Chronic Condition Management - Your Advisory Board Speaks

Following the recent Chronic Condition Management Advisory Board meeting on January 15, 2025, we shared a summary of their discussions with our community members. Questions were collected from the community, and we're pleased to share the board members' responses below.

The conversations explore key themes in chronic condition management - from the evolution of pharmaceutical support in digital health to practical solutions for technology adoption in healthcare settings. Drawing from their extensive experience across healthcare innovation, medical operations, analytics, and digital health transformation, here are their insights.

Julie Fishman, Entrepreneur-in-Residence (EIR), Yale Ventures

Question: How do you see pharmaceutical companies evolving in supporting digital health solutions for chronic condition management?

Answer: I think for pharma it's important to continue with the shift from being product-centric to patient outcome focused models and focusing on patient centricity.   The future of healthcare lies in creating comprehensive, personalized solutions that address the complex needs of patients, particularly those managing chronic conditions. I view digital health technologies as one of the enablers to advance patient centricity in pharma.

I think digital technologies can offer pharmaceutical companies an opportunity to enhance patient trust and engagement. By investing in AI-powered patient platforms, companion digital therapeutics, and personalized treatment support tools, pharma can drive reimagining patient care. The approach goes beyond traditional medication delivery, focusing instead on holistic support. As pharmaceutical companies continue to embrace digital health technologies, they are reimagining their role in patient care, moving from medication providers to comprehensive health partners, which I believe is what patients are seeking.

Question: What specific incentive structures have you found most effective in encouraging healthcare provider adoption of new technologies?

Answer: Adopting new technologies requires a strategic approach that addresses the complex challenges faced by healthcare providers in the United States. The existing business models overwhelm providers, making technology adoption particularly challenging.

Companies must develop a compelling value proposition that clearly demonstrates return on investment for healthcare institutions. This means creating technologies that not only improve patient care but also offer tangible financial and operational benefits. Providers need to see immediate and long-term value in adopting new digital health solutions.

Effective incentive structures must prioritize seamless integration into existing electronic health record (EHR) systems with minimal workflow disruption. Provider interfaces must be user-friendly, designed with the clinical workflow in mind to reduce burden. Ultimately, the goal is to create digital health solutions that feel like a natural extension of a provider's existing practice, not an additional burden.

Dr. Alexander Blood, Director, Medical Operations & Innovation, Mass General Brigham

Question: With the rise of hybrid healthcare models, what are some successful use cases you have in balancing in-person care with virtual tools to improve chronic condition management?

Answer: Yeah, a great question. There's quite a few that have cropped up with the advent of RPM or remote physiologic monitoring and CCM or chronic care management billing streams. You know, there have been additional opportunities to capture the time and effort that goes into this more chronic management.

Obviously, with the rise of value-based care and really more comprehensive approach to disease management, I think that's only gonna further push these types of models where seeing a physician or provider in the office isn't necessarily driven by billing models and the current fee cycle. So I've seen, especially chronic disease management strategies for things like diabetes, for hypertension, for things like heart failure - our research here at Mass General Brigham has demonstrated using scalable teams and allowing pharmacists to prescribe under collaborative drug therapy management programs and allowing a team of care providers to check in on patients and monitor them remotely, so that you can catch issues before they turn into something that's irreversible.

Question: What practical solutions have you found for managing increased workloads while implementing new technologies in your practice?

Answer: The challenge with many new tools is that adding additional portals, separate logins, or other ways to interact with a patient's data stream has been really challenging.

We've found that integrating these tools with regular care as much as possible streamlines the process and makes it much more likely that both patients and providers will engage with it. From a practical standpoint, you want to find tools and solutions that align with the current care paradigm and the way both patients and providers are used to engaging with one another.

As you layer on new tools, platforms, or programs, ensuring that the workflow is seamless or minimally disruptive from both a patient and provider standpoint has been essential. You can have the best tool in the world, but if you make it too difficult to access or engage with, it doesn't get used. We've seen this time and time again.

Dr. Anand Iyer, Chief Analytics Officer, WellDoc

Question: How do you envision AI tools being integrated with Continuous Glucose Monitoring data to create actionable insights without overwhelming providers?

Answer: That's a great question. I think the answer lies in focusing not just on the providers, but the patients too. For both patients and providers, the data value continuum is critical- how do you translate data into information, information to knowledge, knowledge to action, which then leads to outcomes.

