HealthChangers Podcast: Always Begin with People

October 31, 2018

"We hate that people say, 'Your son is a diabetic.' No, he's actually a person and he happens to have diabetes. We've got to treat them as whole people." Glen Tullman was working in consumer software, when his 8-year-old son was diagnosed with Type 1 diabetes. At the same time, his mother was living with Type 2 diabetes.

"I was watching as we made parts of our economy much more “consumerized,” easier to transact in, more convenient, and we did that everywhere but health care," says Glen.

The National Health Council estimates incurable or ongoing, chronic diseases affect more than 133 million Americans, which represents more than 40% of the total population. So, why does today's health care industry make chronic condition management so challenging? What could be done to fix it?

Hear the inspiring story of Livongo Health CEO, Glen Tullman, who is committed to helping people manage their chronic conditions and live healthier lives. Now on our HealthChangers podcast: 

Welcome to the Health Changers Podcast presented by Cambia Health Solutions, where we share real stories of health care transformation from those experiencing it and those helping to make health care more personalized. I’m your host, Leslie.

Glen Tullman: The first inspiration came from my own personal experience, I have a son who was diagnosed with type I diabetes when he was eight years old. He's now twenty-three and healthy. At the same time, my mother had Type 2 diabetes. We understood how hard our current system of health care made it for people with a chronic condition -n this case, Diabetes, to stay healthy. So, I was living with that and at the same time I was in the software business focused on all other parts of our economy and I was watching as we made those parts of our economy much more “consumerized,” easier to transact in, more convenient, and we did that everywhere but health care.

So, one thought process was ‘what if we could make health care much more like the rest of the economy?’ That was number one. Number two, there are all these programs thatsay they want to engage people more with regard to their health. The messaging was, ‘we want your son, in this case, or your mother to spend more time focused on their chronic conditions,’ and yet the more people I talked to in that space said, "I want to spend less time on my chronic depression."

Leslie: Right.

GT: "I want to make my chronic condition just go away, disappear as if it never happened and I just want to live my life and I'm on the go all the time, so don't give me solutions that require me to go to a hospital or sit at home," and so when we came up with Livongo and we actually surveyed people and said, "What do you want from your chronic condition?" They said, "I want to be empowered and I'm living my life. I just want to live my life and I'm on the go." and so consequently Livongo came from live on the go.

LC: Oh, okay.

GT: It wasn't just about diabetes, it was about all chronic conditions. We hate the fact that people say, "Your son is a diabetic." No, he's actually a person and he happens to have diabetes. We've got to treat them as whole people.

LC: Tell me a little bit about that focus on people. How revolutionary do you think that is for the health innovation space or healthcare as a whole? I mean, obviously health care is about serving people, but we know that it's also complicated, cumbersome and confusing.

Consumers Want To Feel As Normal As Possible

"No, he's actually a person and he happens to have diabetes. We've got to treat them as whole people.”

GT: What we're trying to do turns out to be very disruptive in some ways. One of the reasons I wanted to start in Silicon Valley was because of its consumer-focused orientation and the advancements it makes in technology every day.. But why hasn't Silicon Valley been more successful in health care? Because they were all focused on the technology, and when somebody has a health care issue, they don't care about the technology. They care about getting their problem solved. So Silicon Valley generally has not been successful because it was all about the ‘wizbang wow!’ technology.

LC: Right.

GT: So what we tried to do was sprayall of that health care experience and marry that with this technology in a very consumer focused way; that really hadn't been done before. It's one of the reasons that Livongo is the leading consumer digital health company, that uses technology to actually change people's behavior in positive ways. Now, in terms of this idea of the ‘whole person,’ today, most organizations that yougo to, larger health systems, payers…if you go and survey them and you ask them the following two questions, you’ll get certain responses. First question, are you patient focused? They'll say ‘absolutely.’ Then if you ask them, ‘do you have an engagement program?’ ‘Absolutely,’ probably 99% of them will answer. Those are exactly the wrong answers. That, by the way, just saying that upsets people, is controversial in this light.

LC: What do you mean by that?

GT: So would you like to be a patient in a hospital today? Yes or no?

LC: No.

GT: The answer is ‘of course not.’ No one wants to go to a hospital. No one wants to be a patient, and yet we're very patient focused. We ought to be people focused and we ought to say our job is to keep people out of the hospital, to keep them out of the doctor's office. We see a big movement today. Let's let people get treated, whether they have to have infusion therapy or anything else, or if they're at the end of life. They want to die at their home. They want to be treated at their home. They don't want to go to an institution, so we have to reorient our thinking to say, "Stop calling people a patient." Nobody wants to wear an ill-fitting gown that doesn't button in the back. Okay, that's just not a fashion that's catching on anyway.

LC: No, not really.

GT: Patients have all kinds of expectations. They're not treated well. They're put in waiting rooms. When's the last time you went to The Gap and were told, "Before you can spend your money, you're going to wait in a waiting room." Well, no one would do that. No one would go. We can learn a lot from this idea of focusing-on-people not on ‘patients,’only. Second, no one had to engage a billion people to use Facebook or people around the world to use Airbnb. You didn't need an engagement course. You didn't need training. You knew you should do it because you sense the value. So why is it that we have to engage people to participate in all these programs? That should be a red flag right there. Now remember, Livongo is totally opt-in. No one's forced to use it. They choose to use it. They choose to change what they're doing and to try this new thing. So that alone tells you, well why is that? Answer: because we add value.

