Taking New Technology from Research to Commercial Scale: The SureAdhere Story with Dr. Richard Garfein and Dr. Kelly Collins

This transcript was generated by AI and may contain typos and inaccuracies.

Amie Vaccaro: Welcome to High Impact Growth, a podcast from Dimagi about the role of technology in creating a world where everyone has access to the services they need to thrive. I'm Amie Vaccaro, Senior Director of Marketing at Dimagi and your co-host, along with Jonathan Jackson, Dimagi's CEO and co-founder. Today we share the how I built this story of SureAdhere, a company that Dimagi acquired last year. This is the story of how an idea can move from research and academia to commercialization, told by SureAdhere's founders, Dr. Richard Garfein and Dr. Kelly Collins.

Dr. Garfein is an infectious disease epidemiologist, healthcare innovator and educator focused on understanding disease causes and translating research into impactful solutions. Dr. Kelly Collins, who you've heard from once before on the podcast, was a co-founder and the first CEO of SureAdhere before getting acquired by Dimagi. As a social entrepreneur and infectious disease epidemiologist, Kelly's career mission has been to support the implementation and scale of evidence-based, high-impact digital health interventions globally. Enjoy.

Welcome to the podcast, Dr. Richard Garfein and Dr. Kelly Collins. Really excited to have you here today. So I want to start with you, Dr. Garfein. I want to hear a bit about your background and what led you to working with infectious diseases. Yeah, thanks, Amie. Happy to talk about it. So I started out as a researcher in HIV and viral hepatitis back as a graduate student in Baltimore many years ago. And was primarily interested in understanding how these diseases are transmitted among high-risk populations and figuring out ways to prevent transmission.

And that led me to a position as an epidemic intelligence service officer at the CDC. And I did that for the two-year fellowship in the division of viral hepatitis and learned more about working with vulnerable populations and learning about the system at the federal government. And then I stayed on an extra six years in the division of HIV-AIDS prevention, continuing to work with vulnerable populations and developing recommendations and guidelines that were promulgated by the CDC.

And, you know, these guidelines are very important, both for health departments in the United States, but actually they're used by programs around the world as guidance for how to implement public health practice. And they're all based very heavily on evidence. So the CDC would not make guidance recommendations without evidence to back it. So that was a really important part of my background in public health, really understanding how that system works. And then I moved to UCSD in 2005 and joined the faculty.

And while I was there continuing to work with these vulnerable populations and bloodborne viral infections, it became clear to me that even though we don't think about tuberculosis much in the United States, because we've done such a good job of controlling the infection, in other parts of the world, the disease is very prevalent still. And I learned that between the U.S. and Mexico, Mexico has about twice as much TB as the United States. And when you look at all the states along the border, the border states have a higher incidence of TB than the rest of the countries on both sides.

And then when you dial down to San Diego, San Diego and Tijuana have the highest rates among those two countries. And so that kind of said to me, well, this is something I need to pay attention to. And it's also an infection that affects vulnerable populations who live in shelters and congregate settings. And so I started doing some research on TB and we did actually find quite a bit when we started looking for it. But what was really sort of driving my interest in this area was the occurrence of drug resistance for TB.

And that occurs when people don't take their medication consistently and correctly and the bacteria mutates and develops resistance to the drugs. And then you need to start using other drugs to treat the disease. And so that kind of what led me down the path towards Video Dot was this interest in TB and particularly drug resistant TB and how that caused by improper medication adherence. And can you talk us through a bit of what was TB treatment like in these days and why did you see a need for it to change?

Sure. Well, the important part about treating TB, as well as other bacterial infections, where resistance is a problem. Is that instead of treating with one drug, we treat with multiple drugs. And in the case of TB, it's actually you start with four different drugs. And the reason is that if a bacteria mutates, it's going to develop a resistance to one of those drugs. But that's OK if you've got other drugs on board, because then the other the other medications will kill the bacteria and you don't develop resistance.

The problem is when you treat with one drug at a time, those those mutations form, the bacteria becomes resistant and and then you switch to another drug and then develops resistance to that drug. And then you have producing you've got a strain of bacterium that's resistant to multiple drugs. We call that multi drug resistant TB. So the way that we handle that is by starting the patient on a regimen of multiple drugs. And in the case of garden variety TB, non drug resistant TB, we start with four drugs for the first two months and then after two months of daily treatment on those four drugs, then it'll switch to daily treatment with two drugs.