So, when you start with the end-user, the consumer, integrating CGM into an AI, you want to think about simple visualization, display, but not just the CGM trace. You want to superimpose their activity. You want to superimpose their medication doses. You want to superimpose their sleep so that you not only get a display of the one variable, CGM, you get the display of multiple variables.  The value is not just one data source but connecting data across a consumers health.  This is what allows you to derive actionable and meaningful insights.

Why is that important? As a type 2 diabetes patient myself, what I want to see is the correlation between these things. I want to see if there was an action I took or is an action I should take that will either cause my CGM to be better, if you would, or it'll help me understand what it is that I did, perhaps good or perhaps not so good, that I may want to correct. So being able to superimpose and display is very important.

Similarly, for the provider, the last thing you want to do is inundate – you can imagine a doctor with 100 patients, and they're getting 288 CGM values on a daily basis from each patient? It'll drive them crazy, right? So how do you actually extract valuable insights? How do you store those insights in their clinical workflow? How do you give the doctor, the provider, the set of clinicians who are managing this patient, insights to say, "That's what's going on with your glucose and your food, or your glucose and your exercise. Well, let's work on that. I can adjust my treatment pathway." So I think being able to manage that data continuum, going from just raw data to insights, knowledge, action, outcomes, I think that's really what we want to focus on.

Question: What specific strategies have you found successful in maintaining long-term patient engagement with healthcare technology?

Answer: I think it's really 4 things that come to mind. 

• First, whatever coaching and feedback you provide has to be personalized to be both temporally relevant - meaning it has to be delivered at the right time - and it has to be contextually relevant. It has to be in the right context based on that individual's data and journey. If I have diabetes,  a message about losing weight when I'm suffering from hypoglycemia misses the mark.  Someone with diabetes needs clear feedback and direction, for example 2 or 3 things that they can do to avoid hypoglycemia - timely, meaningful and actionable specific to them.

• Secondly, is what I call longitudinal feedback. Giving them trends and insights over time so that they can correlate with their own behaviors. So it's not giving them the universe of diabetes knowledge, it's what matters to them and what will support changes to their behavior over time.  This is also key to supporting meaningful data-driven conversations between an individual and their provider.

• Third, don't ever forget that this has to be simple and engaging, so let's not forget the user experience. The user experience has to be one that's pleasurable, easy to navigate, something that fits into their life flow. 

• Lastly, digital health and care cannot be siloed.  They must be integrated.  I view AI, digital health and CGM as integral parts to long-term engagement.  Bridging this together can help illuminate insights for both individuals and providers that cannot be seen by the naked eye.  It guides towards determining the best treatment pathway decision specifically for that individual.

Mohamed Datoo, Senior Director, Global Digital Health, Johnson and Johnson

Question: Based on your experience, what do you see as the biggest barriers to achieving true interoperability in healthcare technology?

Answer: So I think there's a few things here that we can unpack. One, I think the incentives for the big players within healthcare just aren't aligned. Right? So if you think about where technology is today and what we're hearing from a lot of our HCP customers and people who are out there treating patients is that they want everything simplified. They want everything in their EHR. They want everything in one place.

And the incentives for a lot of the EHR companies and organizations who are managing these platforms are very, very different. They're trying to differentiate themselves from their competitors at the end of the day. So if you look at some of the large EHR players out there, they're trying to penetrate the market as much as possible. So for them to build a bespoke integration platform or capabilities to integrate these solutions, it's a value proposition for them. Right? And it's a way that they can sell their platform to their customers.

Working together across EHR platforms really doesn't make sense for these folks because, again, at the end of the day, it doesn't offer them any sort of value proposition or way to differentiate themselves. So I think, first and foremost, just simplifying it for physicians and making it to a place where everything can be centralized and embedded into their workflow is a barrier. And until we figure out a way to make these integrations or make these plugins into the EHR systems more standardized, that's going to be a huge barrier.

Second, I think you have a lot of companies, whether they're startups or more mature companies, innovating at a very rapid pace. And when you do that, you're unable to standardize anything at that point. Right? How do we measure certain vitals? There are so many different capabilities or different ways to monitor blood pressure or monitor temperature. And there's no truly good way to standardize which methodology is better than the other.

I do think that there needs to be some sort of regulatory body or agency or player out there that can help bring these technology players together and actually start standardizing how some of these solutions are brought into market. And I know DIME is doing some of that, but I think it requires a lot of folks across the industry to come together to say, "Hey, this is actually needed, and we need this and we want this." It's about companies coming together to be willing enough to collaborate in these areas to create some of this standardization.