The Future of Digital Health

​​​​​​In this episode, Dr Martin speaks with Francoise Marvel, MD, about innovative approaches to implementing prevention guidelines, including the future of digital health and cardiovascular care.

Additional Resources:

• Digital health. AMA. Accessed May 3, 2022. https://www.ama-assn.org/practice-management/digital
• Digital health. AHA/ASA Journals. Accessed May 3, 2022. https://www.ahajournals.org/precision-medicine/digital-health
• Corrie Health. Accessed May 3, 2022. https://www.corriehealth.com/
• Contact Mary Byrnes with The American College of Cardiology Digital Health and Devices and Health Care Innovation Group at mbyrnes@acc.org

Francoise Marvel, MD, is a cardiologist and an assistant professor of medicine in the Division of Cardiology at Johns Hopkins University School of Medicine (Baltimore, MD).  Dr Marvel is also a co-founder of Corrie Health, Inc., aimed at improving engagement, experience, and guideline-directed care with health technology.

Seth Martin, MD, MHS, is a preventive cardiologist and an associate professor of medicine in the Division of Cardiology at Johns Hopkins University School of Medicine (Baltimore, MD). Dr Martin is the director of the Advanced Lipid Disorders Program and Digital Health Lab at the Ciccarone Center for the Prevention of Cardiovascular Disease and the center director and the principal investigator of the mTECH Center, part of the AHA Health Tech and Innovation Network. Together with Dr Marvel, he is a co-founder of Corrie Health, Inc.

Disclosure: Under a license agreement between Corrie Health and the Johns Hopkins University, the University owns equity in Corrie Health and the University, Dr. Marvel, and Dr. Martin are entitled to royalty distributions related to technology described in the study discussed in this publication. Additionally, Dr. Marvel and Dr. Martin are founders of and hold equity in Corrie Health. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies.

TRANSCRIPTION:

Moderator: Hello and welcome to Cardio Care Now, a special podcast series led by our moderator, Dr Seth Martin. Dr Martin is a cardiologist and an associate professor at Johns Hopkins University School of Medicine in Baltimore, Maryland. The views of the speakers are their own and do not reflect the views of their respective institutions.

Dr Seth Martin: Hello again. Seth Martin here, host of the Cardiac Care Now podcast. Welcome back to our second episode. We're really thrilled to have Dr Francoise Marvel as our guest today. I think you're going to be really blown away by her insight. Dr Marvel is a cardiologist, a fellow cardiologist with me at Johns Hopkins. She is a fellow co-founder of Corrie Health, a digital health startup company in the cardiovascular disease space, and she is an expert clinician and digital health innovator. We're really lucky to have her here today. So welcome, Francoise.

Dr Francoise Marvel: Thank you so much, Dr Martin. I'm really thrilled to be here as part of this podcast talking about digital health today.

Dr Seth Martin: Thank you. And we can go by first names. You and I are quite good friends at this point.

Dr Francoise Marvel: That's very true.

Dr Seth Martin: So I think in our last episode, we got to touch on some really important concepts with Yvonne Commodore-Mensah around health equity, and we started to explore the potential of technology as one of the tools that we can use to advance the mission of health equity in the cardiovascular disease space, but for health in general. And I think as you and I have our conversation today, we will have a chance to really dive into the potential for technology even further and build on that by our conversation and really give the audience a glimpse into what's going to be the future of digitally enabled care.

I think, though, to start to set some context for people to better understand who you are and where your insights are coming from, would you mind sharing some about your personal journey into digital health and why you're so passionate about digital health?

Dr Francoise Marvel: I'd love to, Seth. Thanks for the introduction and for the incredible contributions that you've been making in this field too. So it's really an honor to be here with you. And I think starting with the journey is so important because I really hope today that we get a chance to inspire those who are interested to expand their impact, whether it's cardiology or medicine or being a clinician by engaging in digital health, whether it's at the patient's bedside or maybe undertaking a research project.

