Jeffrey Wessler, MD, MPH is a practicing cardiologist, assistant clinical professor of medicine at Columbia University Irving Medical Center, and founder and CEO of Heartbeat Health of New York, NY.
Tell me about yourself and the company.
I’m a cardiologist by training. I started Heartbeat Health three years ago with goal of bringing a virtual care model to cardiovascular disease. Virtual care has evolved from telemedicine only as a platform, then urgent care chatbots, then some of the singular disease verticals such as diabetes. Now with Heartbeat Health, we have a chance to take on some serious disease processes, such as cardiovascular disease.
Little of a cardiology practice’s work is preventative, right?
That’s right. The majority of cardiovascular care happens after patients get sick. They get referred into the system after they have had a heart attack, uncontrolled blood pressure, or resistant symptoms. That made sense 20 years ago, when we really did need to focus our resources on treating those who had advanced disease.
But we’ve gotten pretty good at that as a field now. The advanced treatments are amazing and they work really well. The next phase, and where the ball is now, is now to keep people out of that advanced disease, emphasizing early disease management and prevention. That is the huge missing component with the care system.
Standalone healthcare apps tend to move the overall needle very little, so you have integrated your platform with your cardiology practice that provides the hands-on component. How do you see the company scaling?
What makes cardiology different than, say, weight loss management or exercise management is that these are really sick patients who need physical care. It’s this hybrid model of virtual when you can, digital when you can, but then get patients to the right care at the right time when they need it.
By that, I mean the physical care environment for diagnostic testing, in-person evaluation, and hospitalization if needed. Being able to navigate between those two settings is really not done in the market right now. That’s our sweet spot — how to get people to the right place when they need it and everything else managed via the app.
You are offering services to employers and individuals. From the individual’s perspective, how would that work for someone who doesn’t live in New York City?
The best way to think of the New York office is as the test kitchen or the R&D lab for our clinical experience. But across the country, you would download the app, go through the risk assessment and data collection phase, undergo a tele-visit to speak with the doc and discuss the specific results — what the risk factors are, what they mean, and what the necessary next steps are. Then we would get you to a Heartbeat preferred partner who can do a stress test or arrhythmia monitoring as needed, then get that information back into the app for ongoing management.
The physical care happens very successfully in cardiology across the country. It’s just that too often, the wrong patients are getting to those doctors. By that, I mean not necessarily the right time or the right level of patient getting to the right specialist. That’s where we step in and say, it doesn’t matter where you are — California, Nebraska, Florida – the key step that we do is getting your data, interpreting it, organizing it, and then telling you and showing you where to go.
Do cardiology practices see Heartbeat Health as a competitor or a potential partner?
As a cardiologist, I’ve given a lot of thought to this. My goal is to become a partner for the highest quality cardiologists across the country. I have incredible respect and admiration for the level of work that’s being done. I want to make their practice habits better, faster, and easier, to trim some of the inefficiencies and administrative burden of what happens when you get the wrong patient and have to figure out parts of the care model that you’re not necessarily best at. Let’s focus you to get exactly who you want to be as a cardiologist and get you to do your best care. In that sense, I think Heartbeat really is a friend and a partner rather than taking business from them. We’re helping to augment their practices.
Will you integrate wearables, EKG, and monitoring solutions?
We are leaning heavily into the wearables and the device landscape. This is such an exciting part of the field right now. We have all of these consumer devices — the Apple Watch, AliveCor, Omron blood pressure cuffs – and cardiologists don’t really know what to do with that information yet. There are now hundreds of thousands of patients with Apple EKGs who are asking, what does this information mean?
This plays a role in how we find the high-risk individuals based on those wearables, identify what that information means for their care pathway, and determine when it’s relevant. This is a layer of service that is being provided on top of the devices to cut out some of the unnecessary data, focus on the relevant and important ones, and then use it to help people and help patients get into the right care.
Atrial fibrillation is probably the highest profile cardiac condition now that consumer devices like the Apple Watch and AliveCor issue warnings to users. How do you manage those newly worried consumers?
