The Dialogues – Episode 5

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Hi, everyone. and welcome to episode five of the dialogues. I’m really excited for today’s chat. We’ve got a guy called Henrik we will let Henrik introduce himself in a second. Well, I’m in Sydney, Australia. I don’t think I’ve mentioned that in previous dialogues, but it’s worth mentioning because we’ve got guesses from all over the world. Once again welcome Henrik. How are you? 

Thank you. I am really excited to be here. I am doing great. I’m unfortunately not in Sydney, Australia. I would wish to be. I am currently in San Francisco, California, where I live these days, but originally come all the way from Sweden, the very north of Europe. 

Awesome! When I think about the places I’ve been and lived, Sydney is an amazing city, and I feel very lucky to live here. But I have to say, when I think about similar cities in the world like San Francisco has got a similar vibe as it has lots of water and many undulating hills that is why it is filled with natural beauty. So it’s a great city you are living in. 

Yeah, it is definitely a pretty amazing place to live. Though slightly more challenging these days with climatic changes and wildfires in the middle of a pandemic. but yeah, it has. This state in general has a lot of natural beauty, which is one of the reasons why I moved here in the first place. 

Yes, it’s an amazing place and I suppose the similarities overlap even further like we also had a lot of wildfires in Australia, New South Wales in particular, so six months ago, we were shrouded in smoke here in Sydney, and it sounds like San Francisco is a similar place and hopefully they get that under control. We hope that everything is okay with you and your family over there. 

Yeah, We’re coping with the situation for sure and we have a lot of people that are firefighting and doing a great job to get this under control. So I’m pretty sure that in a few weeks we’ll do a little bit better. 

Indeed, It’s scary stuff. Just reflecting on the chat that we had last week, I think a few things that excited me were that first, you are type one diabetic, second you have a tech startup, an entrepreneurial flair which is really fascinating and third you’ve got the Swedish background. As there is a difference in health care systems between Sweden and the US that we’ll discuss further: But it’s a kind of stuff that I’m really interested in. So let’s dig deeper into each component one by one. You’re a type one diabetic so would you like to tell us a little bit about your one day journey?

Yeah, Exactly. I’ve been the type one for about 20 years this year so I got diagnosed when I was somewhere between 19 and 20. You know, where I am today was really a kind of like joining forces of three major things in my life, being from Sweden and then living in the US. just appreciating how different those systems are and what things we can borrow more from the swedish model and roll that out to the US, obviously, being challenged by the disease on my own. Then thirdly, having a very deep, interesting experience in technology, building applications, software and having the ability to see how software can really help not only on the care delivery side, but also on the side of patients’ experience. I am really excited to come and talk a little bit about that. 

I got diagnosed at the age of 20 when I was actually in the Navy in Sweden. I was doing military service when we had a routine health checkup, though I’ve been feeling pretty under the weather for a number of weeks, but never really figured out what the problem was. Then they pricked my finger, and the doctor was like, Oh my God. this is not good, you need to cancel the service. They then rushed me to the hospital 

What is the rule in the Navy or the army, If you’ve got type one diabetes? 

Apparently, there is a rule that you cannot be in the navy if you’re reliant on any type of medication on a daily basis, because it’s too risky. If you end up forgetting it or losing it, you can end up in a life threatening situation. 

Yeah, we probably wouldn’t try to get into it as that could be construed as being a bit discriminatory, I suppose? But I guess those lines need to be drawn sometimes. 

Yeah, I was pretty devastated, actually. Back then I was really looking forward to it and had already been there for a number of weeks, and then all of a sudden I was kicked out, you know, I had nothing to do. so it was pretty upset actually. 

But maybe you are fortuitous as you wouldn’t be doing what you’re doing today, If this had not been the case, and it’s interesting how diabetes does this for so many people in the world. It doesn’t end up just being a disease that you have to live with or a condition that you have to deal with but it ends up contributing, in some way, to the life that you lead. 