And that goes on for six months. And that's sort of at a minimum. Sometimes patients have to stay on treatment a little bit longer if they don't respond appropriately to the medications. Now, in the case of drug resistant TB, in that case, patients can't take those original drugs because they don't work. And so other drugs are used. And the problem with these other drugs is patients need to stay on them longer, typically nine months to a year. They're less effective against TB.

They have worse side effects and they tend to be harmful. And some of these medications have to be taken by injection. So the patient actually has to go to the doctor every day and get painful injections, which can make it really difficult to get a patient to want to continue taking meds. So in order to help the patients to ensure that they're taking the medications every day as prescribed so they're not missing and then potentially creating new drug resistance. The health departments have recommendations by the World Health Organization and the CDC have developed a method called directly observed therapy.

And what that means is that the patient takes the medication in the presence of a health care worker every single day. And in the United States, we have the luxury of having not too many patients with TB and more resources. So typically the health care providers go to the patient's home and they watch them take their meds every day. And at the same time, they can kind of check in on the patient and make sure that they're doing all right. But in low and middle income countries where the resources are less, the patient actually has to go to the clinic to get their medication.

So you can imagine in both of those scenarios when the two people can't be at the same place at the same time, the question is, does the patient take their medication at all? And if the patients are going to a clinic, for example, if they can't make it, that means they didn't take their meds that day. And so you're sort of creating the potential for drug resistance with this process. And so tell us a bit about, you know, what were some of the early studies and results you saw?

Like you saw that directly observed therapy was the standard of care, but it was quite challenging for many reasons. Tell us about some of those early studies. Yeah, sure. Well, we were really interested in trying to figure out how to improve adherence. And around that time, I had read a paper from, it was a small pilot study that was done in Kenya. You know, if you think about it, this is in 2009 and, you know, the iPhone apps really were being rolled out in around 2007. So iPhones weren't kind of what they are today.

Same with Android phones as well. And what this study did was that they were asking patients to make a video of themselves taking their medications and in rural parts of Kenya. And they did that for a small number of patients. It was less than 20, I believe. And they showed that patients were actually willing to do it. And it seemed to be feasible. But that research never went anywhere after that. And then I was talking with our health department in San Diego and learned that they were actually using these old landline based video phones.

We affectionately like to call them the George Jetson phones, where they are doing synchronous video conferencing like we are doing right now. And they would meet with the patient every day and have them turn on their video phone and they'd watch the patient take their medication remotely. And that worked really well for the health department. And they had a number of patients on them. But it turns out that the device itself wasn't the phone. On iPhone it was a box that they brought to the patient's house and they plugged it into their landline and they set it up.

And they had one back at the health department. And it was cumbersome and clunky. And what happened was the company went out of business and they couldn't get replacement parts. And so they were having a hard time continuing to do it, even though it worked quite well. So that's where we came in and we said, huh, this looks like a great idea. I wonder if we can do this with smartphones and mimic this and make it a little bit more accessible. So we wrote a grant proposal to the NIH and we got funding in 2010 to do a pilot study.

And through that pilot study, we did focus groups and interviews with patients and providers to see what they thought of this idea and if they would even be willing to do it. And at the same time, we had some engineers at the Qualcomm Institute at UC San Diego who worked with me on developing an app. And interestingly, we were originally trying to do a synchronous form of video dot, like to mimic what they were doing with the landline phones. And it turns out that we kept saying, well, what happens if they don't have a good connection and what happens if the person misses their appointment time and what happens at this?

And the solution was always, we'll just have the patient make a video. And then it turns out we decided, well, why don't we just do it all with video? So we ended up creating the app so that it was purely asynchronous video dot. And in that process, we had to think about, OK, how do you train the patient to make the video and show what we need them to show and make sure that they're not shaking the pills and hiding them and spitting them out later? How do you do this whole process?

So that's where the research really came in is using the app and trying it in different ways. So with that first pilot study, we ended up, we wanted to show that the technology would work both in high and low resource settings. So we decided, you know, being on the border with Mexico, it would be very convenient to be able to do a study in both locations. So we recruited patients in San Diego as well as in Tijuana, and we trained the health workers in both countries on how to use the app.

And they did it for six months with the patients through a whole course of treatment. And we found out that it was very acceptable to patients and the providers. It was feasible. We can make it work and overcome any problems. And the patients all liked it. A hundred percent of the patients in both arms said they would be happy to continue to do it or to recommend video dot to other patients. So we said, I think we're on to something. And so from there, we received a grant from the California Health Care Foundation.