This is a very hot topic right now. You are wise to be identifying it as a real issue. The first answer is, we don’t know yet what to do with asymptomatic patients who are being diagnosed with AFib because of an Apple Watch or an AliveCor. All of the guidelines for stroke prevention and heart rate and rhythm control have been done in patients in whom we know that the atrial fibrillation is causing problems. That is mainly symptomatic patients, those with elevated stroke risk due to age or comorbid conditions, high blood pressure, diabetes, and prior strokes. These patients are fundamentally different than an otherwise healthy person who is being diagnosed with AFib through a screening device.
This group needs to studied rigorously, and Apple is working on that. They just launched their first important study, the Heartline study, which is focused on older adults wearing Apple watches and what to do with those who are diagnosed with AFib.
But our best guess of what to do with the younger population is to take the arrhythmia or the AFib that is diagnosed by the Apple Watch and use it to focus on modifiable risk factor controls. Make sure blood pressure stays controlled, make sure cholesterol stays controlled, make sure these patients are exercising and eating well so they don’t develop diabetes. In that sense, use AFib more or less like a elevated risk factor that gives us indication of a higher risk of cardiovascular events or heart disease, but one that we can work hard on reducing if we can control everything else that’s modifiable.
Health apps often fail to change user behavior and are abandoned quickly once the novelty wears off. Do you have an advantage in having self-selected people with cardiology concerns, or do you need to use psychology to keep them interested?
I am a huge skeptic of behavior change apps. I think they have proven time and time again that they can work for very short periods of time, but have no sustained, long-term results.
My hypothesis, and where Heartbeat stands in this challenging landscape, is that it is important to establish a care environment. In particular, a patient-doctor relationship, in which an expert in the field with clinical experience can discuss one-on-one with a patient – face-to-face in our case — what your specific risk factors are, what they mean, why they affect the heart, and based on thousands of patients before you, what happens if left uncontrolled.
The tele-visit sets the stage for downstream adherence, engagement, and going to follow-up appointments and diagnostics. It’s a relationship-based intervention, not dissimilar to coaching, but we think of it as clinical coaching. Patients are more likely to do something and to follow through into care when the doctor explains the importance or the relevance of this condition rather than just an app popping up and saying that it’s time to stand up, go for a run, and eat well.
How does the model work from an insurance perspective?
By being an enterprise-based business model where the self-insured employer or the payer is sponsoring this as a benefit, we refer to people within that network. The advantage of that is that we can focus on finding providers that are doing high-quality care. For us, that means following evidence based-guidelines. Not using the diagnostics that will net them the most fee-for-service money, but the ones that are appropriate based on conditions and risk factors. In doing so, this is the classic value-based play to the payer. We can improve outcomes at a reduced cost, and therefore by starting with Heartbeat, we can guarantee a value-based process, lower events at lower costs.
Will be be a challenge to accumulate enough outcomes evidence to get employers to have confidence that their cost of offering the service will be offset by benefits?
Wellness interventions are in a rocky territory right now. Most people are getting wise to the fact that they don’t really provide clinical benefit. We take that head on by saying, if you want to provide clinical benefit, go after the people that you can demonstrate clinical outcomes on.
Our first layer is to identify those high-risk patients. This is the hot-spotting concept. It has come under fire a little bit lately because the data is not necessarily bearing out what everyone thought would be the case. But for cardiovascular disease, if you take high-risk people and those with comorbid conditions and elevated cardiovascular risk if not early disease, those are 100% the people who are leaving to the cost centers of these healthcare employers and payers with heart attacks, arrhythmias, heart failures, hypertensive crises, and ED visits for chest pain. These are very predictable numbers. If you can get ahead of it and get these patients early care, we can predictably reduce those episodes. That comes with really tremendous cost savings.
Do you have any final thoughts?
The landscape of digital health is changing. We have landed at a place where wellness and digital solutions are coming under fire. The disease-specific ones are starting to work, mostly in the diabetes prevention space, but we are left with this next era of digital management, which is, what do we do when patients actually get sick and need, quote, “traditional healthcare?”
This is the area that I’m incredibly excited about and that Heartbeat Health is taking on. When patients move from digital-only solutions into the traditional care system as they’re getting sicker, how can we get in there and try to halt the disease progression process, provide some online app-based and virtual touches to early care and early progressive management so that we can prevent these outcomes? This will be the next decade of digital healthcare, using it to manage those patients who need it the most.