It actually totally did because one of the first things that I did when I came home from the hospital, I had all of this time on my hands, really nothing to do. So the first thing I did was that I started to get into engineering, writing code and writing software that propelled my career into what it is today. So In my opinion, diabetes plays a huge role in my life overall, not only because living life as a diabetic is more complicated, but also, it has helped me in a lot of ways. 

One thing I find sometimes is that because I have type one diabetes and now I’m working in a diabetes field. I would like to ask you if you find any need to escape ever. How do you switch off that thought? 

Yeah, I actually had one of the scariest things about starting a company in the health care and diabetes space which I will get into and talk more about. The thought that I was getting was that, now I did not only have my own diabetes to think about, but also my career would be wrapped up in It  so I had a lot of anxiety before deciding that starting a company in the space would be a good idea or not? but it actually has turned out to be totally fine. 

I think my escape is to really find the absolute balance that I have in terms of knowing the safe meals and to know how exactly my body reacts when I take them when I just need a break. I just stick to those meals and certain types of exercises to keep a balance. It’s completely automated because I know how my body will react.

The thought is that if you’re eating the meals and you know how your body is going to react, then you don’t have to worry about what’s happening with your blood sugar so you can kind of switch off. Exactly when that idea or thinking came from?

Yeah, So it actually came from when I discovered CGM. I discovered CGM in 2017. Although, I had heard about it before, but never really tried it. And my doctor never told me anything about it or anything like that, which I found very strange. I was actually referred by a patient with diabetes. He told me Hey, Henrik, you should really try a CGM. It’s really amazing and I was like, Okay, I ordered it in Europe to my mom, and then she brought it over when she came to visit me. When I tried it, I was just like, Wow, this is incredible. Not only do I not need to prick my finger, but also I get so much more information about how my body reacts over 24 hours.  

My career in technology has over the last decade or so been all about product management. Product management liaises between design and engineering and also a little bit on the business side, trying to create products that solves problems. The methodology that a lot of product managers apply is that we use data to try and learn about a certain behavior that our potential customers have. Then we try and solve that problem with some kind of solution like we run an experiment essentially, and then we look at the data again to analyze and learn what happened when we introduced this new solution or idea into the mix and then we refine it therefore its an iterative process. 

CGM has enabled me so that I could run an experiment for example eating some kind of food that I like and observing the result,  then tweak my insulin based on the results and doing it enough times to find the things that I can eat for breakfast that I know exactly how my body will react to. I did that for breakfast. I did that for lunch, and I did that for dinner so that it is like a repertoire – I know roughly how my body will react. That’s been tremendously helpful to keep me balanced when I don’t have time to think about my diabetes at all. I mean, there’s always some amount of uncertainty like there’s no perfection.

I take it as a never ending chess game and we can never ever achieve perfection. You’re always learning and tweaking things up. Even, I don’t think you actually want to get perfection. You know, there are those type one diabetics out there who have managed to get perfection that their HBA1C is as good as a non diabetic. Infact, I don’t think I wanna be one of those people because It requires a greater amount of control and the pedanticness that makes them live a pretty compromised life. 

Yeah, I couldn’t agree more, I think one of the things that we always talk about with our endocrinologists and nurses is not only how good control you can have, but also how much time you are spending on getting that control. There should be a balance between the two, because if you spend every single minute of your life trying to control your diabetes, it actually becomes very easy to get to the perfect numbers, but it’s all about finding the balance between those two, We call it time on task that includes how do you balance or how do you reduce the time on task? It also includes finding or getting reasonably good numbers that lets you live happy, healthy and long life. And that’s the key to good control.

The whole concept of how you described the product management based mindset and the iterative process enables more control in life. When I was listening to you it reminded me I’ve got an undergraduate degree in health information management, and I’ve spent the last 20 years working in healthcare and technology. Particularly the last few years in informatics and big data consulting roles previous to ‘Not Just A Patch” stuff and one of the things that I used to present at some hospitals about the data for suppose on freestyle libre, it was always a good way of thinking about the power of informatics. That tells you how to improve. Actually, that’s all we’re talking about with CGMs. They give you almost micro information so that you can tweak constantly, and that it’s basically health Informatics in action.

