Healthy, Smart and Resilient Cities

Cardiovascular disease and diabetes contribute significantly to the global disease burden and represented approximately 46% and 13% of the 37.9 million non-communicable deaths that occurred globally in 2015. 

Together with Surbana Jurong, Healthpals is developing smarter, healthier cities. Surbana Jurong is one of Asia’s largest Engineering, Infrastructure and Masterplanning firms, having developed urban masterplans in over 30 countries.

HealthPals’ Clinical Intelligence platform maps patient electronic health data to the appropriate guidelines, best practices, and value-based quality metrics to produce actionable recommendations specific to each patient, and optimises the treatment plan using a machine learning layer.

By integrating sensors, remote diagnostics, and health driven urban design, Surbana Jurong and Healthpals can deliver smart, healthy and sustainable cities in Asia.

HealthPals aims to reduce the prevalence of and deaths due to non-communicable diseases such as cardiovascular disease (CVD), diabetes, and stroke.

While mortality rates have been in decline for several decades, CVD still causes almost 30% of all deaths and poses significant social and economic costs on domestic economies and societies. Similarly, diabetes affected approximately 425 million adults in 2017 and accounted for 12% of total global health expenditure in 2015 (USD$673bn) and is expected to exceed USD$802bn by 2040. Importantly, much of the diabetes and cardiovascular disease burden is preventable. Successful prevention lies in identifying and treating preventable risk factors, such as prediabetes, high blood pressure, and high blood cholesterol.

Currently, there is a systemic failure to institute preventive screening and treatment appropriately. One issue is that physicians are often stretched to stay up to speed on the latest clinical recommendations, and there is insufficient technology-based support for those physicians to make informed decisions. A 2003 report from the RAND Corporation showed that ~50% of all medical decisions do not adhere to medical best practices. HealthPals aims to provide an innovative technology solution to improve physician decision making and to enable preventative intervention to scale to the population level.

HealthPals is committed to improving health outcomes across the world with its unique Precision Prevention platform. The platform currently focuses on diabetes, heart failure, and stroke from atrial fibrillation, and aims to support physicians with the necessary tools and information to make individualised medical interventions for people at risk of these diseases.

The clinical and medical expertise and domain knowledge in the business comes from Dr Rajesh Dash who has over 17 years of experience in academic medicine and has won national and international recognition for his work in predictive imaging techniques to identify and treat patients at risk of early heart disease.

For a healthcare provider or care team, the platform is able to output an evidence-based risk assessment and dynamic treatment dashboard showing recommended treatments for each patient, the impact of treatment on their risk score, and the level of evidence supporting each recommendation, along with a link to the primary literature behind that recommendation. This will help physicians to make more informed decisions when identifying, assessing, and preventing disease in patients.

Healthpals has partnered with Surbana Jurong, one of Asia’s largest Engineering, Infrastructure and Masterplanning firms to deliver healthy, sustainable, and smart cities across Asia. This is centred on integrating AI with low cost smart health diagnostics and medical care teams to prevent Cardiometabolic NCDs and catalyse affordable and equitable access to health.

HealthPals has developed a robust clinical decision guidance platform, CLINT, that addresses the data overload in medicine. CLINT extracts the relevant EHR patient data and maps these attributes to applicable medical guidelines and best practice statements to generate an automated, personalized, and evidence-based ‘checklist’ for each patient. This checklist then scales to a population level, providing actionable intelligence for avoiding major clinical events, reducing spend, and optimizing for different types of patients in the population. 

Another distinguishing feature of CLINT is HealthPals’ collaboration with the American College of Cardiology (ACC), making it one of only 2 companies to receive full access to the ACC patient databases, which represent the largest cardiovascular and cardiometabolic databases in the world, providing the platform with ~200 million patient-life-years of data to power HealthPals’ patented AI for optimising treatment pathways.

The HealthPals platform is able to communicate the care plan and risk levels, as well as the evidence between these two elements, to both providers and to patients (via a smartphone app).

The combination of Large-scale urban decision, smart health diagnostics, AI for precision prevention and distributed health service delivery allow for a transformative model of healthcare.

HealthPals has developed a robust clinical decision guidance platform, CLINT, that addresses the data overload in medicine, and that is unique amongst the other population health platforms available today. CLINT begins with individualized patient medical record data and then combines this data with encoded medical guidelines, making its population dashboard the most powerful tool available for at-risk health systems. 