And with that funding, we were able to recruit 50 patients in New York City, San Francisco and San Diego and do a similar type of a pilot to show that it would work not just in San Diego, but in other metropolitan areas. And we found similar results with high rates of acceptability and feasibility and high rates of completion of treatment. And then we received a grant from the Verizon Foundation, who generously donated phones and service and some funding to us. And we were able to look at how video dot would work in rural settings versus urban settings.

And rural settings are really important because if you have a nurse driving to a patient's home, they're traveling much further. And so we wanted to make sure it would work there. So we did that in five different counties in California. And again, found really high rates of feasibility and acceptability. In addition, we also found a large cost savings by doing the study or by using video dot compared to in-person dot. And then at the same time, the National Health Service in the United Kingdom through the College of London received a grant to do a randomized controlled trial of video dot versus in-person dot.

And so they contracted with us to use our technology and they ran the trial. And in that study, they found that over 90 percent of the doses of treatment were observed in their trial among the patients using video dot. And they found that 70 percent of the video dot patients completed treatment compared with 31 percent of the patients that were not on video dot. So very big increase in efficacy. And then they also found a very large difference in the cost of big cost savings using video dot.

So all this evidence is sort of, you know, compiling. And that evidence was really important in helping to drive the guidance documents. So, Richard, just to hone in on what you said there, I think it's often viewed as digital health or these digital technologies can approximate, you know, current standard of care or can help augment it. But in this case, you're saying the patients actually had better outcomes. So introducing this technology was actually an improvement on the clinical outcomes and presumably also an improvement in the patient experience.

Is that correct? Yeah, I would absolutely agree with that. Interestingly, when we first began this process, what we learned was that patients develop a rapport with their providers. And that rapport is so important because, you know, when they first are diagnosed, they're sick and they start taking the medications and they feel better. And so they're motivated to take their medication. But then once they feel better, now they're told, but we want you to continue taking these medications for another four months or so.

And they're going to make you feel sick. You're going to have side effects from them and it's inconvenient and it's a bother. And so keeping the patient motivated was so important. So the providers are just immensely important in maintaining that kind of high level of adherence. And what we learned was that after six months of being on treatment, when the treatment was over, patients oftentimes missed their providers. It's like, I've had this friend for the last six months that I've been seeing every day.

We have coffee and, you know, we meet, chat, and now it's over and I'm going to miss them. So not only did the providers talk about that as being a potential problem with VideoDot, the patients also expressed that as well. And what we learned was that the patients could still have access to their providers. And that's super important. We wanted to not replace the provider with VideoDot, but to make VideoDot a tool that the providers can use to make, to avoid all those times when it would be inconvenient for the patient and provider to get together.

So, you know, send the videos and they can do that any time of day. They can do it, you know, at 10 o'clock at night before they go to bed, which they wouldn't be able to do synchronously. Or they could do it on weekends when the health department is closed and the nurses aren't working. So we found that this tool really helped to remove some of the barriers to doing directly observed therapy that the patients were experiencing, but they still had access to their providers. So that's something that we actually want to think about moving forward is how do we improve the technology to make sure that we're enhancing that relationship.

That articulation you just had of making sure it's enhancing and augmenting that provider relationship is really part of what drew me to share it here as well as we started our initial discussions. Before we jump to that story, I know that regulatory approval and WHO guidance is a huge part of TB in general, whether it's drugs or therapies. And your work has been instrumental in informing guidance both in the United States and globally. At what stage and at what level of evidence did this start to get on their radar and did you really start to ramp up those discussions with WHO and others?

Yeah, you know, as an academic, you know, publication is the coin of the realm, as they say. And so we do the research, but it doesn't really mean anything until you get out there and you publish it, you make other people aware of your findings. And part of that process is going to conferences and meeting with colleagues and presenting the findings. So I was able to present these findings at the National TB Controllers Conference in the United States. And then there's an international conference that occurs every year called the World Union on TB meeting where people from high and low income countries get together and we talk about TB and how to solve the problems.

And so I was presenting at these conferences and I was meeting with other colleagues and hearing about other technologies that were being used. So in addition to various forms of video DOT, there were other technologies that were coming out. And so we sort of all started to talk about what we were doing and how we were using technology and commiserating about the problem of people saying, well, that sounds good for the United States, but it'll never work in India because not everybody has a phone.