LC:  How does Livongo help consumers and people on their health care journey and what are some of the pain points that you're solving?

GT: If you have diabetes like my son, then for your whole life, you worry about, "Do I have to reorder strips? Are my strips running out? How many do I have? Oh, I thought I had four vials left. Now I have two and I'm going on vacation. Oh my goodness, what am I going to do? I have to call my health plan and they're going to tell me until I use at least one more vial, I can't order yet." That's a huge hassle. So at Livongo we say to people, "What would it be like if you never ever had to order strips again?" They arrived at your home automagically and why is that? Because every time you use a strip, we know that you've used it. We have a counter in the sky and then it says, "Okay, you're within a month of running out. We'll send you new strips." That way we don't send people strips who don't need them and you always get them, and you get them just in time. You don't have to worry about that again.

Second, people with diabetes are told, "Keep a log of every time your blood sugar goes up and down." Well, we already have all that information. We can send it anywhere you want, so where might you want that sent? Well, you might want it sent to your doctor of course, and you might want it automatically inserted into your electronic health record and that's done all automatically, if you give us permission, because you, as the person with the chronic condition, are completely in control so you can have it sent anywhere you want instantly. That's a few of the ways we eliminate the hassle map.

LC: What's the word that you're using again? Hassle mat?

More Personalized Care for People, without the Hassle

“We'll send you new strips." That way we don't send people strips who don't need them and you always get them, and you get them just in time. You don't have to worry about that again.”

GT: Hassle map – we detangle the hassle..

LC: Oh, map, okay. No, I like that term.

GT: The term was stolen from one of the partners at our venture firm, Tom Mayne, who I think invented the term. What he used to do is work with consumers and examine  the problems, all the pain points, all the hassles you have, and they would tell him and he would map them out and say, "How can we use technology- or better process redesign- to actually redesign a process that makes it easier to stay healthy rather than harder to stay healthy?"

LC:  Yeah. That's cool. How has the learnings with the diabetic chronic condition solution helped you as you've expanded to support people with other ... Living with other chronic conditions and enabling them to live better, healthier lives?

GT:  What we've learned is how to make it easier by, exploring those pain points and that hassle map. People will use the product more, but mainly they will stay healthier andethey'll adopt healthier behavior. We know that, as I mentioned, 68% of the people who have Type 2 diabetes also have hypertension, so that's the first product that we introduced on the same platform. So we said, "Well, if you have diabetes, let's make it easier so you don't have to download a separate app, you don't have to talk to a separate health coach if you need advice, you don't get two kinds of advice that are conflicting." So that's the release of our hypertension product, and along with that product we wanted to be able to say again, "How can we monitor your information and share with you further insights and nudges ?"

There are two things that we do. Insights come from questions such as, ‘what did people like you, what have they done, what behaviors have they shown, what exercises might they do, what foods might they eat that they found to be helpful in either managing their hypertension or their diabetes?’ So those are insights we get because at Livongo, we now have the largest near real time and real time database of diabetes information in the world.

LC: Oh my gosh.

GT: Data scientists look at that and say, "What can we learn? How are men who are 60 years old different from women who are 30 years old different from kids who might have Type I?" All of those require different solutions and so that's what we call “Insights.”

The second thing are ‘Nudges.’ What is the right time to tell somebody about a behavior change? So we might analyze your data and say, "Well, you know what, on Fridays you always wake up with your really high blood sugar," and we may ask you a simple question and that simple question is, "What are you doing on Thursday night?" So some people might say, "Well, I was exercising," but it turns out exercise is bowling and there's pizza and beer there.

LC: Got it.

GT: They wake up with? a really high number. So there is a solution. It's not, "Hey, you have to stop doing that." It's, "Change your insulin dosing on those nights to give yourselves a little more long acting insulin that night so when you wake up, your numbers are balanced."

LC: Right.

GT: It's a really concrete nudge of what you can do. Now, in that case, we want to be careful because we wouldn't normally give somebody, we might say, "Talk to your doctor about doing this."

LC: Yeah.

GT: We aren't going to tell them, as a digital solution ,to change their prescription, but we will give them suggestions, identify behaviors and the like. We might say, "Be careful what you're eating." That's a nudge. We might remind them on next Thursday night, "Hey, if tonight is your bowling night," now that's really personalized care, but we can do that because again, that's the value of what computers and technology and data science allow you to do.

LC:  It sounds like you've done a lot of research with your users. Are there any stories or anecdotes that stand out for you about how Livongo has helped somebody?

