By JESSICA DaMASSA, WTF HEALTH

“It’s fair to say that, in Italy, we are doing 10 years of digital health evolution in 10 days.”

Our “man-on-the-street” in Italy (well, man-sheltered-in-place in Italy) Roberto Ascione, CEO of Healthware, reports in on the Covid-19 outbreak and what’s happening with digital health startups, health system partners, and hospitals as Italians continue battling at the forefront of the coronavirus outbreak.

A few weeks ahead of the U.S., there are many things to learn about Covid-19 testing, treatment, outcomes, and timing from the experience in Italy, including some foresight on how pathways for telehealth and digital health continue to evolve as conditions become more serious and the outbreak progresses. (For all you Gretzky fans, this is “skating to where the puck will be” kind of stuff…)

Some navigational guidance on this chat which took place March 26, 2020:

• Update on Italian Covid-19 outbreak from health industry insider
• 10:25 minute mark: Digital Health startup case study, Paginemediche, self-triage chatbot data from 70K Italians, data sharing with Italian government & WHO, telehealth model flipping to give overwhelmed physicians opportunity to triage and “invite” patients based on needs
• 19:10 mark: How to work with Italian digital health startups to advance Covid-19 work

Read the interview transcript here:

Jessica:

Hi, it’s Jessica Damassa with WTF Health. Thanks for joining us. I’m doing a special series on how different health technology companies and businesses from around the world are responding to COVID 19 and so joining us right now, we have a friend from Italy. This is Roberto Ascione. He is the CEO of Healthware. So Roberto, it is such a pleasure to have you with us on the ground in Italy. Tell us where you are, first of all.

Roberto:

Hi Jessica. Thank you for having me. I’m connected from home as everyone else in Italy, and I’m today connected from the South of Italy around the Amalfi coast.

Jessica:

Okay, well give us an update on what’s going on there. You are somebody who has… You’re a doctor, you got your start in infectious disease, and have gone on from there to have a career and most people probably know you from Frontiers Health, or they’re from the work that you do through Healthware with different pharmaceutical companies, in terms of helping them build and source different startups with digital solutions. So, I want to catch up with you on what’s happening in digital health in Italy, but before we get there, give us a word on the street here, what’s happening in Italy right now, and what are you guys hearing and seeing from the healthcare system, from the people that you’re working with on a daily basis? For those of us in the U.S., give us an update.

Roberto:

Yeah. And this is a big deal. It’s a tragedy in many regards. It’s something that you maybe studied on the books when you think about this big pandemic and epidemiology, but it’s of course a complete different thing to be right in the middle of it. And of course, you know we work in digital health, and so we are not fighting first line, or maybe also, but in a way. But of course our friends, doctors, nurses that are really fighting night and day nonstop in hospitals, those are the real ones that are holding stronger than anyone else. And then the whole population behind, because we are in total lockdown as of now, a couple of weeks.

Roberto:

And when I talk of lock down, I mean the entire country, it’s completely locked down, rightfully, because what is clear through our experience is that complete lockdown, hopefully augmented by certain digital initiatives, which I’m sure we’ll talk later about, it’s probably the best path through this, and to overcome this big issue. So right now, we are in this situation. The north, as you see in the media is struggling much more, unfortunately. The south regions of the country are relatively less impacted so far and that’s why lockdown is so important, because it’s important not to allow this to spread at the same speed towards the south as well. So, that’s pretty much the situation. We are starting to see a little bit of a less steep curve over the last few days but it’s way early to say it’s over. So, we are through it, and it’s super important to keep all these lockdown measures very strict for the foreseeable future.

Jessica:

Yes. Real quick, I want to run through a couple of things with you just to compare notes from what we’re seeing here in the U.S. Obviously we’re a few weeks behind you guys. I’m talking to you, it’s Thursday, March 26 here and so I’m curious, how are things going with testing? That’s still a big issue here in the U.S. Are you hearing anything about the different… Are you guys able to deploy tests as quickly as you want to? What’s happening there?