Another distinguishing feature of CLINT is HealthPals’ collaboration with the American College of Cardiology (ACC), the world’s foremost medical society for cardiovascular care. HealthPals has become an innovation collaborator with the ACC, with full access to nearly 200 Million patient life-years of longitudinal medical and pharmacy records. This longitudinal data has unlocked a massive AI/Machine Learning opportunity, through which CLINT can now identify responder and non-responder populations to any given treatment over time, optimizing each disease treatment pathway for a specific patient type. 

Combining this technology with the capabilities of Surbana Jurong in smart-city design and urban development will enable this project to scale rapidly and deliver substantial impact on managing health outcomes for both urban and rural populations. This is applicable both in retro-fitting existing built environments, as well as in greenfield developments.

CLINT integrates health data from smart health diagnostics, EMR systems and other sources, and performs two transformations on this that are moved to two output platorms. 

First, a ‘Prescriptive’ transformation uses an inference knowledge engine that contains codified medical guidelines, best practices, and customised treatment protocols, to produce actionable and personalised treatment recommendations (Point of Care)     

Second, HealthPals’ own longitudinal dataset (nearly 200 million patient life-years) has trained advanced ML algorithms to map the same patient data into “Predictive’ optimal care pathways based upon ‘patients like you’. 

This bottom-up approach generates a Precision Public Health dashboard (Population Health) for entire health system populations, which guides resource allocation and treatment programs as it is also clinically actionable. The care plan and risk level, with the evidence supporting these two elements are communicated to both providers and patients via a smartphone app.

In audits conducted on specific decision pathways, CLINT deployments at Stanford Health Care and Sutter Health in the Bay Area successfully identified 100% of all available opportunities.

This integrates with the following key technologies:

• George Health SMART Health: Community Health workers in India and Indonesia have used smart tablets and diagnostics to screen 100,000+ people for Cardiovascular Disease in both rural and urban settings.
• Smart Diagnostics: These include smart toilets used by Stanford Medical School for improving communicable and NCD outcomes for Mexican farm workers, amongst other low-cost IoT solutions.

The implementation of HealthPals will focus primarily on the prevention of diabetes conversion, heart failure, and stroke in atrial fibrillation. 

For diabetes, HealthPals will screen patient records for all individuals with a HbA1C between 5.3 and 6.4, or, fasting glucose levels above 100mg/dl, and will further scrutinise the likely conversion to diabetes over a 1-3 year period. These insights will be transmitted to Intervention Health Service Providers, who will connect with high risk individuals to deliver medical therapies (metformin; a safe, well-established and low cost medication) and engage patients with lifestyle therapies to prevent conversion.

For heart failure prevention, HealthPals will screen all patient records with an automated and evidence-based calculation of an established heart failure risk scoring methodology, the ARIC risk score. A public health institute will connect with these high risk individuals and perform a screening program on this elevated heart failure risk cohort. Based upon the CLINT screening results, HealthPals will produce - at scale - all indicated heart failure medications to prevent heart failure exacerbations and hospital admissions. 

For stroke prevention, HealthPals will identify atrial fibrillation (Afib) patients and also register the status of their current stroke prevention therapy, compared to the recommended standard of care (anticoagulation for those with CHADS2VASC ≥ 2). Patients with gaps in their preventive therapy will have the appropriate anticoagulation therapy initiated.

All patients will be followed over the next 5 years to ensure appropriate preventive care is delivered, and that indicated utilizations of public health services are tracked.

Current number we are serving: 20 million

One year: 100 million

5 years: 500 million

Globally, the health burden of non-communicable diseases such as diabetes and cardiovascular disease is increasing rapidly. With an ageing population, a limited pool of public resources and a lack of an existing scalable and sophisticated means of managing health at the population level, many governments around the world are struggling to meet the rising demands of healthcare expenditure to sustain positive health outcomes for individuals. 

The statistics on this are clear; out of 37.9 million non-communicable deaths that occurred globally in 2015, 46% were due to cardiovascular disease (comprising coronary heart disease and stroke), while approximately 13.1% were due to diabetes attributable deaths (International Diabetes Federation, 2016).

Urbanisation is another important trend; projections from the UN show that the world's population living in urban areas is expected to grow to 68% by 2050 from 55% today, an actual increase of approx. 2.5 billion people. A sustainable approach to development will be paramount to meet demands for public goods such as healthcare and transportation.

This solution directly addresses both of these themes with the implementation of HealthPals in smart cities and sustainable development of urban infrastructure. The key lever for making this a reality is the billions of dollars of institutional capital being devoted to impact investing, and towards outcome based financing more specifically, with over $370m of capital being raised across 134 projects in 27 countries to deliver projects that solve a social or environmental problem.