And we kept saying, well, we'll get there. So it's just this sort of sharing of ideas and sharing of information. And the World Health Organization, along with the Stop TB Partnership, started paying attention to what was happening. And the World Health Organization put together a global task force on digital health and started looking at these technologies and asking the question of, well, do we have enough evidence yet? Can we start to make recommendations to use these technologies?

Where are the gaps in what we know and what new research should we do to make sure that we can make recommendations based on evidence? And I think my experience working at the CDC and actually writing these kind of guidance documents, I was always very sensitive to the fact that I don't care how good your technology is and how slick everything is until you actually have the evidence. They literally, their hands are tied. They can't make these recommendations. So that was something that I worked hard to try to help them to produce and to provide the evidence and also to find other people that were doing similar research to be able to combine their knowledge as well.

That's great. I can't imagine how fun it is to attempt to promulgate new regulations based on evidence-based with the WHO and others. That sounds like difficult work, but also, you know, in some ways that's the point of research is to really, you know, affect this evidence base and see change. The other part of seeing that change is having a scalable product that can reach, you know, a wide audience. And I imagine that's where you started thinking about the academic setting versus a commercial company and SureAdhere came onto the scene.

So talk to us a bit about, you know, what led to the decision to start a company and then Kelly would love to hear, you know, from you and how you got involved and then came to be the first CEO. So it was interesting how this happened. We first got our grant funding and we went to our health departments in San Diego and San Francisco, New York, et cetera. We met with them and told them about our technology and tried to convince them to participate in the trials and to recruit participants and be engaged.

And it was a bit of work at first because as they said, the program directors were on board because they saw the potential benefit. But then when we started talking to the nurses, the actual people that were engaging with the patients, there was a lot of skepticism. There was a lot of concern about losing their jobs and losing the connection with the patients. And so we worked with them carefully and had a lot of meetings with them. We'd have weekly meetings to talk about how things are going and troubleshoot.

And it turns out that when the studies ended, we had to go back to the site and say, all right, we're all out of, you know, we're out of funding. And they were saying we have to stop the project. They were really disappointed because they wanted to continue using the technology. So at first we tried using some contracts through UCSD as service contracts and providing the service. And it was difficult because it's not just a software package. You actually have to run the software on servers and you have to maintain the system.

And it had to be HIPAA compliant. And it's not something where we could just hand off some software to a health department and then they can spin it up and run it themselves. So we did that for a little while, but it turns out that it was very cumbersome in terms of contracting with health departments, working through a university, and it was expensive. And so I started talking with a mentor of mine, Bill Coyne, who was just sort of guiding me in terms of, is this something that we can turn into a business?

Would it work better if we did it as a commercial enterprise? And we didn't know how big it was going to go or where it was going to go, but we bantered this around for over six months. And finally, I think he was convinced and he said, you know what, I'll do this with you. And so he ended up becoming my first investor and my partner in starting this business. And so we licensed the software from UCSD and we started SureAdhere Mobile Technologies. And we ran it as a company and we signed up health departments to use the technology.

And it worked out really well. I mean, it was slow to get started, but we had our first few clients. We learned a lot about what it means to get contracts from health departments, which are complicated because they're government agencies and they've got a lot of rules around them. But we managed to work that out. So, Kelly, I know you were also doing a doctoral program in global health. So take us through your background and then how you came to be in this sphere and running SureAdhere.

Yeah. So thanks, Iwi and Dalton for having us on this podcast. It's fun to talk about this. I'm going down memory lane with Rich. But Rich is my mentor, my Ph.D. mentor at UCSD. And so I was part of his research team working to coordinate the video dot studies on the ground. I had really been kind of this boots on the ground person who had been into integral from talking to nurses, understanding their needs, taking it back to engineers. And kind of doing that very early user centered design with the health departments.

And in addition to the rest of our research team at UCSD. And I was also helping Rich write papers on the subject as a doctoral student. You do a lot of that. And it was you know, I was really dedicated to the cause of trying to see this through as a doctoral student in global health. It was really important to me to see interventions going not just from academic work, but to understanding, you know, how can we actually get them out to the broader public. And create access. And so when I understood that Rich was going to be spinning shirt here out or spinning video dot out of the university, I got really excited.

