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How Environmental Health Insights Improve Patient Outcomes

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Tamir: So, for those of you joining us for the first time, BreezoMeter provides the world's most accurate environmental insights across over 100 countries under 5-meter resolution. My name is Tamir Kessel and I lead BreezoMeter’s healthcare business. Today's event is a special one as I have with me Eric Klos, the inventor of Daily Breath, which is a mobile app for those with asthma that pinpoints triggers one symptom at a time. 

Eric's been a health IT professional for over 30 years and has a couple of startups under his belt. He spent the last five years accumulating over 10,000 hours in the domain of environmental factors and respiratory health. Eric, welcome. Thanks for joining.

Eric: Hi Tamir, thank you for having me today.

Tamir: Eric has joined us today to share the story of Daily Breath including his personal journey to finding better, more personalized health solutions for chronic respiratory disease sufferers. I'm sure this resonates with those of you on the path or working towards a similar goal. Eric, perhaps you can start with your origin story and what motivates you to help those with respiratory conditions?

Helping Respiratory Patients - Eric’s Motivation

Eric: Sure Tamir. Well, you asked how this started. There was a lightbulb moment about four to five years ago. My sister was living with the family at the time and she has rheumatoid arthritis. One morning she came down with kind of her gnarled fingers indicating that she was having a flare-up of her rheumatoid arthritis and she casually kind of said, you know Eric, you ought to develop a mobile app that would tell me when my RA is going to flare up based on weather changes and things like barometric pressure, humidity, precipitation. 

And so it was kind of a lightbulb moment for me. I just kind of thought about environmental factors as a determinant of health. I felt like the medical community really didn't talk about it that much or it wasn't something that was really highlighted. So I began a journey at that time to kind of do my own research around the topic and start learning about it and I ultimately decided to focus on respiratory conditions because, you know, obviously, pollution and pollen and weather you know the impacts of that on a respiratory population are pretty apparent, right? 

Then also I realized that the disease burden is pretty significant for patients, for family caregivers, and for the health care system as a whole. But ultimately I did not necessarily have a family member who had asthma but what really moved the needle for me from a passion perspective was an article I read that said that doctors were trying to pinpoint the cause of an asthma attack after a 15-year-old girl had had a traumatic event. 

The nonchalance of the title of the article really kind of struck me. Because when you read the details, this young person was basically down for 20 minutes, obviously stopped breathing, and she's now traumatically impacted. She's a paraplegic for life. So it just kind of struck me. As you know, determining triggers after the fact is really not what we're trying to do. We should be trying to pinpoint triggers ahead of time and really preventing asthma attacks.

So that really is the source of my passion and it's why I'm driven to kind of ensure that one life breathes easier.

The Environmental Impact on Asthmatics - Reclaiming Control

Tamir: Thanks for that. Makes a lot of sense. I really understand why you're so passionate and so focused on this bit. Do you think the general asthmatic population understands how the environment impacts their symptoms? Why do they not make more trigger management systems in place?

Eric: Right. Well, I think there's a loose understanding. But I think to your point, I mean people have a general sense that they're kind of at the mercy of the weather and the environment. It's not like you can change the weather. But the reality is you can be health prepared right? And that is really the goal of changing the focus of how we're approaching asthma attacks. 

Instead of really looking at asthma attacks as kind of a default, if you have asthma you're going to have asthma attacks, we want to kind of change that paradigm. We want to focus on trigger management, trigger education awareness, reduction, and avoidance, as opposed to just assuming that if I go outside I may experience some type of exposure that will cause an asthma attack.

How Daily Breath Empowers Asthma Patients

Tamir: That makes sense. In that context, tell me about Daily Breath. What is it and how is that unique in solving this problem?

Eric: I came up with kind of an idea that I felt the weather, pollution, and pollen actually converge. Usually, you look and you see an air quality index or you see a pollen count or you see some weather variables. But it's actually how all of these things converge to create a kind of personal exposure index, right? When you go outside you're individually susceptible to this confluence of factors. It's not just one particular thing that triggers an asthma attack but it's the entire environment that surrounds you that actually causes you to have an asthma attack. 

So I felt you could develop a personalized risk index over time by tracking symptoms. In the mobile app, you actually are able to track symptoms, and that ultimately drives a personalized symptom forecast for you. And then there are some unique characteristics where you're actually able to track the place where you're having these experiences. So again, that gives another filter for risk. Where in my community am I experiencing that confluence of pollution pollen and the weather that's causing me to have difficulty?

The Challenges of Traditional Environmental Monitoring

Tamir: What have been the obstacles and frustrations that you faced along the way when attempting to develop a better solution? And what have you learned since?