Roberto:

Yeah. There’s a big debate about this. Italy is following the WHO recommendations about testing, which are being adapted over time. So, when we started, we started with testing those that symptoms and had an epidemiologic connection with the regional epicenter in China. Then this has been modified into broader testing, so right now there is a fair amount of testing but there is a debate whether more people should be tested. The key thing is there is for sure a ratio between those that are known to be positive and those that are truly positive in the population, and there’s discussion whether this ratio is one to five or one to 10. There are different studies of… Some reason one, it’s even making some hypothesis around one to 20. I think probably one to 10 is a fair assessment of the situation. So, probably an expansion of the testing would be good to have a better picture of the situation, but really now you can probably say that the ratio of people with the infection is probably one to 10 to those tests and at least this is what I hear the most.

Jessica:

Okay. What else are you hearing from the front lines in the hospitals? Everywhere around the world, this is no surprise to any of us who work in any aspect of healthcare, overburdened health systems. So, give us a sense of what’s happening in Italy. What are you hearing from the front line there?

Roberto:

Public health here is extremely good. Our national health system, it’s one of the top in the world and even the people that work in the system, I’m talking about doctors, nurses are extremely, not only professional, but they are loaded with that really extra charge or overcome this kind of extremely challenge situations. And a lot of them that had been infected that as well and despite that, you have people that are recovered and then went back to the front to fight the disease they are seeing. So, this is really amazing, the reaction that the system is having. The issue is that when you have a…. In the most challenging cases it’s all about the ability and the capacity that you have in terms of providing intensive care and ventilation.

Roberto:

So, the real issue is that when there’s a too high peak and so those beds are saturated and you are working at capacity or above capacity. There is where basically you start to struggle. And in order to fight this new, basically… Wards have been being converted to COVID wards in hospitals, new spaces have been opened and also a number of different initiatives have been put in place to augment the capacity to provide ventilation. So, we are coping with it, fighting hard, holding really strong. But the key is really to have a less steep as possible curve, as basically the infection spreads out. And this is basically what countries that have been able to observe Italy, which is the first Western country with a comparable health system and government model and social model, basically that has been hit. There’s a lot of learnings that you can build on Italy over there these last four weeks, which I see that are being probably partially followed. If you look at the not so fast probably, way lock down is being deployed, and I’d also think that the other risk is the expectations. This is not a two weeks thing. This is a several more weeks thing.

Jessica:

Yeah, I was going to ask you about that, we’ve got president Trump saying, “We’ll be back to work by Easter,” and here you guys are now, four weeks ahead of us. What kind of information are you getting from your government in terms of the timing?

Roberto:

Nobody knows yet for sure.

Jessica:

Fair enough.

Roberto:

My personal opinion it’s that probably safe to say there are four more weeks of comparable lockdown, maybe six, but then it’s all about how this evolve with the immune response and so, how to predict how this will evolve. Do we need more lockdown? Do we need maybe locked down by areas? There are some pulsed lockdown schemes that also being discussed, but certainly I don’t think it’s a two weeks thing to be honest.

Jessica:

And then what are you finding out about patients who have been infected, who recover. Is there any takeaways from there as people are starting to come out of the other side of this?

Roberto:

To be honest, I don’t have information about that or heard nothing. But I also don’t think there is capacity to study those patients deeply as of yet because we’re still the peak of the emergency to fight and you need to of course assist those that are in critical conditions. I think the immediately after, and especially through digital, we should be able though to monitor better and to observe longitudinally, so to speak, what will be the population dynamics about that. But I don’t think there’s much data as of yet about this.

Jessica:

Well, let’s talk about this digitally for a minute because I do want to get an idea from you of what’s happening with digital health in Italy and Europe as you guys are tackling this virus as well. And so, we in the U.S., we’re looking at digital solutions, tele-health solutions, digital therapeutics to help keep people out of the hospital or help remote monitor or things like that. Same things. So, give us a sense of what’s happening there and you’re coming at this… For those who may not be familiar with Healthware, it’s a big organization and partly you do work with different pharmaceutical companies. So, I’d love to hear a little bit about what’s happening there but also you are in an investment fund as well and you work with startups and you have a couple of startups in your portfolio, one of which is a telehealth company. So, tell me a little bit about that side first, I guess, what’s happening that you guys are working on directly?