And I, you know, voiced my interest in potentially continuing with them as they started to do this work. And what was fun for me is that I had again, I had the most knowledge of the technology at that point being, you know, that very in-depth working with the engineers. So I understood very deep, you know, where the bugs were in the platform, how the app worked. And I could explain it in a way that was actually made a lot of sense for me to go on and start selling it as a product.

And so, you know, I was brought on pretty early before the first client of shirt here. We were working on an RFP for New York City and Rich and Bill brought me into the hold and I helped bring New York City on as our first client. So it was exciting first couple of months, a lot of work and trying to understand how best to roll this out to health departments that came on as I was graduating with my doctorate from UCSD. Yeah, I think a really important aspect of why we felt like Kelly was just the perfect person to come in and lead the company was the fact that she really did have hands-on experience training nurses on how to use the app and troubleshooting with the patients when they're having difficulty with the app.

And so she understood the technology, but she also had a really keen sense of what the patient and the provider were going through. So she knew the target population that was going to be using the technology. And so she was able to put those two together. In addition, she also really understood the evidence and how important the evidence was. So she was able to talk clearly about what makes VideoDot work and bring in that those insights for how it was being used in other locations and how it could be made better.

And so she had just like so many amazing perspectives on the technology, on the patient and provider side, on the research that she was like the perfect package of everything that we would have wanted in a representative for our company. And it really worked out well. And, you know, we were super excited when the company was feeling some pain points in terms of how to scale and how to expand. And she introduced us to Dimagi and we learned how the goals of Dimagi fit so well with ours that it just worked out to be a perfect partnership.

Well, I strongly agree with that, Richard. And in my experience, you know, after the first call with Kelly, I kind of wrote to our team and I was like, she's one of us, you know, she's a global health diehard. She speaks tech. She, you know, understands the evidence. So I completely agree in starting a company, you know, this level of impact in this complex of environment is extremely challenging. You just mentioned multiple different disciplines you have to be good at to see the scale and that's generating the evidence base, knowing how to talk to the regulators, knowing how to sell the government, both in high income markets and in global health and build a product and ship that product and expand that product.

All of these being very difficult things to bring together and all of which, Kelly, you've done an amazing job at leading. So take us through some of those stories. I mean, what was it like trying to get this off the ground? How did the expansion into global health, you know, after landing that first contract in New York City? Right out the gate, as we were starting to expand in the U.S., health departments started coming to us directly when they found out that we had a product that was not available because they'd seen us speak at conferences and we're going, oh, you can buy this now.

So it became a much more sort of inbound sales effort in the U.S. where we could turn contract based on tiered pricing. But outside of the U.S., the evidence base was still fairly thin. And I think that even the early WHO recommendations were conditional on setting. And they said, look, if, you know, if the connectivity technology is available, then it could be used as a viable alternative. But really, that didn't that wasn't the case early on with, you know, most TV settings.

So we really spent a lot of time working in collaboration. For example, the Stop TV Partnership, they funded TV reach grants that looked to build the evidence base and low resource setting context. So we did work in Uganda and the Philippines, South Africa, Ukraine, Vietnam, Kyrgyzstan, a number of places where we said, look, we need to get the evidence to show that, yes, this can work in low resource settings if the patient has access to a phone. And I think what we started finding, which is exciting, is in urban areas where patients were starting to gain access to smartphones, the technology worked very similarly to how it works in the U.S.

As long as the patient was comfortable sending a video, the process was very similar. Where we have seen inequities is really where smartphone and connectivity access exists. And so I think that that's an important consideration that we still deal with, where we understand that VideoDot may not be appropriate for all settings or for all patients. And that's completely fine. And we have never tried to sell it into a setting where it doesn't make sense. I think we've always tried to say, look, let's deploy this technology where it makes sense, where it's acceptable, feasible, and there's access to the technology and then find different interventions that can support patients in other settings.

In 2022 and 2023, you had really exciting changes to some of those guidelines and regulations. What is kind of the standard of care now, both internationally and in the U.S. with respect to these video observed techniques or digital adherence in general? Yes, so in 2022, actually based on a study that was conducted by the CDC in collaboration with New York City, they used the SureHear platform to conduct their randomized controlled trial that was looking for non-inferiority between VideoDot or EDOT, as the CDC calls it, and in-person DOT.