Eric: I think my experience probably wasn't much different than BreezoMeter’s founder right? You’re looking for air quality and pollen information and my impression had been that it was fairly granular, you know, it was very hyper-local and that it was real-time. That it was very timely. 

And unfortunately, when I looked at that, I looked at air quality measurement and pollen measurement and learned that it wasn't very granular, that you know for me in Fairfax, Virginia, the closest air quality station or measurement station is over 30 miles away, right? So it wasn't very granular and so that's somewhat problematic.

And then with pollen measurement, you have a very antiquated way of measuring pollen right? It's a piece of flypaper that captures pollen spores on it and someone literally brings down that paper, looks under a microscope, and determines the pollen count and what the pollen type is. I really felt that was the biggest gap.

Environmental Insights Enable Better Protection

So for me, when BreezoMeter emerged as kind of a global air quality leader, they were taking inputs from satellite data and vegetation data and really getting down to a hyper-local five-meter level, so you can actually deliver personalized symptoms forecasts because you're tracking specifically what symptoms they're experiencing with that particular granular data available.

Tamir: Yeah. And I guess having information from just station data is very useful for doing aggregated types of research. But if you're an asthmatic, knowing that pollution is high you know three miles down the road is important but it may or may not be relevant to you so that hyper locality is absolutely critical to really understand how it's gonna impact you personally and your condition, right? 

In the market, I speak to all sorts of new digital therapeutic solutions for respiratory diseases. Why do you think that is happening now? Why are there so many, what's changing in the market? Is it around awareness, is it around the technology, is it to do with Covid?

Why The Shift to Digital Health Solutions?

Eric: Let me take that a couple of different ways, and I'll talk about Covid last. I think the first thing is that I think you actually see that we have a very changing climate and you see an increased number of extreme weather events, whether it's hurricanes, whether it's extreme heat, whether it's wildfire smoke. You have a map behind you of California with wildfire smoke visualization. I think that's kind of heightened the awareness of what these impacts are on a vulnerable population like people with respiratory conditions. 

Then you hit the Covid thing and that is one additional layer that's really accelerated the interest, right? Because people who have asthma and COPD already have vulnerable airways. And so they're potentially vulnerable to getting Covid more. We're also seeing some reports early on that are saying you know areas with higher levels of air pollution have a higher incidence of Covid. 

So you're seeing some type of correlation. I don't think that's totally known right now, so we have some gaps right there. But clearly, the other element is that people who have allergic asthma, they're having allergy symptoms and they're confused. Are these allergies early onset symptoms of Covid? So there's some confusion there and so that creates a need or a desire to have tools that can tell me: okay am I experiencing allergies? The tool itself will actually say, okay well, there's an exposure nearby so maybe it really is just allergies it's not necessarily Covid, right? I think that's what's kind of accelerating this. 

And then from a health care perspective, I think what's clear here is that there's been a great movement in self-care management. Without the ability to visit your doctor in person, people are looking for digital health solutions that can help them manage their own care between either those televisits or in lieu of going to visit the doctor, what can I do just to keep my condition in check?

Tamir: Yeah. I think everyone's talking about how Covid is changing the world and accelerating some trends and this is definitely one of them. They think about telehealth as being just the ability to talk to your doctor remotely, but it's also about being able to have at your fingertips the ability to take care of yourself and having more personalized information, right? Tracking your own symptoms, your own condition, and the environment around you as well as what's enabling this.

The Power of Personalized Health-focused Solutions

So how do we encourage that self-care? How do digital therapeutics use the data to help people manage and improve their conditions better practically?

Eric: Right, well I think one of the keys here is that digital health solutions can offer kind of a feedback loop. And so what's unique about Daily Breath is we want to track your symptoms, your earliest onset symptoms, the warning signals that are associated potentially with your exposures outside. And once we start tracking those then we're developing a kind of profile for what is your individual susceptibility to specific conditions that you may experience. 

So next time we can forecast, if you're going to go out, what you might experience. I think that it's that feedback loop that becomes really powerful because people want to receive personalized insights. The way we've treated exposures to date has been based on what I call kind of a distributed public health broadcast model. You see an air quality index for a particular zip code and what that's defining is that everybody within that zip code is impacted by that air quality exposure the same way. 

What we're trying to do is flip that and say, listen we each experience the exposures differently, right? Our exposure footprint is just like our genetic footprint, very very unique. So can we begin to capture that information and then use that information for the patient? I envision them actually using that information to reduce and avoid their triggers. But also we actually can begin to develop information about the drug interaction with those particular exposures. Are particular allergy medicines or particular asthma medications more effective or less effective? Can they be more targeted with precision medicine in the future?