I really believe in this old cliche, which says that you can’t improve what you can’t measure, says Drucker. If you don’t know where you are coming from, where you are and where you’re going, there’s no way for you to actually make it better. It actually ties back to the whole thesis around running an experiment or finding out whether or not the change that you made was positive or negative so that kind of learning behavior is incredibly powerful. Just as you said, it requires information to be available at any given time and I don’t believe that five finger pricks a day is actually giving you enough information to understand that what you did yesterday or two weeks ago was positive or negative for your numbers, right? So I think CGMs open up a whole new field for a giant opportunity of experimentation for people. We are fortunate enough to be able to use them continuously. 

Absolutely. So just going back to your type one diabetes journey, I guess you didn’t immediately jump to the tech role in diabetes. Would you like to share with us your entrepreneur journey? 

Yeah,  I am actually an engineer by training and I studied computer science which is engineering of software. I completed it in Stockholm, in Sweden and then after graduating, I ended up moving to Berlin, Germany, joining a very small company called Soundcloud. I’ve always been super interested in music so that was a venture of music and technology together which was a really interesting emerging industry. So I moved to Berlin and then spent about two years working with Eric and Alex, who were my schoolmates and the two founders of Soundcloud.  I really fell in love with Berlin as a city and after leaving soundcloud in 2008, I ended up staying there and then starting my own company which was my first company with an old school friend. That was kind of my first foray into being a founder or entrepreneur. Our company is known as Read Mail, which was an ebook startup, we were doing a similar thing that Soundcloud had done for music but taking it to ebooks, creating a social platform for ebooks. Although It was much harder than we had anticipated and never competed with Amazon, It’s a very complicated player to compete with, especially on their core business, which is books in general but in a way, we managed to build a small, very good team in Berlin. 

In 2014 we started conversations with a few companies in the US such as Dropbox (a big Cloud Storage Companybased in San Francisco).  We really hit it off and there were some parts of our technology that they were really interested in, especially what we have done on mobile in terms of rendering books and a few other things. So we decided to join forces hence in February 2014 our entire team moved to San Francisco, where I joined the product management team together with a bunch of other people from my old company. This was like a whole new type of career for me and in product management, I got to learn a lot of things over the next 3 to 5 years in working out of San Francisco at the Dropbox headquarters, where I met a lot of like minded people and learned a lot of new things. 

In 2017 after discovering CGM, I was also kind of at the end of my stint at Dropbox, and I decided to take a year off so that’s really when I started to think more deeply about the problem of care delivery in terms of diabetes, and what kind of CGM would unlock in terms of delivering diabetes care to the next generation. I took about a year sabbatical to start thinking about the problem and then started my own venture in 2018. 

What a great story and what an amazing experience you had as well. This brings us to your current situation at ‘Steady Health.’ You mentioned a word  “Care delivery” so I do wanna get on to that because it’s an area that interests me as I’ve worked in that field quite recently but I want to know where you saw the opportunity? I mean where you saw that there was an opportunity for improvement in management of type one diabetes? Because I think healthcare is a challenging space. Changes or effects of medicines happen slowly and there’s a risk averseness – you’re dealing with people’s lives. So the whole medical history is built on critical decisions with really good information that is statistically significant with randomized control trials. You know, the doctors who generally run healthcare are trained to move slowly on the basis of robust information.  This is why we see change being so slow in health care and there’s also a reluctance,  Maybe a little less in the US because it has a slightly more entrepreneurial mindset, however I think in Australia and the UK it is hard to get a foothold due to the ingrained ways of working. So I’m curious about hearing your thoughts on that and how that impacts your vision?

