Monday, November 10, 2014

Dexcom's conference call and some disturbing trends.

Dexcom is currently the clear leader in Continuous Glucose Monitoring. I believe that CGM, as it is commonly abbreviated, is an essential tool in diabetes management. Within a few years, I am willing to bet they will be seen as the cornerstone of correct diabetes management, possibly replacing blood testers, just as blood testers replaced home urine test sets.

Unless, of course, some breakthrough technology becomes widely available... While the artificial pancreas currently in development will rely on CGM, long term implantable sensors or non-invasive sensors that actually work could disrupt the landscape. And a fully functional encapsulated ß-cells implant would obliterate it, much to the delight of Type 1 diabetics.

That being said, assuming we don't see any of those drastic changes, Dexcom is likely to remain a significant player in the field for a few years. That's why it is interesting to pay attention to where they are going.

Dexcom talks

Dexcom is clearly trying to have its cake and eat it. On one hand, they would like to have as much control as it is possible on what is done with their products and its data output. Being a Class III medical device has its advantages: "Prior to doing so however we would want assure ourselves that any such third-party has a robust quality system and regulatory resources required by FDA to develop and maintain a Class 3 medical system." But they would also love to grow their market tremendously, using the opposite argument: "We have always considered CGM to be a consumer product, it has requirement of a medical device, but the utility of it and its power as a consumer tool." Yes indeed, wouldn't it be nice if everyone was constantly monitoring his glucose levels and sensors sold as razor blades?

That's the behavior of a fairly typical business in a capitalist society. Capitalism drives innovation. We need innovation therefore we need to live with the drawbacks...

How is your licensed data flux doing, Sir?

But we can also see the hints of a disturbing trend.

"When it comes to retrospective display of our CGM data we have announced open architecture policy whereby we will allow third-party software developers, companies such as Tidepool, Diasend and others, to display retrospective data from our G4 PLATINUM system within their data aggregation platforms."

While "open architecture policy" sounds very nice, there is quite a bit of discrete semantic drift here. Note that your blood sugar levels aren't really yours anymore: they have become "retrospective data from our G4 PLATINUM system". Dexcom is not even the worst company on the data access issue: they still allow you, to some extent, and for now, to choose where you'll look at and analyze your data. But the blood glucose levels that you used to consider yours, to be shared with your doctor, is slowly becoming a licensable data flux. 

Repeat it often enough and it will start sounding natural.

We know a ton of things about you, would you like to buy that, Sir?

This, almost casually, came up in the discussion about the "Share", their remote monitoring platform.

"And we have learned a whole bunch in a very short period of time about our patients behaviors and patterns and their glucose reading."

Again, this sounds very positive, very smooth and innocuous. But let's think about it for a minute, step by step.

Glucose reading: that is, I believe, the less controversial part of the statement. After all, Dexcom is in the glucose reading business. Sending your data to them (to look at) seems logical. But do HIV test manufacturers need to know if you are HIV positive? Does Dexcom need to know how you are doing in terms of diabetes control? From what they say, they apparently had a very extensive look at the data of their users. It would be interesting to know who has access to that data (server admins, contractors, etc) and how it is controlled.

Patient behaviors and patterns: this one is, in my opinion, a scorcher! Why would Dexcom analyze patients behaviors and patterns. Look at the graph below

Can you spot when my son took his bath? Yes, right before 7 PM, as shown by the loss of connection with the Dexcom receiver. Is Dexcom really the ideal partner with whom you'd like to share your behaviors and patterns? That's none of their business!

But of course, it is!

The issue, you see, is what we commonly call Big Data. Companies would love to know as much as they can about your life and behavior patterns. That's the Google and Facebook business model. They know a lot about us, we kind of know that they know a lot, even if few of us have a precise idea of what "a lot" means. Our profile is the product and, in exchange, we get to use nice free services. That deal is a bit controversial and often attracts a lot of attention.

In the diabetic patient case and in health care in general, companies are jumping on the trend and  would love to sell you analysis software or even better, simply the analysis itself. They would love you to subscribe to a service that gives you "meaningful advice based on large scale pattern analysis" and all that kind of stuff. That's where a part of Dexcom's future business lies. (but you'll still get to pay for your receiver, emitter, share and sensors... )

We still have a choice.

Today, that kind of service is still "opt-in". You can still look at your data in the privacy of your home, choose when and with whom you will share it. However, you can be sure that in the next few years, you'll have to defend the right to "opt-out". Security and confidentiality reasons will justify locking your own data out of your direct reach. Convenience will pressure you into hosting it with commercial providers. Incompatibilities and data sharing contracts with private insurers will prevent you from switching vendors and lock you into what may have become a sub-optimal solution...

But this remaining freedom hangs to a single fragile thread: the ability to have full access to our data. Once we have lost that, we will have stopped being patients and become licensable data flux.

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