The Digital Health Revolution by Kevin Pereau

ACKNOWLEDGMENTS
First and foremost, I want to express my love and gratitude to my
wife Beth. I often tell people that she knows more than anyone does
about health care, because that is absolutely and completely true. She
came to it because she is someone who cares deeply about people and
miraculously, she cares about me too. I also want to express my love
and thanks to our wonderful daughter Megan, who also caught the
health care “bug” and who now works as a consultant in the field.
Without the support of Beth and Megan, this book would never have
happened.
I express profound gratitude to all the experts who contributed
their views to this book, enriching it miles beyond what it would have
been without them. They took what was an interesting book and
made it exceptional.
I would also like to thank just about everyone I have ever worked
with over the course of my career. In their own ways, each of them
shaped and changed me as a health care thinker and professional. And
let me give special thanks to Rick Lee, my collaborator and co-founder
of TranscendIT Health.
I thank Barry Lenson, the writer and editor who helped me turn
a lot of ideas and plans into this book. We had fun and became good
friends in the process, and I thank him for that.
Last, I would like to thank you, my readers. You and I will enter
an amazing new world of connected care in the years ahead, an amazing
and healthy journey we will take together. Thank you for joining
me, and welcome aboard!

FOREWORD
Penny Moore,
Partner, Commonwealth Health Advisors
Digital Health Enthusiast
Stop for a moment and think about the mobile apps you access on
your smartphone more than five times a day. Text messaging. Email.
LinkedIn. Facebook. CNN Newsfeed. Would you say these mobile
apps are embedded into your daily routine? Would you say they have
impacted your approach to life? No doubt, they have.
Now imagine a program designed to help individuals with chronic
conditions change their lifestyle habits and get healthier by sustaining
an average of 5.2 daily interactions with its participants over 16 weeks.
Impossible, you say?
It is happening! I have seen it.
The Digital Health Revolution explores how progressive technology
advancements are democratizing health care for the consumer.
New digital technologies, big data analytics, and sophisticated AI are
now innovating health care delivery with powerful digital apps. It is
the contemporary creative digital design that draws an individual in to
easily consume clinical evidence-based medicine in actionable methods
that naturally become part of daily living.
I am a seasoned health behavioral change skeptic! The hardest
thing to do is to get people with chronic conditions from lifestyle etiologies
to change their behavior. Even people with the best of intentions
fail at sustaining healthy behaviors.
For more than twenty years, I have dedicated my professional life
to the evolution of population health and disease management. My
passion has been driven by the sobering realization that during the last
century we were dying from diseases and viruses we caught when we
left our homes. Now, it is from things we do to ourselves. Our daily
lifestyle choices matter, and they all add up over time.

Since 2011, I have immersed my focus on the advancement of
behavioral change programs by the digital revolution. I am awestruck
by the exponential improvement that consumer-centric digital design,
machine learning, and conversational bots can have on achieving what
clinicians, behavioral scientists, and others have only imagined for
over twenty years.
For over three decades, physicians have been taught that the
first line of therapy for type 2 diabetes and early stage cardiovascular
disease is diet and exercise. It seems physicians have given up on people
changing their lifestyle contributors to disease. Many societal and
health care trends have played into that. It is much easier for physician
and patient to utilize drugs to manage these chronic conditions and
slow their progression.
Current digital and technological advances are making it
possible for lifestyle behavioral change to not be dependent solely on
individual willpower. Today’s digital tools, leveraging modern data
application, are empowering consumers to put skillpower to work
changing their lives. To sustain behavioral change, people need consistent
input. They need the right information, timed to a meaningful,
teachable moment, suggesting actions based on their own data to build
skills and routines that shift their daily approach to living. Consumers
are quickly catching on that these digital tools are creating sustained
changes in their lives that are relieving them from the burden of a life
sentence of taking drugs to stay healthy.
So, plug in - get connected to The Digital Health Revolution
and benefit from the insights of how health care is now transforming from
physician-driven care to empowered patient-physician partnerships.

Penny Moore is a partner with Commonwealth Health Advisors. She
has devoted her career to providing leadership to growth-oriented
companies that are transforming population health through innovation
with digital technology. Most recently, Penny has led the commercialization
for early stage digital health start-ups Kurbo Health
and Better Therapeutics. As the Chief Revenue Officer for ShapeUp,
a venture-backed company that pioneered social wellness, Penny’s
leadership created a high-quality book of global business opportunities
that paved the path to a successful exit. She has held executive
leadership roles with large health plans such as Kaiser Permanente,
UnitedHealthcare and Aetna.

