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How the Tidepool Data Integration Platform Can Ease Diabetes Management: Our Interview with Tidepool CEO Howard Look.

by Adam Brown and Alex Wolf

Twitter summary: Interview w/ Tidepool CEO Howard Look on how device data will ease T1D burden; @JDRF, Insulet, Dexcom, Asante already on board!

Short summary: The diaTribe team recently interviewed Tidepool CEO Howard Look. Tidepool is a diabetes non-profit organization that has developed an open-source data platform, allowing apps such as “Blip” to integrate data from multiple diabetes devices all into one place. Mr. Look – a parent of a child with T1D – discusses the need for data integration, what challenges exist for Tidepool, and its ambitions for the future.

Earlier this year, we wrote a conference pearls piece about Tidepool, a non-profit organization that aims to use its open-source data platform to make diabetes management simpler and more accessible. One of Tidepool’s applications, Blip, is a web-based program that integrates data from all kinds of diabetes devices (CGMs, meters, pumps, etc.) on a single, sleek interface (see more pictures of it here). Tidepool is also developing an innovative “Universal T1D Device Uploader” tool to make the data import process easier, and today, announced a partnership with JDRF to accelerate development. Tidepool has already made official partnerships with Asante, Dexcom, and Insulet. The Blip program can currently integrate data from Medtronic and Animas devices as well (though these are not official partnerships). Tidepool plans to make all of its products available free of charge.

Data uploading has historically been unpopular in diabetes due to the hassle it can cause, but Blip allows patients to access data from multiple products and brands (e.g., an Asante insulin pump and a Dexcom CGM) all in one easy-to-use platform. UCSF is currently hosting a pilot trial of Blip (to enroll, please visit this page), and Tidepool hopes to have a market-ready version of Blip, the Universal Device Uploader, and the Tidepool platform by the end of 2014. These products will need FDA approval, so they likely wouldn’t be widely available until 2015 at the very earliest.

As a non-profit organization, Tidepool seeks to collaborate with industry, rather than compete with it. The organization gained full 501(c)(3) non-profit status this June and recently partnered with the JDRF. The diaTribe team recently sat down with Tidepool CEO Howard Look to learn more about Tidepool’s mission, foreseeable challenges, and goals. Mr. Look is the parent of a child with type 1, and we admire his passion and commitment to improving diabetes care.

Q: What has been the biggest challenge in bringing Tidepool from just an idea to its current stage?

HOWARD: Funding. Fundraising as a non-profit is much more challenging than I anticipated, and very different than my prior experience doing startup fundraising through the usual Silicon Valley, for-profit, venture capital channels.

But being a non-profit was, and is, the right decision for us. We could not have made the progress we’ve made as a for-profit entity. We would have been threatening to the industry, who would have thought “Wait, if there’s value in liberating the data, then I want to keep it to myself!” That’s how we got into this mess of closed, vertical and proprietary systems based on terrible software.

Only 6% of people in the T1D Exchange upload their data on a regular basis, and only 30% of people with type 1 diabetes use pumps or CGMs, despite clear evidence of better therapy and outcomes. By liberating the data and making software that is much easier to use, we can make it easier for doctors to prescribe devices and easier for patients, parents, and doctors to engage with data, make more effective therapy changes, and overall reduce the burden of managing type 1 diabetes.

By being a non-profit, we are able to credibly say to the industry, “This is better for everyone. This will help make your devices more valuable, and it will grow the overall market. And we are good at building software, so please let us for type 1 diabetes.” Being a non-profit allows us to truly deliver on our mission of helping everyone with T1D.

Q: Thinking about what you have learned, what advice would you give to yourself if you were to start over again?

HOWARD: Maintain laser-beam focus on delivering a “Minimal Viable Product” as soon as possible, getting feedback early and often, and iterating as quickly as possible. We did a pretty good job at this, but we can do even better.

Q: As you look at your product roadmap, what is your biggest current challenge?

HOWARD: From a product development standpoint, nothing we are doing is rocket science. This is all very straightforward software development. Silicon Valley delivers great software with a great user experience routinely; it just hasn’t had a focus on type 1 diabetes before.

Really, our biggest challenge in delivering great software is funding, again. Nearly everyone working at Tidepool took a significant pay cut to work at a non-profit. We have no stock options. No one is in this for the money. We’re doing this because we believe that this is the right thing to help people with diabetes, and it needs to be done. In addition, we will need to hire a few more folks to pull off everything we want to pull off, as well as enlisting help from an FDA consultant.

Six Tidepool employees have type 1 diabetes. Two of us have family members with type 1 diabetes. Three of our four board members have family members with type 1 diabetes. We like to say, “We have pancreas in the game.” We’re doing this for ourselves, and we’re doing this to help the entire type 1 diabetes community.

Q: For which of the following groups do you imagine Tidepool will be the biggest gamechanger: patients, clinicians, payers, researchers, others?