There are several barriers that exist to scaling and implementing this solution.

The first is the market, which will involve establishing buy-in from governments, institutional investors, healthcare practitioners and other relevant stakeholders that are involved. Working closely with each of these parties is central to the product being adopted appropriately, as it will need to connect and interact with local healthcare systems and providers of care. 

The second constraint is financial, with the need to achieve funding to scale the solution and implement the product through an outcomes based financing structure. Similar to the above, this will involve the successful communication of the idea to multiple parties, including investors and government, in establishing the outcome based financing proposal and launching it off the ground. 

The last issue is around culture, and being able to win trust from healthcare providers and members of the community, that this product is best aligned to their interests, and focusing on achieving a positive, measurable impact.

To develop government and market buy-in, we plan to collaborate with multilateral institutions, such as the UN Development Program and the UNDP SDG Impact Finance initiative. The HealthPals founders have extensive experience in medicine and in software engineering and design, and this will help to establish trust on the clinical efficacy of the product. 

There is already a large appetite for impact investing from institutional investors, but work will need to be done to convince them of the viability of specific projects that use an outcomes based financing approach. It will be important to communicate what the measurable outcomes of the project are, and how this will determine contingent returns that investors may receive, and how the impact of the project will be measured. We have engaged with large institutional investors such as QBE, HESTA and BNP Paribas who collectively hold $200bn+ in assets. They have already invested into at least one outcome based financing models and are seeking to increase their allocation. 

On the cultural front, we plan to work with trusted local partners in healthcare, such as the George Institute and ASHA Workers, to better integrate with the local healthcare market and to increase the likelihood that the approach is viewed favourably. 

The following people work in the solution team:

• There are 10 full time staff on the solution team at Healthpals.
• In addition, there are a team of 15 staff at the George Institute who support our work
• Surbana Jurong has a team of 100 engineers and planners who we work with in their urban masterplanning team 
• Stanford Medical School has 3 key faculty members who we are working with on smart health diagnostics

The HealthPals team combines world class clinical expertise, thought leadership in preventive medicine and cardiometabolic disease, and a talented, Silicon Valley data science and engineering team, along with impact investing capabiltiies.

On the clinical side, HealthPals is led by Co-Founder and Chairman Rajesh Dash, MD PhD, who is an Assistant Professor of Cardiovascular Medicine at Stanford University. Dr. Dash has over 17 years of experience in academic medicine and has won national and international recognition for his work in predictive imaging techniques to identify and treat patients at risk of early heart disease.

On the engineering side, Sushant Shankar completed his bachelor’s degree in computer science at the University of California, Berkeley and his masters degree in computer science from Stanford University, applying machine learning techniques to computational biology in autism research. He then joined several startup companies in the ad-tech space and gained

Finally, Shanthakumar Bannirhcelvam is experienced in impact investing, having worked in corporate law in London and Sydney, and having advised institutional investors on investment into sustainable infrastructure project. Shanthakumar is admitted to practice as a Solicitor in the Supreme Court of NSW.

The combination of skills and understanding in this project of clinical medicine, software engineering and data science, and impact investing approaches to financing impactful businesses makes this proposal uniquely placed to deliver this concept. 

• HealthPals has formed a memorandum of understanding (MOU) with the George Institute for Global Health to work together on improving health outcomes in cardiovascular disease management globally.

• In addition, we are collaborating with the UN Development Program and UN SDG Innovative Finance to support the implementation of this solution in various jurisdictions, including in South East Asia with the Indonesian government.

• Lastly, a MOU has been signed with Surbana Jurong, one of the largest urban infrastructure and development consulting firms in Asia. Signed on 21 January 2019, the MOU will offer mutual support between the two parties, where Surbana Jurong’s master planning expertise can tap on Healthpals’ healthcare expertise to create a smart platform for illness prevention activities and community outreach projects, leading to collaborations on urban planning projects in the healthcare segment. This initiative aligns with the Ayushman Bharat Scheme and other key initiatives by the Government of India to promote national access to healthcare.

The business model for Healthy Cities is to use Outcomes Based Financing (OBF). In this structure:

• Outcome Payers (Government, Health Insurance, or other entities facing the liability of healthcare) enter into a contract to share their savings from reduced expenditure on cardiometabolic disease (and TB if relevant) over a 5 year period. There is no upfront investment required from the Outome Payer.
• Institutional Investors finance the upfront costs and working capital of a precision prevention program that combines:
  • Healthpals CLINT Platform
  • Low-cost healthcare IoT integrated into urban environments - this includes smart toilets and other sensors
  • Community and Primary Care workers, Smart Tablets, and Diagnostics
• As population health outcomes improve, the Outcome Payers provide a return on investment to the Institutional Investor from a share of their derived savings.