All of these things I think are possible when you have an information loop that defines symptoms and exposures.

Leveraging Environmental Data to Create Individual Symptom Profiles

Tamir: So it's not just about personalized environmental data, what is the exact level of pollution or pollen or specific pollutant that you're being exposed to but, it's how your body, how you react to each one of those pollutants. So there might be a high level of oak pollen or carbon monoxide, and you might be an asthmatic that's reacted in one way and I might be reacting to it in another. Understanding the relationship between each individual and the exact pollution environmental factors that they're touching on.

Eric: Exactly. I think the one thing that's been the gap is the way we've approached pollen previously is to focus on trees, weeds, and grasses, and that's usually by seasonal observations, when do I experience allergies? Oh, trees in the spring, grasses in the summer, weeds in the fall. And yet we're actually vulnerable to specific types of trees, as you indicated. Some people might be vulnerable to oak trees. Well, we don't even have that predominant pollen type you know in most of the applications that are out there. So if you want to really deliver kind of personalized information we need to know exactly what they're being impacted by.

The second thing you identified is we don't even know what the interaction between CO2 and pollen is. What is the impact of carbon dioxide on the intensity of pollen or the allergenicity, which is kind of the impact it has on the individual? It could definitely be impacting you differently on any given day based on some weather changes or some weather impacts and those kinds of things.

Tamir: Yeah I think that that interaction, the more local we can get information, we can also better understand the interaction between the different elements of the environment with climate change. There's a lot happening in that sense, pollen season is getting longer, etc. So the market's fast-forwarding ahead, it's moving from preventive to predictive, it's being accelerated by COVID and telemedicine. But putting aside all these fancy words of AI and Big Data, all that stuff, can you paint a vision of what digital health will look like in the respiratory space, say, five years' time? What will the patient journey look like, where do you think it can be?

Eric: I think the areas of opportunity are really in what I call ‘wearable sensors’. So we're beginning to see some things that are emerging where they're starting to capture PM2.5 and ozone literally on a keychain. And that's really giving the ultimate personalized profile for exposures. Right in your immediate environment, what are you experiencing? Not not a mile down the road, not five miles down the road, but right around your person. So I think wearables are an interesting area of opportunity. 

The second thing is we're going through a transformation where, as I said, this information has been pushed by zip code. Now what we're going to do is say, well the individual needs to pull the information to them, so how can I pull information that's personal to me and receive information? So this is where alerts become very dynamic, whether it's alerts in the app or whether it's text messaging. 

Can you be notified for example at the aggregate level where the Daily Breath risk index is above 3and you get alerted or if there's a specific variable that you determine is a prevailing factor for you experiencing asthma attacks, then you get alerted when that threshold is met. Maybe it's on days when it's 90 degrees or above that you seem to have more difficulty, so you could get an alert on that particular day. I think that pull model is really emerging. 

And then finally what's very unique about Daily Breath is what I call the community-based flare-up map. That's crowd-sourcing flare-ups or symptoms, and what that allows from a health perspective is individuals within a community to understand where the levels of highest risk are for a similar population like Asthma sufferers.

But beyond that, it actually from a community perspective shows stakeholders where pollution is worse. It’s something that the community might be able to address. Things like environmental remediation or specific mitigation activities in order to support a healthier population within that community. So I think those are some really creative ideas of how things will change over the next five to ten years.

Tamir: That's amazing. It's looking ahead not just at hyper-local personalized environmental information and or personalized risk factors but how by accumulating that data over time from a community perspective we can sort of feedback more information about the environment based on what we know from individuals. And then that sort of circular kind of feedback allows us to be even more personalized and more accurate. That's an amazing vision looking at it from a community to the individual. Thanks for that.

Q&A

I think we're coming towards that part of the chat where we'd like to open it up to the audience. So if anyone has any questions please type them in the Q&A. This is the best time to do that. We'll see how many we can get through and if we don't get to your question we'll follow up with you directly. 

So interesting questions come up and I think you touched on this: in your experience, what is the relationship between pollen and pollution, and how does this affect how you account for personalized tracking? 

You sort of touched on this a little bit. Maybe you can expand a bit more about what we know about the relationship between the two.

Eric: Sure. And again I think this is a fundamental reason Daily Breath is somewhat unique. I felt that it's the convergence of weather pollution and pollen that impacts an individual, it's not those particular exposures in isolation. So to be frank we don't know a lot of information because we haven't been measuring it. You can't manage what you don't measure. So I do think that's where there are a lot of opportunities and I do see you know in academic areas academic research people exploring what's the impact of CO2 increased levels of CO2 on a community or a particular type of pollen.