HOWARD: First and foremost, for patients, we think that what we are doing is a game-changer because it will help make engaging with data and devices much easier, which in turn will make it much easier to achieve effective therapy and reduce the overall burden of managing type 1 diabetes. We hope that apps like Blip and Nutshell [an app that helps you “remember what you ate, how you bolused for it, and how your body reacted to it.”] will simply make life living with type 1 diabetes easier. Also over time, we believe that an ecosystem of apps will emerge, such as an app for athletes with type 1 diabetes, or an app for pregnant moms living with type 1 diabetes.

For clinicians, our software makes it much easier to get data from devices, and much easier to engage with patients about their therapy. Early anecdotal feedback from doctors at UCSF is that using Blip makes in-clinic visits much more productive.

We have not yet spent a lot of time focusing on the needs of payers, though we do believe that over time the data will show that better software will lead to better outcomes and therefore lower costs from both the acute and long-term complications of type 1 diabetes.

And finally, we’re not there yet, but we hope that the Tidepool platform will enable a whole new class of research studies based on “ground truth” data acquired directly from devices. We’re excited about the possibilities that this will enable.

Q: If the whole suite of Tidepool products was out tomorrow, what fraction of patients do you estimate would ultimately download their devices? Is your dream to automate everything, so that patients and providers don’t ever need to even look at their data – they just get actionable recommendations? Or is this fairly unrealistic given regulatory challenges?

HOWARD: Really, there’s no place to go but up – T1DExchange data shows that only 3% of pumpers upload their data more than once per week, and 60% never upload. And that’s from a self-selected group of patients at highly-engaged member clinics.

We think that’s just a crime, but it’s not a surprise when you actually try to do it. For example, getting up and running with CareLink is an endless barrage of Java security warnings, OS incompatibilities, USB incompatibilities and more. And even if you are able to get it up and running, the user experience is complicated and inaccessible to most. I’m a smart guy and do software and user experience for a living, and I can barely get it working. Medtronic could solve this by simply making their data protocol available so that others, like Tidepool, can write software to access the data.

If we can cut that 60% number of pumpers who have never downloaded in half, I will consider it a huge win. But I think we can do even better. I do think that automated recommendations will come, but as you said that has a much higher bar from a regulatory, safety and efficacy standpoint. We may get there, but for now our goal is to simply make it easier to engage with existing data.

Q: Do you imagine that automated insulin delivery will reduce the need to analyze diabetes data?

HOWARD: Automated insulin delivery will increase the need to analyze diabetes data. But the way we analyze the data will evolve. Today, much of the burden of data analysis is on the person with diabetes, their parents, and their healthcare provider. Together, they use data to refine insulin-to-carb ratios, insulin sensitivity factors, and basal rates to optimize insulin therapy.

As insulin delivery is automated, the burden of analysis will be shared with the researchers who create the delivery algorithms. These researchers will need to understand how their algorithms are performing on real people so they can continue to improve them. For example, does the system effectively detect intense exercise in time to prevent hypoglycemia? Or, under what conditions are bad sensor readings causing undesirable insulin delivery? These are just some of the questions that may be analyzed.

The data generated by the system can be augmented with data from accelerometers, activity trackers, and other sources and be used to answer these questions. For researchers, automated insulin delivery will be a forcing function for more sophisticated data analysis.

From the perspective of a person using an insulin delivery system or their parents, automation will reduce the number of times they have to intervene with the therapy, but it will increase their need for visibility into what their devices are doing and why. Trust drives adoption of new technologies, especially when lives are on the line. Transparency through remote monitoring and telemetry will create trust in the automated insulin delivery system. This is a new kind of analysis for people living with diabetes that will require elegant, intuitive, real-time data displays that they don’t have today.

Q: What would be a home run for Tidepool in 2014? In 2015? In 2020?

HOWARD: Home run in 2014: We deliver Blip, the Universal Device Uploader, and the Tidepool Platform to multiple clinics for IRB-approved pilot studies or clinical trials. Two-run home run: Blip is available for broad deployment with all necessary regulatory filings in place. Three-run home run: We get funded to complete Nutshell development and deploy it to at least one clinic for a pilot study. Grand slam: All of the above, plus we generate revenue from at least one device maker.

Home run in 2015: Everything we didn’t get done in 2014, plus we become a self-sustaining non-profit by the end of the year. Two-run home run: We deliver a research query interface that enables free access to our donated, anonymized research database. Three-run home run: We deliver a robust platform for custom-designed research studies. Grand slam: All of the above, plus multiple FDA-approved third-party applications are delivered using the Tidepool platform.

Home run by 2020: Multiple closed loop systems are deployed and in wide use. Their data is automatically uploaded to the Tidepool Platform, enabling further research and validating post-market safety and efficacy. Tidepool software is in wide use around the world, and data clearly shows that we’ve made it easier for doctors to prescribe and maintain devices, that patients find it easier to engage with their data, and that outcomes have improved while lowering costs.

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