn’t, like, it didn’t get to the commercial stage, or didn’t ever get a prototype, you know. It’s like oh, no, we final design, you know, all that stuff. And then, you know, fully manufactured, it all was very real. We found some really, so in credit to Dave and Marty, ‘cuz really clever ways to charge it wirelessly with having a larger screen and a bigger case, but still being lighter found, and again, this is probably 12 discoveries along the way, it was not loud enough, right? So what you needed is you needed a louder tablet that didn’t then blow out the rest of the room. So we had to go with directional speakers. It had to be really, really loud, all pointing in one direction. You needed a tablet that was touchscreen, but not touchscreen, because the patients would touch stuff. And if it didn‚Äôt jump it out. And so there was an enormous amount of, I think, industrial design and testing. And I’m incredibly proud of actually all three components but I thought that part was very compelling.

 

18:07 Ed Cox 

So then the next problem solved was, how are you actually going to get any of the content from the family? Right? Because if people were willing to upload it, then we’d already do that. And so, we found again, testing. A bunch of them, will they download an app? Will they upload it? Will they curate? Nope, nope, nope, nope. What they would do though, is they would respond to text messages. So we built, you know, we said an AI, but that‚Äôs probably inaccurate. It was a goal seeking chatbot that would effectively ask people to text us photos, text, the server photos, and then send a photo back and say, ‚ÄúHey, can I call you‚ÄĚ, and you record a voicemail, and they would stitch it together. So that all the family had to do was send text photos to this phone number, and then it would slot it into the stories. And then it would send a photo to the family and say, ‚ÄúHey, would you, like, tell me a story about this photo, if so, can I give you a call?‚ÄĚ Then the persons just said text ‘Yes’, and the phone would literally ring. And you’d have, like a Siri-like, I think it was actually Amazon, and I’ll say, thanks for taking the time and tell me a story about this photo, when you’re done, simply hang up. So you would just talk into the phone, you know, click. So, exactly, so seamless.

 

19:16 Ed Cox 

So the way that we were trying to do is say, Look, just pretend that you’re texting with your mom’s caregiver. Wouldn’t you send some photos? Wouldn’t you send some voicemails? So they would take those things, stitch ’em all together, and then it would flash on the tablet. And then the last part, which I think was probably the highest science of what we created, is an emotional recognition software that used the front-facing camera on the tablet to track the emotional reactions of the patients, to know whether or not a story was working or not working. And so that could be done passively. So instead of, like, a caregiver sitting and saying, Hey, is this working? It’s like this seems to be working. And so when you created that full, that full circle, you could at scale delivery CBT to a patient population that cannot use technology, getting content from a cohort of consumers that did not have time to lean in and actually create a virtual cycle that showed that it worked.

 

20:11 Eugene Borukhovich 

So unlike some others that have, you know, CBT as a core component on a device that people can use, you guys have to take into consideration everything from ergonomics, and facing the camera to feel, touch, to your point in the industrial design. And, you know, from one side, this sounds like an amazing proposition to pharma, just, you know, as a companion, pre-launch or post-launch. So let’s let’s jump to the pharma. So, 2018, you guys got the FDA, right?¬†

 

20:41 Ed Cox 

Right. 

 

20:41 Eugene Borukhovich 

Breakthrough and went public. Because to me a lot of these experiments, you had to fund it somehow. Right? So.

 

20:50 Ed Cox 

Yeah, I mean, you know, sort of. So, we merged with an OTC company. So we never, we never achieved a national listing. But you do bring up a good point. So one of the things about Dthera, and I certainly, you know, many things I wish had gone different than they had, and plenty of decisions I wish I had made differently. But we never started with VC backing. And so it was, we had to find pretty creative ways to fund it. And and again, we’re looking at the lens of 2016, 2017 and 2018. And so, the idea of who was gonna fund this app, you know, an app for healthcare, that was not an EHR, was not something like that. There were some really future looking VCs, but there weren’t many of them. And they had, in my mind, they largely made their bets. Right? And so you had to find, you had to find, sort of, creative funding sources to drive this forward. And I think that we found creative ways to patchwork together the capital that we needed to kind of get to those next stages. And so that, you know, that we wound up with a product that was one commercializable, you know, ready to ship and then two, had gotten breakthrough status.