I know of studies in Detroit around ragweed. I know of studies in Texas around mountain cedar and they're looking at these types of dynamics. So I think what's interesting from a standpoint of the mobile health app or the digital health solution is that now we start to aggregate more volumes of data, we know more information about what is the experience of asthma sufferers in relation to these different types of pollution and pollen variables, and this information can really support the research community in kind of beginning to understand what are these specific correlations. 

Because I just think again we don't have enough data. And that's really where this is an exciting time because you use the code words of AI and Big Data but the reality is that's what's enabling all of this, right? It's the ability to aggregate all of this data. It's the ability to apply machine learning to the data and really come up with more information that's helpful both for the patients and the provision of care to those patients but also for the community at large.

Tamir: Yeah. And what I see is it's really helping to accelerate the awareness around this. Because even when I speak to some of the healthcare life sciences companies in the allergy space, they're very interested in pollen data but they don't often look at pollution. They think, okay, obviously if you have asthma I think that's well known and asthmatic and COPD sufferers know that both pollen and pollution are going to affect them. 

But I think people with seasonal allergies are less aware of that interplay and the fact that there's already proof that carbon monoxide directly affects, intensifies, as you said, or triggers more pollen. So being aware of pollution levels as somebody who suffers from allergies is something really really critical because it's gonna again help better inform you on your exposure, help you better plan your daily life, and be able to avoid that.

What would you say is the best route, in terms of growing awareness, for businesses like yourselves to help patients and the general public grow their awareness and reduce their exposure?

Eric: I think we're going to see that as these types of incidents occur, I'll give you an example, we have the wildfire smoke out in California and one of the things on my roadmap is kind of the capacity to build a wildfire smoke alert. So what that means is, based on dynamic winds and the plumes that are coming from the smoke that travels literally 300-500 miles in a particular direction, is there a way we can dynamically alert people that that particular smoke may be another exposure that you might experience today? 

So I think you're seeing extreme weather events, the changing climate, have things that people are looking at and going, wait a second, yeah these exposures are impacting us. They're impacting us more dramatically. We haven't focused on it from a health perspective. And yet those risks are becoming more acute. So we need to address it from a health perspective and empower the patient to understand these impacts more. And if we can do that in a changing climate, we’ll hopefully potentially preventable asthma attacks. And that's one of the keys here. 

Unfortunately, I think the health system has accommodated asthma attacks. They think it's a norm for patients, right? But if you talk to asthma patients and family caregivers they don't want to experience asthma attacks, they don't want to use their rescue inhaler, they want to avoid asthma attacks, they want to avoid the symptoms. So that's what we're really trying to do is empower patients.

Tamir: I agree 100%. We'll take one last question here that's come up from Mark, who's asking, asthma and COPD are chronic diseases that require managing over time and patient compliance to meds is typically poor, which also leads to exacerbations and deterioration, but are you aware of more forward-looking trigger data sources in weather, pollen, and air quality?

Eric: I think there are a lot of things that are emerging out there. Most people know about Propeller Health. Obviously, it's something that attaches to inhaler medication and tracks when people use their inhalers, the time and the location, and some of those issues, and potentially may even connect to the weather and environmental conditions. 

The challenge with that is if we're only stamping the time at which they actually have respiratory difficulties that require the use of a relief inhaler? The question is are there other symptoms that the person might have been experiencing, other exposures that the person might have been experiencing even hours before that ultimately led to that final flare-up? That final asthma symptom that tips over to the point of feeling some level of respiratory difficulty that requires this relief or rescue inhaler?

I think those are things that are emerging and I think they're very positive in some sense and they give a good profile. But is there a way to actually capture maybe early warning signals of asthma symptoms?

Tamir: Yeah, and I think this touches on what you were saying earlier looking into the future and wearables. If you can take biological signals, be it from oxygen levels, say for COPD, and combine those with forecasts for air quality and pollen, then you know, here's somebody whose condition is deteriorating he or she doesn't even know. And we can warn them. Hey, your condition is currently very susceptible and the environment's not quite healthy in the near future, because we know the forecast for the next few hours is not great, protect yourself, be aware. 

I think that's a really intelligent combination of all of those factors, which, as you said, some companies are already using to build sort of prediction algorithms. I think those are going to get richer and more sophisticated so I think that's a really good question to sum up on, actually. 

There are a few other questions we'll try to respond to those directly. I just want to thank everyone for joining and thank you for sending the questions. I want to give a really big thanks to Eric Klos. Thanks for your time, thanks for joining us, and for sharing your personal experiences on this journey. We look forward to seeing you all in the next live event.

Eric: Thank you.