So where my life really started going in the direction of digital health was a very personal topic, actually. I was always fascinated with how digital health and technology tools were starting to become part of everyday life. In fact, when I was a medical student, I was interested in how we could go from scribbling notes in a notepad from our attendings and those pearls of wisdom to actually having it on our phone. And so that was my first attempt and first adventure into developing smartphone applications and creating a guidebook for medical students to get tips, pearls, and guidance from attendings and leaders in the clinical field by creating an app that helped to provide those tips digitally.

And I knew as I was training that, really, this was such an interesting space that I think could really take off both from the clinician's standpoint to patient-facing tools. As I had the excellent and great fortune to start training at Johns Hopkins, I started to really seek out those kinds of opportunities. But as I was seeking out those opportunities, I was at a crossroads in my personal life in that my father was diagnosed with a rare cardiovascular disease. And that really impacted my passion and my vision for how I wanted to change the way that patient care engagement and empowerment happened because I was with my father, with my family at the bedside really experiencing what it was like to be a patient. And it's challenging. It's frustrating. It can be overwhelming.

I realized that really a lot of times patients and families go to their phone. They go to websites. They go to try to figure out if there's tools to better understand and connect the dots. And it inspired me to figure out a better way to approach patient engagement, a better way to deliver guideline-directed care, and a better way for us to really understand as clinicians the patient experience and how we're going to better care for them.

So during my intern year, I had a big milestone and challenge as I did lose my father to cardiovascular disease, but it left an impression on me that was so incredible in that I knew things had to be different. I knew that I could help and this was really going to be my journey, building digital health tools around engaging and empowering patients around delivering health technology at the bedside that makes care delivery better, it makes health an everyday activity, and it brings patients, families, and clinicians closer together.

So this is where I started my journey at Hopkins in training in digital health and building a digital health solution. I started that by becoming part of an accelerator program, which I really encourage those listening to seek out, whether you're here at the Hopkins program, and I was part of the Hexcite program, maybe you're on the West Coast looking at Stanford's bio-design school, or maybe your institution has programs that can help get you involved in accelerated programs. But I was part of this program that connected me with like-minded individuals looking to take ideas from concept all the way to a product, a commercial scalable solution that was going to help change healthcare. So that was really phenomenal, and it actually led me to finding out who was the leader in digital health and cardiology in really making innovations and thoughtfulness and really leading the way in the space. And it led me to you, Seth.

So what I'm building up to is that I was there in the Hexcite program, meeting business leaders, engineers, innovators and thought leaders, and it really compelled us to try to figure out who's the best in the field that's going to move this forward? And I have to say, it's not just because you're leading the podcast here, but that networking and connection with meeting you was a key point in accelerating what became a really cool and impactful Corrie Digital Health platform, which we'll talk about more.

But in summary, I think finding out what digital health means to you as a person, how that's going to be professionally or personally really important, and then seeking out pathways to start to grow in terms of your skillset and your network to make that happen was critical. And I'll pause there because I do think that there's much more to the story, but these were some key points that really led me in the direction of digital health.

Dr Seth Martin: Well, thank you, Francoise, and we can, of course, feel your passion, and it's a really amazing journey that you've had in digital health, and I'm personally very thankful to have met you and to be on the journey with you.

I think it's a journey that's just beginning, right? Had some exciting progress and learned a lot. And I think maybe now is a good time to reflect a bit on what we've learned so far, and you have such an exciting vision for the future. As you think about where this journey is going and the impact that you can have, where do you see this going in terms of the next 10 years or so as you envision the world of digitally-powered cardiovascular care? What does that future look like? Tell us more about that.

Dr Francoise Marvel: Yeah, thank you. Thank you, Seth. I think we're both similar in this, but we're futurists. We're thinking about what's not just happening now, but what's happening in 2050. And when I think about what the next 10 years holds for cardiovascular care or internal medicine, what your specialty may be, the point is that wearables, sensors, smartphone applications that used to be thought as something that patients were going to struggle to adopt or it was going to be difficult to disseminate, it's becoming part of everyday life. And I strongly believe that we're going to move beyond the intermittent evaluation that occurs in our current healthcare system where we use routine follow-ups and a clinic-based appointment. We have hospitalized care for emergencies. I think we're going to move beyond that health model to more of a continuous model that's supported by health technology.