And they looked at both live streaming EDOT and recorded or asynchronous VDOT. And what they found was fantastic. They found that EDOT was non-inferior to in-person DOT and actually the patient preferred the VideoDot almost across the board. So exciting from that perspective to have when the study being conducted where they can come out definitively say this technology is as good or better than in-person DOT. And what happened as a result of that is that in 2022, WHO was able to strengthen their guidelines around VideoDot and say that it could be a stronger recommendation around VideoDot taking the place of in-person DOT where connectivity technology is accessible.

And then CDC came out just in 2023, a few months ago on World TB Day to say that VideoDot is as good as in-person DOT and essentially gave health departments carte blanche to roll out VideoDot as their standard of care, as a tool in their toolbox, if you will. So really excited to see these recommendations come. So now health departments can actually make a real decision to move forward with this without having to wonder if the evidence is there and, you know, just pick this up as they would any other tool.

And Kelly, if I could just add one piece to that is that health departments, state and local health departments depend on the CDC guidance to determine what interventions they will implement in their programs and what can be funded. So oftentimes there is funding that comes down either from the federal level or the state level. And the funding is restricted to interventions that have been shown to be effective or that meet guidance. So having CDC guidance that allows for VideoDot really sort of opened up the door.

Well, that's great. And congratulations to you both. I think having gone from, I guess, Richard, you said 2009 to, you know, established international guidelines and national guidelines is a pretty quick trajectory for technology. And I think it's amazing that you've been able to, along with others, demonstrate this field and technique that really is improving the patient experience, saving money, improving clinical outcomes. That's really awesome. Which brings me to part of the narrative that I'm really excited by, which is why Dimagi and SureAdhere thought it'd be great to partner together to further expand this technology.

Richard, you alluded to this earlier. Kelly, I know when we first started talking, it was during COVID was still, you know, all around us. And so SureAdhere, while the history came from a strong focus on TB, has expanded much more beyond TB. So can you take us through just how it came to be used for these other use cases? Obviously, Richard, you mentioned how telemedicine became much bigger during COVID. But even prior to that, I think you were looking at other use cases and then since then. So aside from TB, where else have you tried to apply this technology and where are you excited to bring it?

Yeah, so we almost, I guess, out the gate when we started working from a contract perspective, you know, actually being an enterprise as opposed to working outside of the university, started giving inquiries on using SureAdhere for different types of use cases. I think we started initially with depression medications. And one that was really interesting to us was supporting patients on medication assisted treatment for opioid use disorder. So we worked with the Howard Center in Burlington, Vermont, and a pilot study that has since expanded into a statewide project in Vermont.

Our team in the UK has supported hepatitis C patients using VideoDot, especially patients who are vulnerable or substance using populations, homeless populations that need strong support for their hepatitis C medications. We saw a paper came out recently in the U.S. to this effect as well. And then also moving deep into clinical trials, so supporting medication adherence and compliance to protocols for clinical trials. So really excited to see these use cases started gaining traction, catching on both in the U.S. and internationally and finding deep resonance with the type of support that SureAdhere can provide.

That's great. And I think, you know, we first started talking in 2021 about the potential for SureAdhere to be acquired by Dimagi. And when I first heard about the technology and all these amazing use cases, I was really excited by the potential because, as you said, I think there's so many different ways this could be applied to other medical domains. But most importantly, I think it was something you alluded to earlier, Richard and Kelly, this came through loud and clear on our first discussion.

This was a way to augment the incredible work that our public health professionals, nurses, doctors are doing to support patients. And it's something that helps the patient experience as opposed to gets in the way. I think so many digital technologies today sound good on paper. And there's, you know, knowing for both the doctor and the patient and kind of make the patient experience even worse. And Exhibit 1 in the U.S. is unfortunately a lot of what medical record systems have become here.

And I think the goals that SureAdhere has had this whole journey have been amazing in terms of really honing in on improving that provider experience, improving that patient experience. And that's why I felt like this partnership between our organizations could be so strong. And when we were in these discussions, Kelly, I think a lot of that ethos of like what is really going to help public health professionals. It's not kind of replacing the public health workforce. It's not replacing public health nurses and trying to come out with telemedicine apps for everything or verticalized apps for everything.

It's these core foundational technologies like SureAdhere that give a capability to a health department and to a government that can be applied to multiple disease verticals in order to really supplement and assist our incredibly burned out and limited workforce. And I was really struck by just the potential of what we could do with SureAdhere. And that's when we started talking two years ago. And you've already done a lot to go after specific new marketing clinical trials. I'd love to hear how that came to be.