 

21:55 Eugene Borukhovich 

And I mean, it also brings a, with sort of being a public company, however, you got there, even the OTC, brings some level of transparency. Which, yes, on one side, we’ve all been asking in healthcare, right? On the other side it brings its own challenges, right?

But let’s hop over because you mentioned pharma, and you also know my recent background, and you know, I’ve been describing this to the folks that I’m interviewing with, as a frenemy relationship between, you know, pharma and digital therapeutic companies. Where’s your head on it? Because again, on one side, it was a great path to monetization for you guys at the time. But then what it’s sounding like, and I don’t want to put words into your mouth, was also a bit of the demise, right? As a pharma companies…

 

22:41 Ed Cox 

I think, so I am, I am a pharma bull. I don’t think digital therapeutics are the frenemy of pharma or more like so pharma is a frenemy of digital computers.¬† I think they are disproportionately an advocate and an ally, through this. Not the least of which is through most of the years of digital therapeutics, we’ve still been been growing our commercialization strategies. And so I I think like any product that is going to potentially partner with pharma, you de facto take on their clinical risk. But, if we already had a clear way to pay for our product, if Medicare could already reimburse Dthera, then I wouldn’t have gotten on that strategy. So, in other words, I thought pharma was the best option that we had of limited options. And I don’t regret going down that path.¬†

I think that we had, you know, several, and including some advanced, fantastic partners, I think they would have been great partners. But I also don’t think it’s a one size fits all. It kind of depends on what your product does, right? There there are digital therapeutics that are making label claims as a direct competitive dynamic to an existing drug; that’s true. There are digital therapeutics that are going after effectively undruggable categories. That’s also true. There are digital therapeutics, that, you know, their name notwithstanding, are by their nature, medical devices, and the competitive threat and allies would be med device companies. And so, I think that as digital therapeutics as a sector are maturing. We are realizing that, it’s, they are all going in these different directions and saying, so a product that treats the symptoms of a disease, that a drug would help the underlying disease, that is extremely well suited for a digital therapeutic and pharma partnership. A digital therapeutic, that’s making a direct claim that’s different. A digital therapeutic, that’s very much a medical device, which again, let us not forget this is how all these things are regulated in the US. So, I, I think it depends and is evolving.

 

24:39 Eugene Borukhovich 

You know, you mentioned something and that dovetails into my next question. You know, PDTs as we alluded to earlier, and there’s many acronyms, but as a prescription digital therapeutic, whether it’s a substitute companion, etc. And I don’t want to say, I keep using the word versus, but I guess in ‘in relation to’ more novel health services, so think about, like, Livongo or Omada, that maybe some of them started out in a DTx kind of space, right, but then, really, surrounded themselves with other services more into primary care, virtual care. Where’s your head personally on any distinction? Or is it all gonna just sort of melt together?

 

25:21 Ed Cox 

I think we’re rapidly, rapidly moving into a great deal more granularity.

 

25:26 Eugene Borukhovich 

Yep.

 

25:27 Ed Cox 

I don’t know if you’ve ever seen the health, digital health landscape that Marty put together.

 

25:32 Eugene Borukhovich 

The HealthXL Team. Yep.

 

25:34 Ed Cox 

So there’s digital health, and there’s digital medicine, digital therapeutics, which is great, except I think that in total, I think he has something, like, 30 circles overlap and it literally looks like a galaxy of like different star systems overlapping, not overlapping, all that. I think the reason I say that is, especially with COVID, especially with the fact that it‚Äôs shifting a lot of the, specifically telemedicine rules, regulations, and reimbursement. We are not going to a more homogeneous ‘catch all’ name, we already have that. It’s called digital health, right? We are going to be going into like very specific: “I do this, and that’s called this, and I do that, and that’s called that.” So I think that, you know Omada and Livongo have been runaway successes. And you know, I think that at one time Omada, you know, called itself a digital therapeutic, but it’s evolved, right? I don’t know what Proteus was, but it was, it was something.