And I think that as we have a vision, as you pulled one of the greatest thought leaders here in your last podcast, Dr. Commodore-Mensah, around health disparities, I believe that addressing health disparities is something that is going to happen in the next 10 years by extending the access and the reach of guideline-directed medical therapies outside of the hospital, outside of our clinics, whether they're here in Hopkins or they're in our community in Baltimore. We have to go beyond the brick and mortar and leverage these tools in a way that is evidence-based, much like the way that we approached developing my core study where we tested the technology within the healthcare continuum and saw that it made a difference, used these kinds of tools to make sure that we're delivering the promise of digital health, reaching more patients and using a continuous care model instead of our current intermittent care model system, which I believe falls short of what we're capable of delivering as a healthcare system.

I also think, to just make one more point here, Seth, and this is something we're both very interested in is harnessing the power of machine learning and the deep networks of data collection and how we can intelligently generate, collect, and then refine that data to make actionable insights.

I'll use a quick example here. I think when you consider what our current hospital discharge process is, and I know many of our listeners are thinking to themselves now, that's something we could probably make some improvement on. We all know that. That care transition's really challenging. And we know that it's riddled with challenges that are very traditional... paper-based models, handoffs, and fragmented care from the inpatient to the outpatient setting.

Using a patient example, we had a patient who was in her fifties and had multiple cardiac issues. I'll use her name because she has co-published with us. Her name's Tammy. She's a 56-year-old who had her second heart attack when we met her. She had hyperlipidemia, hypertension, smoker, history of social determinants of health challenges like low socioeconomic status, incarceration, and low social support. And when we met her in the hospital, we decided let's try something different. Let's move away from the traditional paper-based system. Let's try to re-engineer this process by providing a smartphone application that had the fundamentals of guideline-directed medical therapy, medication adherence, education, strong follow-up and making sure that the patient has guidance towards what happened in the hospital and a way to keep track of that, including their care providers.

And let's provide them with ways to monitor key cardiovascular metrics like a smartwatch, we used an Apple watch in this case and a blood pressure monitor. We used an Omron blood pressure monitor in this case. What happens when you give someone like Tammy technology that we could see being the future of heart attack recovery?

Well, when you look at what we found for patients like Tammy and others that were studied in our MiCORE trial, 200 heart attack patients that were given a new, really innovative approach to engaging patients with guideline-directed medical therapy after suffering a heart attack, what happens to them during that hospitalization and after 30 days? Do they have that same risk of nearly one and six coming back within 30 days, which is our national standard of readmission post-MI? No. Actually, what we found is that by using a new and innovative approach, we were able to drive down readmission rates by 52% using this new technology that's written at the sixth grade level that focuses on guideline-directed medical therapy, and it was designed by a company, clearly Apple, who has a lot of experience in making things simple.

So I use that as an example, Seth, because I believe the data and the empowerment that comes from digital health is going to be a game changer in the next 10 years. And it's happening now. We just need to find ways to scale it and, I think, highlight people like Tammy, who in otherwise traditional healthcare systems would likely be left out of these types of services and perhaps not connect with guideline-directed care due to health disparities, but we were able to reach her. We were able to succeed. And I think these are examples that should be highlighted and be the hallmark of what we can expect over the next 10 years.

Dr Seth Martin: Yeah. Thank you, Francoise. So clearly, we're at a time where we can turn these disruptive ideas into reality and reach patients like Tammy to really deliver the care that people deserve and to close these gaps that come between all the clinical trials and guidelines and then the real-world implementation. And clearly, there's been success with empowering patients that we've seen with our early experience with the Corrie Health app in heart attack patients. And Yvonne Commodore-Mensah spoke some about the power of technology in hypertension.

Dr Seth Martin: I'm curious if maybe you could elaborate some more on the Corrie Health experience. And since so much of our audience is made up of clinicians, if you could specifically speak to the clinician-facing side of things and maybe touch on, because we've spent quite a bit of time specifically in the realm of virtual cardiac rehabilitation where the clinical side of things is critically important to guide the patients in terms of their exercise, prescriptions, but overall risk factor modification.

Dr Seth Martin: So I wonder if you could share a bit more of the details there and as that relates to what clinicians should expect as the digital health field grows, how this is going to change the way that they approach their practice, and what data will be available to them and so forth.