Yeah, totally. So just giving an overview of what we do so Steady Health is the name of the company that is basically a virtual diabetes clinic that delivers all of our diabetes care or full service endocrinology care virtually using telemedicine platforms including online chats and video calls. We also specialize in CGM meaning that we actually prescribe CGM to every single patient that we have in the clinic. To make it effective we have a software that helps our clinicians or endocrinologists and CDEs  to deliver really high quality care including monitoring our patients in almost real time and understand much more deeply like where they’re coming from, where they are and where they’re going, so that we can give them the support and the care that they need.  

As you know that  now everybody has a smartphone so we can also establish a direct communication line between you and your care team so you don’t have to follow that static model which involves that  every few weeks you have to visit your doctor and say here’s what happened in the last three months. So this can be much more fluid and flexible like maybe you don’t need any support at all, but when you go through some big life change as if moving to a new city, getting married or getting pregnant etc. then you need a lot of support to coach you in terms of managing your diabetes and that’s the agenda of steady health in a nutshell. 

Now coming back to your question, what led us to get to that point? I think after discovering CGM, I was amazed I had gone through this iterative process and I had made so much progress on my own care, going from an A!C level to 7 which is, for most people, actually pretty good but if I did not know what my A1C number is then my blood sugar would keep on fluctuating which does not feel you physically fit and healthy right? but after getting CGM my A1C from the past 3 to 5 months got changed from 7 to 5.7 or 5.8 and I was physically feeling great. Even I got much more calm than ever before. Naturally, I had my upcoming three months visit with my endocrinologist so I showed him my progress, and told him what I’ve learned, what I’ve done and also a list of questions like what’s happening when I do this? Why is this happening? I remember my endocrinologist at that time just pushed her chair away from me and told me I am Sorry, I can’t help you with this, we have about 10 minutes so do you need a new prescription? Do you have any immediate needs that you need to cover? Listening to that, I was so perplexed. I was like isn’t this supposed to be your job, right? This is why I’m paying you but clearly the system wasn’t set up for dealing with these types of patients and the amount of data that I had. So I started asking a bunch of questions from patients around the world and from doctors in the US and what I found was that there were three main problems on the providers’ side. The first one was around education like  my doctor had never recommended a CGM because she simply didn’t know that much about it. She didn’t get any training when she was in medical school that had to do with analyzing data so when she equipped someone with the CGM, that just meant so much more work for her, right? which she doesn’t really know how to do. The second one was around tooling, the amount of tools that she has at her disposal actually collect and analyze data are quite rudimentary. We have a lot of things like device manufacturers and like pushing their individual systems which makes it very hard for a provider to actually learn them.  Then the third one was the most important problem. You need to actually solve all of these three problems, otherwise, there’s no chance that this type of great care can exist. I had that fundamental insight that the only way to do this was to start a fully integrated diabetes clinic that actually delivered care to patients. So that led me to start a fully integrated clinic that has the endocrinologists, and we train them on the software and make sure that the providers get paid for the work that they’re putting in.

Fantastic stuff and this is what patient centered care is, right? which is almost the opposite of the historic way of healthcare delivery. Health care is historically being delivered to meet the needs of the doctors and the payers, in a sense so this concept involves high quality customers, and here the customers are our patients. It’s what the system is talking about. I’m kind of interested to know where is the reality  for the system you’re in and for the business that you’re in? And you know, one of the first things that comes to mind is that the payment side of things. The person paying is the person who gets a “Say” regarding how delivery of care should be done to him. To get the funding required to deliver the care of the patient needs is an ideal concept. But in reality, how’s it working out? 