And done a lot to add new capabilities into the platform that are really going to be just amazing value add for our ecosystem of existing users and a lot of new users who have started to approach us. So we'd love to hear how you got started with clinical trials and then also what you're excited about coming up in the product. Yeah. So I think a lot to unpack and not done. But I got personally very excited about the demaggy when I saw that demaggy had started moving into the U.S. during covid and trying to understand, OK, you know, from a market perspective, we're both working outside of the U.S.

because we have a mission for public health and really to support the global health workforce with digital tools, but also in the U.S. And I think what was really surprising to most of us, maybe not those of us on this podcast, but many in the U.S., is that the U.S. was actually needed support in our public health infrastructure from a digital perspective and that they were still using things like fax and paper records. And actually, many of our health departments still are using fax and paper records. Using these older tools, you know, our goal was always to help move the public health infrastructure into sort of the 21st century and give them those tools to, you know, adopt and make their jobs better, which I think that was always our goal. How do we ease the burden on those providers?

And so seeing demaggy move into this space as well was exciting to me. And I reached out to Richard and Bill Coyne and said, look, these guys are moving into the U.S., we need to be partnering with them. They're so mission aligned. And I think that getting introduced to demaggy, we felt the same way. Like we all speak the same language. So really exciting. And I think, you know, as we came into demaggy last year, with the addition of sort of folding ourselves into demaggy's operations, we really started focusing on how do we augment the technology going forward.

So VideoDot was designed as an intervention to not necessarily to replace the interaction. Right. It was to replace the method of the interaction, but not to replace the interaction. And so we've always seen VideoDot as a support tool for patients. And so what we're really excited to do now is to go from sort of this one way interaction of a patient sending a video to a health care provider who only sort of reaches back out, you know, if and when there's a problem to create these feedback loops that can take place within the technology.

And again, continuing to make the platform a simple method of reaching out to the patient rather than having to go through cumbersome multiple methods of reaching out to the patient. So for example, in sort of our early VideoDot days, the patient would send up a video and then the provider would either need to call or schedule an in-person visit outside of the platform to reach out and then support that patient. What we're really excited about is adding additional new virtual care tools to the platform that will allow the provider to reach out directly to the patient from within the platform, create these digital feedback loops that enable the patient to then, you know, reconnect with their provider.

And then this support has seen and then captured in terms of a record within the system. So we're really excited about what's next and that perspective. I think that's also opened us up to really expanding our capabilities in medication assisted treatment and opioid use disorder, because the context is similar in the sense that patient needs support for medication adherence. But the patient's experience is so different in TB versus OUD. And so really trying to understand how best we can use the technology in those spaces and, you know, contextualize it to the patient population is really important to us.

So especially in MIT, I think this is going to be really fantastic expanded use case for us. And then in the clinical trial space, protocol compliance is incredibly important in the clinical trial space. And many of the technologies that are currently out there are every from a monitoring perspective. You know, MEMS caps, for example, can capture whether or not the patient opened their drug container or not. Great for as a proxy for adherence. But VideoDot goes further. It allows us to capture additional data, additional rich data sets that say, you know, did the patient dispense the right amount of drug? Did they take the right amount of drug? Are they using the drug correctly?

And all of that can be captured on a video, whereas, you know, a medication monitor can't capture that type of information. So I think with VideoDot, we're allowing trial sponsors or sites to more deeply understand what's going on with the patient in a day to day basis, as opposed to just having this very proxied measure of adherence. Yeah, I think if I can add something there also, what Kelly said about it's a video. And so the video can contain anything you want. And so it can contain somebody opening up a pill bottle and putting a pill in their mouth and watching them swallow it.

But it can be also used for a number of other things. There's other applications in clinical trials that can also take advantage of video, observing a trial participant, enacting a behavior. And so it's not limited to just taking pills. It's really open to quite a number of things. And the other thing that I would just like to add in terms of what Kelly was saying about patient support is that when we when we think about health department, they're always cash strapped. They're always doing more with less. And they needed resources to make that job easier and more efficient.

And so we learned with Video Dot is you can spread the resources over an entire population of patients where everybody gets a little bit of attention, even if they don't need it. Or with Video Dot, what we found is that the patients who are going to take their medications anyway, and they would send their videos and routinely do what they're supposed to do. They can be sort of left alone, whereas the patients who needed help, the ones that were not going to take their medication on a regular basis that needed support, whether it was clinically or socially or whatever, those patients could get the extra support because the nurses didn't have to divide their time between somebody.