Dr Francoise Marvel: Absolutely. That's a great question. I'd love to discuss this more. So when you think about how... Well, first to describe Corrie Health in a little more detail here, it's an evidence-based digital health program. It really is foundational on a smartphone application that can pair with wearables and sensors that fits your patient's needs.

For example, if you have a patient that you're thinking about I'd like to know what their physical activity, heart rate and I think they'd benefit from reminders. Then pairing that with a smartwatch, whether it be a Fitbit or an Apple watch could be quite useful clinically. And then, of course, if they have high blood pressure or perhaps they're at risk for developing high blood pressure, monitoring with a wireless blood pressure cuff is a another opportunity to pair with the Corrie application.

The application itself really focuses on the fundamentals of guideline-directed medical therapy. So again, using the American Heart Association, the American College of Cardiology's standards of care, it really focuses on helping each of your patients be reminded and stay on track with their daily care plan. That could be making sure that they're taking their lisinopril, their aspirin, their atorvastatin to keep their cholesterol under good control. And then being able to get their activity in for the day based on what their goals are.

And then setting educational goals. As we know, some patients have different health literacy and might be searching for things on the internet or might not know where to get started. But Corrie helps them get started by providing educational videos as well as some articles that are really written at a level for sixth graders and above. So it really makes it simple to connect with key educational concepts.

The other thing is that we make sure to engage and empower patients to stay connected with their continuity of care. So it's really important that follow-up appointments be clear and scheduled within their application so that they know when they're coming up and they don't miss important appointments with you. So really, really critical.

When you think about, well, okay, this is great from a patient-facing, what am I going to see on the clinician side? Well, let me give you an example. We had a retired airline employee who had his first heart attack and it was really frightening to him. And as you can imagine, we met him within the hospital and were able to get him onboarded to our new virtual cardiac rehab program because he's relatively busy. Although he's in retirement life, he still is not able to make three sessions of cardiac rehab every week. And he really wanted to be part of a program that worked with him and met him where he was at in terms of time commitment and could also save him the cost of transportation and parking to the hospital. So we engaged him within the virtual cardiac rehab program.

And from the clinician side, what you're going to see when a patient starts to engage in programs like virtual cardiac rehab is the opportunity to look in real-time over a dashboard that at a glance can give you actionable items. So I know all of us might be a little tired from the multiple clicks of Epic and the layers and depth of Epic that you need to go through to get to the answer, which is does my patient have well-controlled blood pressure? On our clinician dashboard, quickly you can see trends to let you know whether they're at that goal and if not, then be able to toggle over and see what is their medication adherence like? Are they sticking to that ACE inhibitor I put them on last week? Are they having trouble sticking with taking that medication? I need to address medication adherence. Or perhaps they're doing wonderful and I need to consider a second agent to get to the AHA/ACC goal of less than 130/80.

So the dashboard in the clinical experience is to help you better manage patients, and better support your patients in a continuous fashion as we talked about before. Instead of being surprised during a follow-up visit, this is an opportunity for you to be able to take a look and have a sense of how patients are doing with a a program and with therapy.

When we think about Andy, this patient that I mentioned, who's actually shared a video story of his experience he was so excited about the virtual program, I think what was really key here is that he's more than happy to start participating and sharing health data so that we can better care for him after suffering a heart attack. And he's delighted to be able to actually connect with why he's on that statin and where his LDL levels are.

And what's really great is that as a clinician, all in one place, you get to see that impact of guideline-directed medical therapy, both that he's taking the statin at the dose that you prescribed and doing well with it. He's reading about cholesterol and how to lower his cholesterol, and how to eat a heart-healthy diet. And then you actually get to see the LDL level there and see whether he's at the goal of less than 70 per AHA/ACC guidelines.

So this is just an example from a clinician and a patient standpoint how a program like virtual cardiac rehab is not only innovative, but in a way, it's making it easier to reach those guideline-directed goals and it's doing it in a way that's convenient and congruent with what our patients are really seeking, which is make health easy, make health empowering, and make health something that's part of everyday life, not just once every three or six months.