For HealthPals, the product provides value to healthcare providers and patients by providing doctors with evidence-based clinical information and recommendations based on the individual characteristics of patients. This helps to improve the diagnosis of disease, as well as the identification of treatment gaps, should they exist, thereby improving health outcomes for the patient, and for the population once the product has scaled across a healthcare jurisdiction. In this respect, impact can be delivered both to a specific individual on the micro level and to the government health systems or other payers on the macro level in terms of reduced healthcare expenditure.

This model will be implemented and scaled using the outcomes based financing model explained earlier.

Institutional investors will fund the upfront costs and working capital of the program, which will allow the solution to scale and be integrated adequately into the healthcare system as a component of a sustainable development project. The technology business model of the platform has marginal customer acquisition costs that are negligible, and hence the product will benefit significantly from economies of scale and will be able to leverage a very high multiple on invested capital in terms of the social impact that it can generate. 

The challenge is involved in financing the upfront project design and coordination between stakeholders, hence the need to raise capital in this outcome based financing structure. 

Establishing a strong network of partners and collaborators is crucial to achieving HealthPals' goals of improving population health outcomes. By combining our efforts, we hope to transform urbanisation as a force for health improvement while maintaining a human-centred focus. 

The MIT Solve network will be invaluable in supporting HealthPals to receive buy-in to support implementation in various cities around the world, and to raise visibility and awareness of the solution. 

Finally, the catalytic capital and network of Solvers will be pivotal in taking us to a city-wide implementation. While we are grateful for our existing partners, we believe that the ultimate impact we could deliver is far greater with the community of Solvers. Immediate opportunities that come to mind include Akiba ya Roho and Neopenda who we could integrate into our healthy cities solutions to deliver an exponential impact on healthcare.

We are seeking to partner with:

• Municipal State and national governments who seek to improve health outcomes in municipal settings
• Innovative technology and health service delivery companies who we could collaborate with to improve health outcomes
• Outcome payers (National Health Insurance schemes, Health Insurers providing low-cost health insurance, etc) who bear the liability for rising health costs and would be willing to enter into an outcomes contract.

There are several countries that we are currently engaging with to do this, including but not limited to Indonesia, Malaysia, Australia and the UK. We would welcome expanding this through the MIT solve network.

A core component of HealthPals is the artificial intelligence engine that is able to optimise treatment policies and practices for individuals to achieve the best clinical outcomes long-term. HealthPals is an innovation collaborator with the American College of Cardiology, and has been able to train the AI model on one of their datasets containing nearly 200 million patient life-years of longitudinal medical and pharmacy records. The platform can now identify responder and non-responder populations to any given treatment over time, optimising each disease treatment pathway for a specific patient type. The potential for this AI application is limitless, making HealthPals a top 5 real-world medical data company worldwide. 

The AI component of HealthPals is essential in enabling the platform to provide personalised, individualised clinical risk assessment and treatment recommendations, and represents a paradigm shift in existing approaches to population health management. 

We would be eager to be considered for this prize to further advance the technological capability of the platform. Further work can be done to improve the patient UI/UX of the platform, as well as testing and developing additional AI models for patient identification and treatment. There is scope to incorporate various other forms of data into the model that can be used for intelligent assessment of disease. A possible example in this case, which involves large-scale implementation in sustainable development infrastructure projects, involves measuring and analysing the blood-sugar detected in the urine of people who use smart-toilets in rural and urban areas to assess the risk of diabetes. 

HealthPals would like to be considered for this prize. Thus far, the platform has focused on the non-communicable diseases of cardiovascular disease and diabetes. However, the platform is capable of supporting the assessment and treatment other diseases, and is able to support better integration, communication and coordination between healthcare providers, and between patients and doctors. The prize will be used to tailor the platform to support additional treatments and disease categories, and to implement the solution in areas that can deliver a tangible impact. 

An example of another disease category is tuberculosis. Despite being curable and preventable, 10 million people were diagnosed with TB in 2017, and 1.6 million people died from the disease, making TB one of the top-10 causes of death worldwide (WHO, 2019). Tuberculosis has significant comorbidity with diabetes, as diabetes has been shown to increase the risk of developing TB by 2-3x, and is the second most important risk factor for TB. Hence, an extension of the platform to support identification and treatment of tuberculosis is how this prize could be used with significant benefit.