 

26:24 Eugene Borukhovich 

They’re still software interventions, right?

 

26:27 Ed Cox 

Right. Right. And so, I just think that, I think what’s gonna happen is there’s gonna be a blurrier line between tech-only solutions and tech-plus solutions. So that line is gonna get blurrier. You know, it’s very hard to imagine five or 10 years from now that every, every drug in the world that, is there ever going to be a $10,000 a year drug that doesn’t have a digital something next to it? It’s hard for me to imagine that. I mean, eventually, I think they all will. So I think that will get blurrier. I think the way the specificity will begin to come is, you look at two companies that are both using technology to drive a health outcome but in different ways. I don’t think we’ll say ‚ÄúWell, they’re both kind of digital therapeutics, so they’re both kind of PDTs.‚ÄĚ I think what you’ll begin to see is this specificity around what these things are doing. And then I think the terms will catch up.

 

27:14 Eugene Borukhovich 

So it’s amazing how you’re landing into my brain because where I was heading again, and you’d said tech plus, right? So it was kind of drug, drug plus, the plus in the drug plus is becoming tech, and then drug plus tech, and then tech plus, not to confuse our listeners. They’re still human beings, right. And so, I actually would thought about, and and I’m not talking about just the patients or the health consumers, but the surrounding care team. So where, where’s your head on the hypothesis of a digital therapeutic that is even prescribed to a patient, and they themselves do a lot of self-care using that tool, versus, or in addition to, obviously, a doctor is prescribing, potentially the nurse and even health coaches, sort of, though that’s not new, they’ve been around for 20 years, the buzzword in industry has been health coaches. So where, where’s your relation to human beings helping that patient through, even in a drug, drug plus tech, tech plus, relationship?

 

28:15 Ed Cox 

Yeah, I mean, it’s interesting because I think we falsely imagine it’s a zero sum game. I think we falsely say, the more that we push the tech, the less you need the human. The more that you lean on the human, the less you need the tech. That’s a false paradigm. If anything has showed us what is happening is, you know, COVID has changed the game dramatically. So if you had said, okay, imagine that the number of health interactions via technology will increase a 1000 fold. The answer would be like, ‘Wow, it must be using a lot less humans on the other side.’ Nope, that’s not what happened. Right? So, now you need more health coaches, you need more healthcare specialists then you‚Äôd like. So what has happened? And I think that is, any big technological leap, there is always this view that it will like, compress the thing that came before it. Generally, what happens is that once you create access through technology-made-easy, the demand actually skyrockets.¬†

Like, you know, salt went from a luxury good to everybody in the world needs it all the time, because you figured out ways to distribute it and make it in scale. So, I think that’s what’s gonna happen is that bizarrely, as tech delivers better health faster to more people, the demand for healthcare humans, everywhere, from coaches to neurosurgeons and doctors, right, you know, like, like all of these specializations, is going to increase exponentially, because I think people are going to take a lot more awareness of their health, which is going to create demand for more tech solutions, and more human supporting those tech solutions. So, my biggest sort of position on this and, controversial or not, is, I reject the paradigm that tech eats the role of people, at least in health. I don’t think that’s true. I think what it does, is it does the opposite, is that tech creates much faster connectivity, which means you need more people on the other side to connect.

 

30:07 Eugene Borukhovich 

Lovely. We always said at YourCoach.health that while artificial intelligence is here to stay, human intelligence and empathy still beats out. Never say never, you know, well, let’s fast forward 20, 30 years.

 

30:19 Ed Cox 

Well, I mean I, I think we’re living that, my gosh, right? Are any of us okay with Siri being our only interaction? No. I mean, like, I mean, I think, I think the thing is, is that we’re all incredibly grateful. I mean, you and I are doing this because of technology, right?

 

30:37 Eugene Borukhovich 

Right. 

 

30:37 Ed Cox 

And, if anything, this whole process has proved us how desperately we need human interactions. 