So what we realized is that it's a way of reallocating resources more efficiently, more effectively. And I think that what the Maggi is talking about doing next with using more technology to help to provide better care to the patients through technology, giving them what they need and also freeing up the providers to give more attention to the patients that really need more of the hands on approach. And just to add one additional piece, I think we talk a lot about compliance and the provider side, and these are critical factors.

But also for those of our listeners who have experience as a patient within these systems, it is incredibly hard to schedule visits. It's hard to get in. It's hard to park. It's hard to do just everything having to do with accessing health care. And that's time away from your family. That's time away from your job. That's time you're not able to spend on yourself and on doing other activities. And so that's one of the things I love about these use cases and the technology is not just, you know, all the great things we've talked about, too, but simply just enhancing that patient experience and trying to, Richard, as you said, allocate the time where it's needed most and create efficiencies where you can.

Obviously, some patients need a lot more support than others and they should absolutely get it. But for the patients that want to use just the video component and it's totally sufficient for what they need, that's great. And then the resources can go where they're needed the most. And, you know, the results, Kelly, that you shared with medication assisted therapy for opioid use disorder, this patient population has an extremely difficult time potentially finding work that's appropriate, transport that's easy.

And so this can really be a game changer in terms of the ability to stay on the regimen involved with the health care setting and make it appropriate to where they're at in their lives at that point in time. And so that's just a huge win for what technology can be doing supporting these patients. And one of the reasons I'm super excited to continue expanding the technology to all these other areas. So, Kelly, last question over to you. What are you most excited by and looking forward to going forward?

Well, I think what you just mentioned, John, is my team is really focused on how can we both empower patients and empower providers? I think from the patient perspective, we want to empower them to be people again and get back to their lives, do the things that they need to do, be students, be moms, be dads, you know, be employees. So they're not having to focus so much on this acute health care condition that they're dealing with, but actually focus on their lives and then get back to it.

So I think that's our goal. And then, you know, from a provider's perspective, we're excited to continue empowering them to adopt new tools, make their jobs easier, make their work more efficient so they feel like they can get more done and not feel so stressed. And I think, you know, hopefully deal with some of the burnout that many of our amazing health care workers have faced over the last few years and really difficult as public health nurses and those working in substance use fields to support people.

You know, burden of disease has gone up and so we need to find ways to support these health care workers. So empowering patients and empowering health care workers, I think, is really our big next step. This has been such a fascinating conversation. And Richard, really thank you for joining and Kelly as well. I learned a lot. And I also just saw so many of those parallels between SureAdhere and Dimagi and just really reinforced why this partnership makes so much sense. And I'll just give a plug that we're going to have a few other episodes coming out. This is the first in a three part series focused on VDOT and SureAdhere. Our next conversation will be featuring a conversation with a tuberculosis patient who's been using VDOT and their experiences.

And we're also going to have an episode really digging in on that future of the SureAdhere platform with Kelly. So you'll get to hear more about that future that we've been alluding to today. And thank you so much for joining us. I'll share a few of the things that struck me from that conversation. Video directly observed therapy and what eventually became SureAdhere was born out of the desire to solve a very specific and extremely challenging problem. And it's now serving to be a lot more broadly useful. The technology is useful globally in both high income and low and middle income settings.

We heard some of the challenges of scaling in different markets and contexts and how SureAdhere had to consider different value props for different contexts. At the end of the day, they've created a technology that's globally useful with global impact potential. One of the things I love most about this story is that digital is additive in this case. This is not a story of using digital to dumb down a patient experience such that patients are getting lesser care, but for cheaper and faster.

SureAdhere actually leads to a richer, improved patient experience while allowing both providers and patients to save money and allowing us to get more impact for precious health care provider time. I also see clearly in this story the importance of following the evidence. The decision to start a company based on this technology was made only once the evidence was in place to prove its efficacy. And that starting a company was clearly the best path to getting this technology into the hands of health systems and providers who are demanding it.

That's our show. Hope you enjoyed. Please like, rate, review, subscribe, and share this episode if you found it useful. It really helps us grow our impact. And write to us at podcastatdemangui.com with any ideas, comments, or feedback. This show is executive produced by myself, Danielle Ovenwick is our producer, Brianna De Roos is our editor, and cover art is by Sudhant Chukan.