Roberto:

Yeah. So first off, as this started now a month ago, we built an integrated crisis team within the company and this crisis team has been in touch with our clients and partners and is teaming up with them to help first in Italy and now is expanding to other countries unfortunately, helping them to cope with the situation as well, which largely relies on the much wider and deep adoption of digital tools in order to enable remote working, remote collaboration, also think about scientific teams and anything that can facilitate the response to the emergency and to the research.

Jessica:

Yeah.

Roberto:

So, that’s on one side.

Jessica:

Okay.

Roberto:

On the other side, we basically started to team up with the startup companies of our portfolio to see what we could have done to respond to the emergency, right? I think it’s fair to say that we are doing, in Italy, 10 years of digital health evolution in 10 days. This is really crazy to say, but I’ll give you some data that really goes in this direction.

Roberto:

So, to give you an idea about that, we teamed up with a startup called [inaudible 00:12:56] Medica. This is basically a digital platform that connects patients and physicians. So, during the first days there was a big need for information and education. So, the first reaction these guys developed with even our support, a chatbot to triage symptoms and help people to understand better and do self assessments. So, in doing this, what basically happened is this chalkboard was built, was out in the field 72 hours after the emergency started. So, super early and we have been donating and keep donating this chatbots to any hospital, any government institution that basically requested for it.

Jessica:

Great. How has the uptake been? What has the response then?

Roberto:

The response has been great. So, first off I’ve been happy to see that government has been able in few days to validate, to do all their sue diligence scientifically and that’s on many of their websites. So, this was a super easy, privacy conscious, totally anonymous self triage chat bot, easy to integrate on websites. So, it was designed on purpose to be faster response, right, and this has been in place now since already some time and there are, after the last count count, over 70,000 people that have self triaged. And most these data have been recorded and made available to a task force of the minister of innovation in the country that has been created around basically data-driven initiative to take better decisions. Those data are now in the process of being also donated to the WHO, that requested for, to contribute to their own data initiative and this is our full triages with self reported symptoms, body temperature and [inaudible 00:15:03] for geo localized throughout the country.

Jessica:

So, it sounds like lots of government support for that, for getting that data, for getting that deployed quickly.

Roberto:

Yeah, and so that’s why I said there’s been this huge leap frog because government has been able to quickly adopt, to deploy on several sites. More sites are taking on this so that more channels are contributing to accrue more data and has been designed in a way that doesn’t concern with GDPR and privacy because it’s fully anonymous. And so, he’s helping really to have meaningful data points. So, that has been the first basically response. And then in keep working with these guys at [inaudible 00:15:46] Medica, they were providing as a normal business video consultation, right? Between patients and doctors and remote disease management. So, as any other telehealth platform, of course patients were able to book their own visits. But this was not effective for the emergency because if you think situation like this, physicians would have been inundated by requests.

Roberto:

So, they have been amazing in hacking their own solution and what they basically did, they turned the basically user experience upside down ,allowing the physicians to invite patients based on needs, so that through this they are reusing the exposure because they are not seeing the patients face to face, but through video. I can give you some data points which are very interesting. It happened 10 days ago, it’s being made available for free to any doctors in the country. And in basically less than 10 days, more than 1300 doctors registered and started to perform video consultations and these are huge numbers for the country, which was much behind in terms of teleconsultation or video consultation adoption. And as we are speaking now they are reporting data that there’s a new video consultation that starts every other minute.

Jessica:

Oh, wow.

Roberto:

Which is great. So, that has been second line of response and the third and very interesting, which went live only two days ago, as now, big part of the game is to monitor patients that are positive and are stayed at home. Because they have either little symptoms or they have maybe even no symptoms at all, right?

Roberto:

The key is to monitor those people in distance because you need to keep the hospitals that are already at capacity free for those more challenging cases, for emergencies. So, they’d be adding on top of the self triage and the video consultation, a disease management module for the COVID positive patients where either the patients themselves or their caregivers everyday can report symptoms, body temperature, saturation of oxygen. So that the physicians that have them in charge from remotes have a dashboard to basically check how their patients are doing and intervene or alert the emergency, right? Basically ahead of time. And this is where you would win the battle because if the ratio is really one to 10, as we all think, for those that are in the hospital, there’s this large population at home that needs to be taken care of. And so, I’m happy to report that in the first day of operation, already the first 60 patients have been enrolled and started to be managed from home. So, I think this is incredibly if you think because they put all this together in less than two weeks free to everyone and we are extremely proud of.