 

30:43 Eugene Borukhovich 

Absolutely. 

 

30:43 Ed Cox 

So, I think that, I think that AI is amazing. AI is amazing, but AI is not going to be Cortana. Right? And I mean, like the Halo Cortana, not the you know, Microsoft. We’re never gonna have, like, I don’t need human friends, I’ve got this robot that talks to me. That, that we’re thinking about it the wrong way. In fact, what it’s going to be is, this AI makes it necessary that I talk to more humans more often. Right. Right, they’re connectivity machines. They’re not replacements for humans, in my opinion.

 

31:12 Eugene Borukhovich 

And, and I think, to a certain extent, that was the silver lining of where we are as a society now with a pandemic. But let’s hit the big elephant in the room here, alright. Because we started talking about how Dthera kind of came about and the products and maybe just like in a minute or two – what happened? Is it still alive? Shut down? What’s been happening, and what was the decision point for, you know, the executives and, and the team to wind it down?

 

31:37 Ed Cox 

Yeah, so it’s a very fair question. And I think as much as possible I’ve tried to be transparent with anyone who’d ask and in a couple of times from stage. So, once we came to the understanding that it was unlikely a form of partnership was coming in the near term, that made continuing to move forward and again knowing that we were probably two or three years from them, from reimbursement at scale via something like Medicare, the ability to continue develop the product, the ability to, to do that got somewhat limited. But at the end of the day, you know, effectively, some of the ways in which we finance the company made it not possible to continue on as an operating company. And so, and this is public record, the, the assets of the company are, are owned by one of the financiers of the company. I’m sure that everybody who’s ever been involved with this, myself very much included, still would very much like it to get to patients. But, once it became not possible to, we believed, there’s nothing we could presently do with the asset, the financiers decided to effectively hang the noose as it were.

 

32:46 Eugene Borukhovich 

Well, that sound means it’s time for a question from my journalistic partner on this podcast, Brian Dolan, who is the founder of Exits & Outcomes, and as I like to call him, the digital health detective, let’s see what question Brian has for our guests today.

 

33:01 Brian Dolan 

Here’s my question. There’s a growing number of digital therapeutics companies with either an initial focus on Alzheimer’s, or some kind of Alzheimer’s-focused digital therapeutic in their long term pipeline. So what will it take for these up and coming companies to get it right? What advice do you have for them? And among the contenders that we know about today, do you have any favorites?

 

33:21 Ed Cox 

Brian, thanks for that. That’s a great question. It is certainly an indication that I care a lot about, gave five years of my life to it, and, and even more so when you overlap, pursuing Alzheimer’s or, you know, cognitive impairment in the elderly, via digital therapeutics. So, I care a lot about this. You know, I’m encouraged because founding a company in 2020, pursuing this would have been a much better idea than founding a company in 2015. And so, I, I think that there are, specifically because of the regulatory framework, but even more so the reimbursement framework, I am encouraged around some of these companies carrying forward. I need to be a little cautious because I’m actually quite close to a couple of the companies in the space. But I mean, I would say Neuroglee is, I saw the news, when they came out of there. I know that they’re based out of Singapore, when I saw that they raised some capital. And so, I’m excited about that. And to see what comes with that. I don’t, I don’t have a lot of visibility into that one yet. But, I think it’s sort of a new, new player on the board for all of us.

 

34:54 Ed Cox 

Cognito obviously just came out of stealth. I’ve been friends with Brent for many years. And so, to some degree, a company like that, that, that’s kind of stealth with a very high profile CEO, that has a lot of experience in both digital therapeutics and neuro, I, I feel that’s one to be very encouraged about, I think, for, for obvious reasons, the two I said. I think that’s, that’s really one to watch.