Dr Seth Martin: Right, right. And clearly, from a clinician standpoint, we're not trying to replace clinicians with technology, but we're trying to augment clinicians, help clinicians be more effective, help clinicians be more efficient, and reach more patients. And as we reach patients like you described, these may be patients who would've otherwise gone without the appropriate guideline-directed care and suffered additional events and really devastating outcomes. So it's a chance to reach people and really scale up access to all our knowledge and guidelines and effective treatments.

And clearly we're at the start of this. When it comes to health equity and really reaching everybody and giving everybody an opportunity to achieve their optimal cardiovascular health, we will need to have strategies and programs to overcome this digital divide.

In Baltimore, our city is committed to overcoming the digital divide in the next decade. And Francoise, you personally are leading an amazing project, which is really bringing together a lot of collaborative creativity between Corrie Health and CardioNerds and other leaders at Hopkins in Baltimore to address the digital divide. I wonder if you could share more about that specific project and your insights into what our audience can do to really address the digital divide and best support our patients and start thinking about what their particular clinical practice or their health system, how they may be able to get involved.

Dr Francoise Marvel: Absolutely. This is such an important topic, and we're so thrilled to be selected by the American College of Cardiology to lead the Bridging the Digital Divide. Because ultimately, just as our vision is at Hopkins and the mTECH Center at Corrie, at all our digital health labs here, we want digital health for all. All or none, right? So how do we make sure that we reach every patient, whether they have resources or not, whether they have digital health literacy or not?

What we're proposing to do is really a first of its kind. It's so exciting because we're not just bringing digital health technology together. We're not just focusing on the tech. We're focusing on the community. And we're focusing on a community, Seth, which is a known underserved, marginalized African and Hispanic American group of young adults.

And what's so special about reaching these students and these young adults and these future leaders of our country is that they're, unfortunately, some of the least likely individuals to get cardiovascular health screening, to get access to primary care, to get access to preventative services. And by falling through the cracks, unfortunately, these young people are often at high risk for suffering from early heart disease.

So what we're really striving to do... And Seth, the fact that you're part of this and you're a major leader on this project as well with your leadership with Ciccarone Center, with your leadership here in the digital health lab and with the mTECH Center, you have really brought an incredible amount of expertise and resources to basically combine everything that we're doing with Corrie and the Johns Hopkins digital health lab with our partners, the CardioNerds, who have a social media podcast platform to really address this from two different approaches.

The first is that we want to train and we want to inspire our community leaders to be ambassadors of health by learning about these digital health tools, by building their digital health literacy. So that's really our step one, is we're creating an educational podcast series powered by CardioNerds.

Much like as we're learning here right on our podcast, sharing our views and visions with an incredibly talented and inspirational audience out there, CardioNerds is going to do this within our underserved Baltimore community focused in on Morgan State, which is a historically black university. And we have leaders within. In fact, I have a meeting later today. We're focusing on leaders who are within. So these are student leaders that are under-represented African American and Hispanic American individuals who want to champion being part of this CardioNerds podcast, gaining the skills that they need to interact with these digital health tools, specifically the Corrie platform. And then ultimately, we will be taking the Corrie platform and building in educational impactful messages, materials, resources, and screening opportunities to work with hundreds of students and community members within Morgan State to really make an impact on young adults and cardiovascular health.

And once we start to deliver these within these strategic health clubs that we'll be doing based on interest groups within Morgan State and also at health fairs and educational opportunities, we will be having that impact over the next year and ultimately be sharing the results of our community engagement program and hopefully be able to share how we've really improved cardiovascular preventive services by leveraging digital health tools, including a platform called CardioNerds that's based on Twitter, but also has a presence on Instagram, and then, of course, using our evidence-based Corrie Health platform to deliver cardiovascular preventive education and screening to underserved and under-represented African American and Hispanic American groups at Morgan State.

And I can tell you right now, it is gaining a lot of momentum from Hopkins, from Morgan State, from the American College of Cardiology. And the more stakeholders we work with at the community level as well, the more interest we are getting in growing this program. Because ultimately, it has the opportunity to reach that promise of digital health, which is extending access to preventive care, to therapeutic care and screening for people who need it the most and oftentimes do not get it.

So, so excited about this, Seth. Thanks for asking about it and can't wait to keep working on this together.