Jessica:

Amazing. That’s absolutely amazing. I’m listening to you talk and I’m thinking to myself like, “Oh, my gosh. There’s so much for us in the U.S. here who are four weeks behind basically all of the things that you’ve done and implemented to learn from you.” So, it’s wonderful to talk to you and to hear how you have managed through this and how some of these digital health companies, telehealth companies are pivoting to meet the needs of what’s going on there as they’re unfolding. There’s a lot for us to learn. On that data piece of it, as you guys are collecting this stuff, are people able to partner up with you on this? So, for example, if there is out there a startup or a big health system or somebody who’s watching this right now and they want to find out how they can mirror what you’re doing or learn from what you’re doing, is there any… Sorry to put you on the spot and ask, but how can we share all of this information?

Roberto:

Yeah, no, there are two things that we are helping the guys that [inaudible 00:20:07] Medica to do. So, the first one is that the platform is being made available to any physician, group of physician, physician network or hospital that wants to adopt and several really are doing as we speak. Government has also opened a call for startups that have a response to different topics including this. Of course, these guys have responded so I hope that next week the Ministry of Health will basically help you spread this initiative to anyone through their own official channels. But I think it’s interesting to think that we started with them regardless, in a way. The system was built, physicians started to use and word of mouth and reach out one physician to another, has been really totaled, as I said, the 1300 physicians that are using this.

Roberto:

So, I hope that the next [inaudible 00:21:08] will be government adopting this and spreading it even more. Because I think the key to this thing is the usage. Is this something simple enough for physicians that maybe are not used to the systems to take on and use it immediately. And for patients at home to do the same. We now have a huge proof of concept that is true, so now next step is really to spread the distributions. So, that’s basically one of the next steps. Data. [inaudible 00:21:46] and a couple of universities that have strong data science capabilities are teaming up with our own data scientists to look into this data and find if there’s anything interesting there.

Jessica:

Keep us posted, please.

Roberto:

Yeah, no, that for sure I’m-

Jessica:

We’ll find you somebody on either Google or Apple to work with on, and taking that to the next level.

Roberto:

Yeah, and as you can see I’m taking a little bit of a diary on LinkedIn about this thing, so that I’m trying to make everyone aware about this initiative. The other thing that probably is worth mentioning is that the chatbot has been made available in a number of languages through voluntary translation. So, we will publish a page to apply to that in the coming days. And of course there are a lot of startups in around the world that are really in the conversational digital health space, which have deployed their own things and that’s great. What’s special to this initiative is that this is a super fast to deploy, web-based, totally anonymous. So, it’s super easy to embed onto any website and feed that this dataset that is growing behind the scenes and donated to research institutions. So, I think that’s probably part of that. So, in a couple of days the first languages will be available starting from English, Spanish, French, German, Portuguese. So, it will be made available around.

Jessica:

Okay. Well, Roberto, thank you so much for letting us chat with you and letting us visit you while you are in your self isolation there in Italy and hear about what’s going on not only in the healthcare system. What you’re picking up, anecdotally, word on the street, but also what you guys are working on there at Healthware. So, it’s been a pleasure to speak with you. Thank you so much.

Roberto:

Thank you, and we are all in this together. We were hoping this stayed a Chinese, Italian thing, but unfortunately it’s not. The only thing we can do as a global community of digital health people is really to mobilize as we have been doing in Italy and there’s a lot of technology all around the world. So, I think it’s incredibly important that in a [inaudible 00:24:09] focused, probably even organized way, but we come up with whatever we can put in place for the institutions to fight this thing because digital can do so much. Given the specific conditions, given how this epidemic is spreading, it’s probably something that as much as drugs, digital health can contribute just probably in the same way.

Jessica:

Roberto, thank you so much. Thank you so much again for your time. I’m Jessica Damassa and that’s Roberto Ascione from Healthware, reporting to us from the Amalfi coast in Italy and we thank him for his time. If you’d like to check out more of these video interviews with health leaders from around the world and specifically in health technology, digital health and telehealth as they’re working on helping the healthcare system combat COVID-19 please check out my YouTube channel. It is youtube.com/wtfhealth. I’m Jessica Damassa, thanks so much for joining us. See you soon.