Yeah, I mean that was one of the major challenges for sure like trying to figure out but how do you actually solve the third piece? How do you actually get paid? And I think there were  two realizations, the first one was that, actually the change in the American healthcare system is happening slowly, but it is happening, so Medicare, which is the largest payer or insurance company in the country that is run by the government for everyone who is 65 years or older. They set the rules that are then followed by the more commercial insurance plans and they have started something called remote patient monitoring program, which allows providers to deliver care on an ongoing basis without seeing the patient in person. That means collecting the data, making some kind of clinical decision and then communicating that back to the patient. But you can do so as synchronously, which means over messaging or over video calls. That is starting to be adopted by commercial payers as well. However, this requires you to think differently about the operational set up of your clinic that is usually based on in person’s visits where somebody shows up with a credit card, he pays, checks himself with the doctor and then leaves which  doesn’t work anymore, because here you need to actually charge the patients on an ongoing basis. But since we’re a technology company, we’re actually really good at that stuff. We use the payment processor and we have credit cards on file for all of our patients so we can actually do that without as much operational overhead. So it just requires a complete rethink of your relationship with the patient in the clinic, right? It can’t be like a traditional fee for a service model,  where you show up, you get care, you pay,  you leave. It has to be ongoing, say Spotify. As we know that  healthcare is a service, right? Truly, Yeah, and it requires you to have all of those systems and operations in place. That is one of the best things about building a clinic from scratch.

I really loved it and I think it’s also fascinating. I’m interested in knowing about the endocrinologist, the health care deliverers in this process like managing them when you first engage and put the idea forward so I would want you to tell me the feedback that you got. 

Yeah that is super interesting, right? When we talked to the endocrinologists about telemedicine, about delivering care completely virtually, every single endocrinologist was like, impossible, not even interested, get out of here. So strategically we started by opening a physical clinic and we said that “Hey, we’re gonna open a small clinic to deliver care based on data from CGM.” so that was the pitch. 

After running that clinic for about six months, we changed the notion that what if we explore and apply a telemedicine approach? As a result there was a lot of uncertainty from the deliverers’ side. That was in October 2019 when we spent a few months researching making sure all the legal processes are accurately done. Then, we launched the fully virtual clinic on January 15th of this year. Obviously we had no idea how the world was gonna look like two months later, right?  but the timing was just incredible and now everybody is talking about telemedicine, that’s  the future of healthcare.  

We have also realized that it would be crazy to just rely on the physical space to deliver care because what do you do when you’re there as a patient? Nothing. You sit in a chair, you look at a computer screen together, you maybe exchange some papers that could easily be a message or a text message or an email and then you are on your way. They might measure your weight or blood pressure. They might do these kinds of routine things. I think you could get remote monitoring now, right? All that stuff is available and probably plugged into a cloud as well. We actually utilize primary care to do those routine check ups, as they generally have more availability and they work closer to where patients live. So it is a better experience for the patient and cuts down cost for delivering the care in the first place. 

Yeah.. Massive efficiency gains not just in health care but in so many other areas of life. I think that it’s actually hard to talk about the positives of the pandemic because people are suffering right? and you don’t certainly wanna dwell on some of the positives because of that, but In reality this is an example of health care delivery through technology and through the fact that we’re forced to move in this direction. Ultimately it will probably end up with creating a more efficient system that delivers better quality care with more patient-centeredness.

I also think the same. You know, when we started talking about telemedicine, we sat down with our clinical team, really looking at it like this is not a business decision rather it is a care quality decision. You rather have to see where your patients are in their diabatic journey? Here, we do have a connected patient care where we have a continuous stream of data coming from their arm so we can check their A!Cs every 2 weeks. And it was very obvious when you put it down and compare it, you would pick the latter not the former. So that was really the thing that I think propelled us into focusing solely on the virtual piece of care delivery. And I agree with you. I think when the dust settles from COVID 19,  we will have a bunch of structural changes to the kind of health care system in the US that will largely be positive. 

Now there will be probably some downsides as well that I always discuss with other people in the healthcare space that telemedicine is not replacing the in person visits with a video call. That’s not telemedicine. TeleMedicine is rethinking the structure of your care model to enable patients to get more higher touch care with frequent lightweight touch points instead of this kind of old structured system that fits your doctor’s schedule more than the patient, so there’s a lot of improvements that I think are happening as a result of the pandemic. 

Is there a model that you or your system is using as a reference or ideal? Like Scandinavia preferably works on patient centered care and has better outcomes on safety and quality so are you also following the same model? 