Dr Seth Martin: Yeah. Thanks for sharing about it, Francoise. It's exciting in so many ways, including reaching the youth and the youth then benefiting, but also being a way to reach other generations and really spread digital literacy as well as resources and overcome the digital divide.

What I think could happen here is that what's happening with this effort in Baltimore could become a model for others around the country. So I certainly would encourage anyone in the audience that even if you're not in Baltimore, if you're interested in the ideas that are being shared, to reach out and hopefully Baltimore will become a model that could then be replicated elsewhere, and there could be learnings from different cities about what works and doesn't work and so forth. So thank you for sharing, Francoise.

So I guess as our time comes to a close, this would be a good opportunity to... You expressed everything so beautifully and clearly, but clearly there's so much more. And I wonder where our audience, you could direct them to learn more about some of what you discussed, some of the best resources, and we can make sure to include some of these in links below together with the podcast so that our listeners if they have time and interest, can go find out more.

Dr Francoise Marvel: Absolutely. I've really enjoyed this. And I have to say, credit to you, Seth. You're very humble, but I just want to shout out that you are leading the international, and national top programs in digital health through your work at the American Heart Association, as the director for our mTECH Center, just returning from Apple and Stanford recently to being co-director... thankfully, you helped make me co-director, thank you, for our digital health lab here at Johns Hopkins... to leading and co-founding with Corrie Health and really making an evidence-based program that's having such a huge impact. We're so excited about where it's headed. There have been so many other major contributions you make in digital health, including leading this podcast, and I am a huge fan of it.

So I just want to, again, give you some kudos there and thank you. And for those that are listening, thanks for listening. I think your interest in digital health is critical to making this a huge success and to making our patients and our clinicians have another experience and level of impact on their own lives, whether they're the patient and they're getting better outcomes, or they're connecting with a family member who has heart disease, or that clinician where you're sitting back and wondering, gosh, I'd love to just know how to better manage this patient and get them more engaged in their care and bring that joy back in my practice. And I just want to say thank you for listening.

To find more resources, I'm going to list four resources here that I think are really high yield. First is the American Medical Association's Telehealth Implementation Playbook. This is a very well-written description of how you can take digital health into your own healthcare setting. Whether you're in a community practice or you're in an academic center, this really has key points all the way from considering different opportunities, devices, platforms, to how you start those discussions with administrators and stakeholders around adopting new technologies and then really understanding how to make it sustainable. What are some of the revenue streams and CPT reimbursement codes that are currently being used? So all of that is packed into this Telehealth Implementation Playbook, which we will have the link listed.

The second is the American Heart Association has put together a digital health article collection. This really pulls together articles in the emerging and important field of digital health across AHA's vast portfolio of journals. So you really have a lot to choose from, and we'll include a link to that.

I'm also going to include the American College of Cardiology, we have a lot of opportunities to get hands-on with digital health devices and healthcare innovation. We have two dedicated groups to that, and I will include a contact person who, if you're interested, maybe already part of ACC or perhaps you're interested in joining, could provide you opportunities to join these interest groups that are really phenomenal.

And then lastly, if you'd like to learn more, for example, about what we're doing at Corrie in terms of our scientific publications, learn more about the MiCORE trial that I have referenced through this discussion, Tammy co-authored a story with us, so if you'd like to learn more about her journey, and then our cost-effectiveness analysis as well. So corriehealth.com and that'll be listed in the resources.

Again, it's been a pleasure to be part of this podcast, and I really want to thank the team here as well as Seth for such a fun discussion and productive discussion.

Dr Seth Martin: Thank you so much, Francoise. You're always so generous with your comments. And I would like to echo what you said, thank you to everybody who's tuned in. I hope that you found the conversation useful. I hope that we can continue to build a broad digital health community that's going to really advance care... as I said earlier, turn these really disruptive ideas into reality. This gives you a taste of some of the ideas that we're going to continue to explore in this podcast series. I look forward to building on this conversation in future episodes.

Thank you so much, Francoise, for joining us. It was a real pleasure.

Dr Francoise Marvel: Thank you, Seth. The pleasure was all mine.

Moderator: For more cardiology content, visit our website consultant360.com