INTRODUCTION
When I was a kid growing up in a rural New England farming community,
my mom always had her hands full. My two sisters Patricia
and Karen had already pretty much grown up and moved out, but
three boys remained, constantly challenging one another and pushing
against every boundary we encountered. My older brother Bob was
the rebel. He was the reason rules existed. He pounded on us mercilessly
to the point where my younger brother and I had no choice
but to band together in mutual protection. We learned early that to be
fast meant not getting pounded. My mom’s time-honored method for
refereeing the indoor skirmishes was constantly telling us to go outside
and play. That’s exactly what we did.
If you have never spent much time in the country, you probably
have little appreciation for how you keep yourself entertained there.
We had no cinemas or shopping malls. We rode our bikes around
town looking for enough kids to play baseball, basketball or football,
depending on the season. Not all of us were into sports and when you
grow up in a town of about 800 residents, you learn to diversify your
activities. Fishing was probably the most popular. We would pedal
our bikes down to Norton’s Hardware in downtown Fair Haven,
Vermont, purchase just enough bait for the afternoon and let old
Ralph Norton check our poles to make sure everything was in working
order. Then off we would ride.
Mendon Pond was about five miles outside of town and to get
there we had to either take a busy two-lane highway called 22a, which
connected the thriving metropolitan area of Fair Haven to a point
just south of Burlington. My dad used to call 22a the “Ass” highway
because when you looked at 22a in the mirror, that’s what it spelled.
I still think that’s funny. What made it seem like a busy road even
by Vermont standards was that it was winding and narrow. It always
had big freight trucks on it which sometimes honked or swerved at
the kids on bikes to scare them. Sick and twisted, I know, but hey,

welcome to Vermont. We typically opted for the dirt roads that jutted
up one side of Rattlesnake Ridge, cutting across the orchards and
slate quarries that brought early settlers this far up north back in the
day. Of course, going the back way made it a longer haul and the dirt
roads meant constantly dodging potholes and rocks big enough to
send you flying over the handlebars. On good days, we would bring
home the booty. Nobody needed to tell us how to catch and clean
fish. It was hardwired into the DNA of every kid, big or small, growing
up in Fair Haven. On bad days, we would raid Sheldon’s Orchard
and bring home just enough Macintosh apples for our moms to bake
cakes and turnovers.
With every passing season came a new activity. New England
isn’t for the faint of heart. Those seeing the fall colors and thinking,
“What a lovely place,” have never shoveled snow. Sure, they see it
coming down and think it’s beautiful…the first couple times. Those of
us who grew up there knew better. In the winter, the boys’ job was to
shovel out the driveway. I always got out there first and took the part
close to the garage. It was where the basketball hoops were located,
and my incentive was being able to shoot hoops all year long. I was
meticulous about how clear I kept it. I mean, not a bit of snow was
ever left on this part of the driveway. My dad was always proud. I took
the largest section and cared for it like a drill sergeant on new recruits.
My dad happily bought me about three or four rubber basketballs
as a reward. He knew how to keep me motivated. In the winter when
the temperatures dropped, I would store them near the radiators. If
you’ve ever visited a home built in the 1800’s, you’ve seen these big
monstrous-looking metal things in every room. They dominated the
décor. You don’t have to be a Tom Brady fan to know what happens
to the air pressure in anything inflated when the temperatures drop. I
shot hoops while my brothers did the rest of the driveway. When the
ball lost its bounce, I would simply go inside and get another one and
put my Brady ball back near the radiator. I would repeat this while
watching my brothers finish the driveway.