I think the thing that I was inspired by being from Sweden was like around a single payer system or anything like that. Those are very hard structural changes that a small diabetes company probably can’t solve. But the thing that was fascinating was that, in Sweden among type one diabetics, 80% have a CGM so I asked myself Why is that? Well, first of all, it’s because we have a single payer system, so they decided to fund CGM, right, This also means that the patients loved using it, otherwise they wouldn’t be on it in the first place. But what’s even more interesting is that they have a national registry of outcomes per clinic and purchases.  Now that data is public so that they are basically the regulators, they call the bottom 10% of the clinics every year and ask them what kind care model and systems they use to get there. Which means that technology like CGM actually works. It gets high penetration very quickly. And that, I think, was the kind of one of the thing that propelled me into realizing that CGM is going to be on every diabetics arm in the future because we know it works. 

Yeah. I’m loving this conversation and I’m gonna wrap up with one question that is a little bit esoteric but I’m curious to know about how Scandinavians go with their daily life and cultural activities that exist in northern Europe? As you said that about 80% of type 1 diabetics have a CGM which is quite expensive but it is taken as an investment. It’s an investment in the country’s people, and their health.. This is a long term thinking, and it’s about what matters to the people living in this country, and how do we make everyone healthier and ultimately happier so that’s all that really matters, right? And I’m kind of curious about how different systems think differently in those more esoteric philosophical type questions where ultimately every dollar that is spent should be spent to improve health care but it doesn’t really happen. There’s so many factors and conflicting interests and I’m sure Sweden’s also not perfect either but certainly I think it’s on the right end of the spectrum. So I want to know about the relevance of the culture, the relevance of the countries, the relevance of how countries invest in health care to achieve something. As Sweden has invested in health care because it wants that if they were to be healthier, they will be more efficient as they’ll have less people in the hospitals, they’ll have less comorbidities and so on and so forth. I am asking this because sweden’s health system is highly sophisticated and consumer friendly. 

I think, yeah, It’s a hard question to answer, but the thing that comes to my mind is, the challenges we’re seeing in the US are largely due to misaligned incentives. You don’t get these issues that we have currently in the US, where, you know, some insurance companies are unwilling to take the long term responsibility for a group of people so it leads to kind of more short term thinking and trade offs that you have to make, which doesn’t exist in the system like Sweden. However, I do believe that we are seeing improvements on this by implementing technological innovations because it’s not actually only a long term improvement but also a lot of short term benefits.. To get to where Sweden’s numbers are, I do think it will take a sort of a deeper look at what are the keys? What are the incentives that are misaligned in the American systems? That is another 3 to 5 hours conversation that we can have.

The three intersections of capitalism and health care delivery are not ideal that I think is one of the challenges and a readjustment in terms of the incentive being the outcome. You know, somehow the incentive being attached to a patient and their health and welfare generally is I guess idealistic which is the direction that a US style system needs to look at. 

But what I’m excited about is the movement in the US around consumerization of healthcare, giving more power to the patients to pick the provider that they want to. That is a huge force to  improve quality and reduce the cost of healthcare.

I thoroughly enjoyed the conversation. Before we finish off, would you like to share with us anything regarding Steady Health like where you’re heading and anything else that you think the listeners might be interested in? For example the model you’ve got and what you’re doing currently?

I would like to say to all of our listeners that if you’re interested in what we’re doing, you can find us on steady.health and we’re live in California since two weeks ago, also in the state of Washington where we just launched. We have this amazing new startup program that lets you try the steady care model and get a prescription for two CGM’s for five weeks and see what kind of connected care which we call it, looks like and feels like, and how different it can be. We really want to make Steady into the best and the largest endocrinology clinic in the country. So if you’re in one of these states and want to be the  early adopter, please join the sort of hundreds of people that have joined already. 

Henrik  thank you so much for your time. Definitely we wish you well and to your friends and family as well. Thank you again for your time and look forward to following your progress. 

Thank you Pete, I  really enjoyed this conversation as well. Hopefully we get to meet in person someday. Thanks again!!