GT: We had an individual and his mother who was over the age of 70. In the Livongo product you can say “my number, my blood sugar is ever dangerously high or dangerously low.” Please notify and put somebody's name in. His mother had one of our blood glucometers which are digitally connected through cellular automatically and she had checked her blood sugar and it was very high, above 500. So he gets it. He's at work and he gets a text and the text is, "Your mother's blood sugar is above 500, dangerously high. She wanted you to know." That all happens automatically. So he called and no answer at his mom's house. He called again, no answer. He gets in the car and drives to her and finds her collapsed on the floor. Calls 911 and fortunately they came and it all ended up okay, but they told him that another half hour and she might not have lived.

LC: Wow.

GT: You think about that and all that happened. It didn't require anything from us because it was all set up electronically. But imagine if every time someone you love, let's say they were feeling depressed, let's say their hypertension or their blood sugar or something else, they were in danger and you got a text, what would your first instinct be? It would be to help them. So if it was a coworker and they were three desks away and you got a message that said this Sally, this coworker, she needs some fruit juice because her blood sugar is so low that if she gets up to get it, she might have a seizure, you would jump up and say, "Well, that's easy. I can go grab a fruit juice and walk it over to her desk," and you do that instantly. You don't need a doctor. We don't need a nurse. We just need this caring community that we can build through this digital connections.

Even if we go to something like depression, the most fascinating response to people who commit suicide, other people say, "I wish I would've known. I could've helped." There are ways to know. People who commit suicide stop leaving their house. They stop making phone calls. They stop. These are all measurable things. In many cases, they can even say they don't know how to ask for help, but they wouldn't mind signing up for something that says, "If I start doing these things, give me a phone call."

LC: Wow, yeah.

Around The Clock Help, Technology Innovation

“It didn't require anything from us because it was all set up electronically.”

GT: We would all love to help if we just knew. So this idea, it's kind of the good thing about social networks, it's one of the benefits and that is we can stay in touch, we can help people if we just know.

LC: Right.

GT: The other thing is if somebody's dealing with cancer, wouldn't it be amazing if they could talk to somebody who just went through what they went through, had a successful outcome and said, "Here's a few tips. Here's a few things I did to make this process easier"? There's nothing better. Even a doctor can't always tell you that.

LC: That's amazing, Glen. I'm very excited listening to you talk and it's amazing to think what you've accomplished in five years. What does the next five years look for your company?

GT: As in tech, it takes a long time to build a foundation, and part of that foundation is technology. Another part of that foundation is building trust with hundreds of thousands and soon to be millions of people to say, "These people get it. They care. It's hugely valuable what they're doing." Once you do that, you earn the right to offer other ways to provide information and services to your base, and so we started with diabetes, but our vision was never about diabetes. It was always about empowering people with chronic conditions to live better and healthier lives, so we started there with diabetes. We then moved into hypertension. We're now into prediabetes. How can we help prevent diabetes from the onset with a diabetes prevention program? Then we're also moving into nutrition and weight loss and soon in areas like respiratory and certain kinds of depression where we think digital solutions can be empowering.

That's where we're focused. So, this is about a single platform and we're building it with partners and so we're really partnering up with people to say, "Let's build these solutions together." Always keeping the member at the center of the work and putting them in charge and empowering them. That's what we think the future of health and health care is going to look like. But remember, health care is when something didn't work. Health is what we're focused on.

LC: Right, exactly. Well, that leads me to my last question. I think it's a good segue, as an entrepreneur in the health innovation space. What are some of the challenges you've faced and what advice would you give other entrepreneurs who are looking at solving problems and helping people on their journey through health and health care?

New Ideas Are Arriving Along with Upcoming Research

“How can we help prevent diabetes from the onset with a diabetes prevention program? Then we're also moving into nutrition and weight loss and soon in areas like respiratory and certain kinds of depression where we think digital solutions can be empowering."

GT: Well, I'd say a few things. One, always begin with people. Always focus on the person first. Second, don't over complicate things. We started Livongo by asking people simple questions like, "What would help use the most? What are you most looking for?" Second, don't be overly enamored with technology. Be enamored with a solution. So you don't care what kind of chip set is in your phone, you probably don't even know. I know I don't.

LC: No.

GT:   What I know is it works. So that's all that we want to know. Number three, ‘just do it,’ to steal Nike's phrase. I also like the saying “innovation begins by doing something.” I see so many people who are spending enormous amounts of time bringing in consultants, forming committees, setting up future meetings. Let's do a 12-month schedule of meetings to discuss this topic. No, no. Why don't we just do something today. Let's start today and actually start doing something because when you're doing something, you're learning and that's what the innovation is about. I love this quote by Thomas Edison. He said, "I never failed. I just found a thousand ways that wouldn't work." That is what it is. So finding things that don't work, that's not failure, that's the learning and we've got to change that model.

LC: Glen, thank you so much for your time today and for sharing your personal story and the story of your company's journey. It's really exciting to see a company like Livongo putting people at the center of their health experience. Thank you so much for being on our show.

GT: Well, it was my pleasure. I always love to tell this story and most importantly, how can we help solve challenges that all of our members have, because at the end of the day, we're all health consumers.

LC: Well, thanks for being with us.

Produced by Gretchen Kilby with interviews recorded by StoryCorps, a national nonprofit whose mission is to preserve and share humanity’s stories in order to build connections between people and create a more just and compassionate world. Learn more at storycorps.org