I always took the largest section because it was the easiest to do.
My older brother Bob took the middle. It was the smallest section, and
he thought he was getting a good deal. Heck, he would have made our
lives miserable if he thought otherwise. Younger brother Dave always
got the shortest part of the driveway, and the shortest end of the stick.
He got the part closest to the road. It was all good until the snowplows
came by to clear the street. To this day, I still hear stories from my
neighbors who could hear from three blocks away my dad bellowing,
“David Michael Pereau—get out here right now!” I don’t think my
younger brother has forgotten or forgiven me to this day J.
In the springtime, it was planting season. Since I never took to
hunting in the fall, this was one special activity that I did with my
father. I was a gym rat growing up. There wasn’t a sport I didn’t play,
and my dad was always there for me. I was playing catch, shooting
baskets or throwing the football. I always wore the old man out, and
helping him plant and weed the garden was the least I could do. It
was our quality time. He got plenty of that with Bob and Dave during
hunting season. He and I spent many hours out in our back yard and
he let me plant anything I wanted. From strawberries to rhubarb to
pumpkins, I had my own section, but I had to care for it all season
long. Our neighbor had the biggest patch of raspberries, blackberries
and blueberries I had ever seen. We were never hurting for munchies.
We just went out back or next door and ate until we were full. Food
was fuel to a growing boy, and we were constantly on the move.
Come summer time, my brothers and I would scrape our nickels
and dimes together until we had just enough money to rent a boat on
Lake Bomoseen. We were too young to rent anything with a motor, so
we would row out to the island. It was famous for decades as a retreat
for Hollywood stars like the Marx Brothers, Marylyn Monroe and
others. Believe me, there was quite the ambiance when eating out in
beautiful downtown Fair Haven. Truthfully, we didn’t care about any
of that. Years earlier, the older kids had tied a rope to a tree overhanging
the cliffs. We rowed our boat out to jump off those cliffs. We were
too scared to dive, so we all just jumped in feet first. Anyone boasting
about doing any different was lying. Today, there is an eagle’s nest on
the rocks we used to jump off. The tire swing is long gone, as are the
Hollywood stars who used to frequent the Algonquin Club located on
the island.
By autumn, we were in full leaf-raking mode. There were no
blowers back then, and no sacks for stuffing the leaves for a later pick
up. This was pre-environmental anything, so we burned the leaves on
the side of the road in the space between the blacktop and the hunks
of slab used as sidewalks. They were too imperfect for anything else,
and I still remember the horses and trailers hauling them up from the
slate-cutting shops and laying them down along our streets. Nothing
says New England like shuffling through the leaves on a slate sidewalk.
When my mom was overcome with debilitating dementia and
Alzheimer’s disease, I would walk her to the corner and back. She felt
like a kid again.
Looking back, I wouldn’t change a thing about how I grew up.
We were never bored. We had no smart phones, no electronic gadgets
of any kind, and we only played indoor games when it rained. We
were active, we ate healthy foods and we participated in a variety of
activities that kept us moving and kept life interesting.
We resided at the original corner of happy and healthy. Heck, we
probably inspired that as a Walgreen tagline.
Sitting in a health care conference years later listening to the
speakers drone on about chronic conditions and how inefficiencies in
our health care delivery system were contributing to chronic conditions
that were overwhelming our health care capabilities, my mind
wandered back to my childhood. I had the mother of all epiphanies:
We can absolutely fix our broken health care system . . .
and I knew exactly how to do it.

CHAPTER ONE
OUR SYSTEM IS BROKEN, BUT WHO CARES?
Have you ever had a friend who constantly asked why things are done
the way they are done? I was definitely that kid. When I first shifted
my professional focus from technology and management consulting to
health care, I was a nonstop “But Why?” machine.
I must have driven my poor wife crazy. She has logged more than
30 years in the health care industry, where she came up through the
ranks. There isn’t an aspect of how insurers intersect with our lives
that she can’t go into the weeds to discuss. She started in underwriting,
later moved into account management, then did sales and before
long, moved into management and was running regions. Okay, I
glossed over quite a bit there because she is a woman and it took her
twice as long and she had to work twice as hard as her male counterparts
to finally become president of a multibillion-dollar region, and
then CEO. If her name were Bob, we would probably be living on
an island already. But you get the picture. She knows the health care
industry backwards and forwards, inside and out. Forget the fact that
she is only one of a handful of women in leadership roles. That is a
story for another day. She has given me an insider’s perspective into all
things health care and C-level connections any digital health startup
would covet. From health care consumption to servicing, I have seen
it all—and it isn’t always pretty.
AN EARLY VENTURE I MADE IN HEALTH CARE
When some former tech colleagues approached me about an idea they
had about starting a health scoring company, I was intrigued. I had
long asserted to my wife that one of the reasons we have such runaway
costs in health care was that nobody measures anything.
How can you manage something you don’t measure? Seems like
a logical question.
In coming up with a way to measure an individual’s health, we
borrowed a concept from the financial industry and applied it to
health care. We started with a simple score, something that anyone
could track and understand. It was amazing how closely it tracked like
a credit score. We used a sliding 0-1000 scale. At zero, well, you were
probably dead. At 1000, you were taking the leading role in Superman
movies. In between, anything above 600 was good; about 700, excellent;
and above 800, exemplary. We put an arrow by your score to
show whether you were trending up or down.
Yet there are some significant differences between your health and
your credit score. For starters, your credit score only tells half the story.
It shows how much you owe and how well you service your debt. It
doesn’t list wholly owned assets or how much money you make. How
do you account for similar factors when expressing the status of somebody’s
health? We knew that would be challenging, and realized we
had to get it right. After all, you aren’t automatically healthy the day
after you quit smoking, just as you aren’t at risk for a heart attack or
diabetes because you skipped a day of working out.
Starting in 2011, a cornucopia of data-collecting devices, ranging
from the Fitbit to the Nike Fuelband, were already exploding onto
the scene. Withings had introduced scales that could capture and
store your weight, body fat and BMI for later analysis.