 

34:54 Ed Cox 

But the truth is, is that you know, going back to your original question, Brian, what advice do I have? It’s two folded. It, one tactical and one hopefully inspirational. Is, is, this is a very, very different patient population. Almost everything that we imagined about how we develop technology products is not applicable to this group. And therefore, it’s about getting right next to the patient. It’s about going to the care homes, going into people’s homes. And it’s about being, living their life so that when you’re developing a solution, it actually fits into their life, and not as we imagine it to. And I’m sure that both these companies would do that. But that’s a very tactical piece of advice. I think the other one is just don’t give up. This is the plague of society. I mean, $200 billion in the US, a trillion dollars worldwide, there is no more cruel disease than this. And I, I understand how fatiguing it is, I really understand how fatiguing it is. You can, you can give everything and lose. But this is an indication we cannot give up on. And so, you know, if I were to make a call out to the industry, it’s please, come at this. I know that there’s other indications, I know they’re more straightforward, I understand how, you know, it’s easier to imagine how these things will get paid for. But, we, we live in a world that these patients built for us. We owe it to them to try to do something about this. And, and the fact that drugs have been so hard means that we are leaning even harder I mean, if, if the only legacy digital therapeutics ever had, which the legacy will be broad and long lasting, but the only legacy digital therapeutics ever had was they profoundly impacted the lives of patients with Alzheimer’s. That would justify our whole sector, that would be a worthy outcome, an entire modality. And so, I hope when we do this three years from now, I, I hope there’s 10 companies going into Alzheimer’s, I hope there’s 100.

 

36:32 Eugene Borukhovich 

Ed, I want the listeners to get to know the trailblazers in this digital therapeutic space. So what is your Why? What gets you up in the morning?

 

36:43 Ed Cox 

You know, Eugene, that, that’s a very thoughtful question, a very graceful way to frame it. I, I don’t know that I’m a trailblazer. But I, it’s a, a nascent sector so maybe all of us are, but thank you for saying that. I, I think, for me, the thing that excited me originally and continues to excite me is there’s not that much left in the world, or civilization, or society, that is, is yet undone, right? Like we’ve discovered all the new lands, we’ve put man on the moon, many innovations have come and, and so most solutions now are incremental, important, but incremental. There’s something exhilarating about being the first.¬† Like, being the first to ever do anything. I mean like, first to get breakthrough status, or first to get, you know, a major digital therapeutic in Alzheimer’s, or first to, you know, commercialize or first to commercialize at scale.¬†

Like, to me, the idea that we, a very small cohort of people, probably in the hundreds, certainly not in the 1000s. But we, in this sector, could be the first to do something, the first to really create a way to impact these patients through this new mechanism, that’s exciting because you can go your whole life and be very ambitious and very successful, and never once be the first to do anything. Or, even be involved with a small group of people to be the first and at this moment, everyone is the first, you know, everyone is the first GI, everyone is the first neuro, everyone is the first Alzheimer’s, everyone’s the first autism, ever, like, it’s all, it’s all first time. You know, somebody invented the first pacemaker, and then lives were changed. And somebody invented the first stent. And somebody invented the first injector, and hundreds of people were involved with that. And I just think that the idea that we get this whole new modality that we get to shape. And for sure, 30 years from now, billions of humans will use digital therapeutics to change their health outcomes. We’re gonna do something that billions of people are going to do, that’s thrilling, honestly.

 

38:41 Eugene Borukhovich 

Well, you got me energized for sure, so thank you for that. And I appreciate you making the time, Ed, and educating our listeners.

 

38:50 Ed Cox 

Always. Thanks again for having me and congratulations on a great series. I think this is powerful stuff.

 

38:55 Eugene Borukhovich 

Thanks so much for tuning into Digital Therapeutics Edition of Digital Health Today, a production of Mission Based Media. Be sure to hit that subscribe button to this podcast on your favorite podcast player, so you’re then automatically notified when we post our upcoming episodes where I speak with dozens of leaders and trailblazers who are forging the path for digital therapeutics. If you’d like to learn more about YourCoach.Health, or Brian Dolan’s Exit and Outcomes, you can always find the links to this and more in the show notes for this episode. You can connect with me personally on Twitter @HealthEugene, or follow my journey of writing my first book Hard Pill To Swallow at hardpilltoswallow.substack.com. I’m Eugene Borukhovich and catch you next time.

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Ep20: Investing in DTx Businesses The view from venture capital
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