1.
The Future of Connected
Medicines: Promise and Pitfalls

2.
● 170+ marketed prescription drug products
worldwide equipped with Aptar devices
● Successful track record of 34 approved NDAs,
more than 65 approved ANDAs and 40 INDs in
the U.S.
● Worldwide leader in pMDIs (aerosol metering
valves) for Asthma & COPD
Sai Shankar
Vice President, Digital Healthcare
● Digital health company focused exclusively on
connected medicines for respiratory
● Founded in 2010; acquired by ResMed in 2019
● Pharma partnerships with GSK, BI, Novartis,
Orion, 3 unannounced
● Over 70 commercial programs in the US and EU
Chris Hogg
Chief Commercial Officer

3.
Agenda
Digital transformation is
coming to healthcare
(whether we like it or not)
What patients, providers,
payers and pharma want from
connected medicines
Why hasn’t it scaled?
Lessons learned
Scale is coming
What is changing?
The future of connected
medicines

4.
Digital transformation in healthcare is inevitable
Source: McKinsey and Co.

5.
In our field, this means connected medicines are coming
Connected
inhalers
Connected
injectors
Connected
nasal inhalers
Connected orals
● Medication monitoring
● Adherence improvements
● Breath sounds and flow measurements
● Clinical status and level of impairment
● Change in status or clinical worsening
● Prediction of exacerbation risk
● Abuse detection and prevention

6.
Connected medicines and digital therapeutics
Enhance the efficiency of delivery and make medicines
more personalized, contectextual and precise
Improved adherence to
treatment plan
Patient Engagement Provider
Engagement
Robust Clinical
Outcomes
Health System
Integration

7.
Impact of a digital medicines ecosystem
Outcome-Based
Reimbursement
Consumerization
of Healthcare
Better Clinical
Outcomes
Improved Care
Delivery

8.
What stakeholders want from
connected medicines
Propeller has been actively selling connected respiratory medicines into the healthcare market
since 2012. We have done over 75 commercial programs with healthcare systems, provider
organizations with payers, and have enrolled over 75,000 patients to date. Here are some of our
learnings about what different stakeholders want, and some of the key barriers inhibiting scale.
Patients Providers Payers Pharmaceutical
manufacturers

9.
What patients
want from
connected
medicines
Top Patient Wants:
● Being able to see the big picture about how I am
doing now and what my COPD symptoms look like
over time
● Having access to information I can share with my
doctor
● Learning what causes my COPD symptoms
● Being part of something bigger than myself that is
helping improve and advance how COPD is being
treated and managed
● Getting reminders for my daily medication
Source: Propeller COPD User Research, 2018 (N = 234)

10.
What clinicians
want from
connected
medicines
Top Clinician Wants:
● I want reliable data that I can trust and use to make
treatment decisions
○ I want it to feel simple, not information overload
○ I want only to see the information and data I
need to make a decision
○ I want to be able to take a quick glance and get a
sense of how the patient is doing
● I want to know who I need to pay closer attention to
● I want to save time and see the impact of any new
intervention
● They want to get paid for their time using these new
clinical tools
Source: Propeller Physician User Research, 2018

11.
What payers
want from
connected
medicines
Top Payer Wants:
● Identify, manage and lower cost of most
expensive members (top 1-5%)
● Enroll patients who are specifically identified
on a list vs. using broad clinical criteria
● Want data to make payer care management
more efficient and effective
● Want to do things on their own, but are
beginning to understand the necessity of
involving providers
Source: Propeller commercial experience with US payers, 2016-2019

12.
What pharma
wants from
connected
medicines
Top Pharma Wants:
● Improved controller medication adherence
● Increased market share and brand loyalty,
including a direct relationship with patients
● First mover advantage and differentiation
● Change relationship with payers and
providers via focus on outcomes
● Identify patients who may be appropriate for
biologics
● Opportunities for new product offerings and
life cycle management
Source: Propeller commercial experience with global respiratory pharmaceutical companies, 2014-2019

13.
There is now
ample evidence
that connected
respiratory
medicines ‘work’
54%
Sources:
Merchant et al. 2018. Impact of a digital health intervention on asthma
resource utilization. World Allergy Organization Journal.; Merchant et al.
2016. Effectiveness of Population Health Management Using the Propeller
Health Asthma Platform: A Randomized Clinical Trial. Journal of Allergy
and Clinical Immunology: In Practice.; Alshabani et al. 2018 (abstract,
manuscript in prep); Propeller Health (data on file); Propeller user
research, 2018; Merchant et al. 2018. Digital Health Intervention for
Asthma: Patient-Reported Value and Usability. JMIR Mhealth
Uhealth.6(6):e133
Reduction in asthma
related ED/hospitalizations
35%
Reduction in COPD related
ED/hospitalizations
50-100%
Increase in
medication adherence
15+
FDA Clearances /
CE Marks
70+
Peer reviewed
publications
80%
Patient
satisfaction
Over
3 company exits Propeller, Gecko, Inspiro

14.
While belief in the market is high, nothing has yet scaled
The main question remains:
Why hasn’t
it scaled?
Patients, Providers, Payers and Pharma now see connected medicines as an inevitable part of the
future of respiratory management.

15.
Building and implementing connected medicine solutions is hard
PROGRAM DESIGN
& IMPLEMENTATION
● Physician adoption
● Changes to clinical workflows
● EMR integration
USER CENTRIC DESIGN
● Pairing and onboarding
● Seamless functionality
● Simplify interactions
DIGITAL PLATFORM
● Intuitive user interface
● Secure data platform
● Insightful analytics
DEVICE & TECHNOLOGY
INNOVATION
● Bluetooth, NFC, Direct-to-Cloud
● Chip design
● On device diagnostics
● Battery optimization

16.
When a new
medicine is
approved, the
system just works
1. Medicine approved
(1)

17.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique
identifier code
(1) (2)
Unique
Identifier

18.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique identifier
code
3. Medicine shows up in EMR
eRx flow
(1) (2)
(3)
Unique
Identifier

19.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique identifier
code
3. Medicine shows up in EMR
eRx flow
4. Doctor knows where to find
it and Rx it
(1) (2)
(3)
(4)
Unique
Identifier

20.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique identifier
code
3. Medicine shows up in EMR
eRx flow
4. Doctor knows where to find it
and Rx it
5. Rx magically goes to
pharmacy
(1) (2)
(3)
(4)
(5)
Unique
Identifier

21.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique identifier
code
3. Medicine shows up in EMR
eRx flow
4. Doctor knows where to find it
and Rx it
5. Rx magically goes to pharmacy
6. Wholesalers get medicine to
pharmacies
(1) (2)
(3)
(4)
(5)
(6)
Unique
Identifier

22.
When a new
medicine is
approved, the
system just works
1. Medicine approved
2. Medicine gets unique identifier
code
3. Medicine shows up in EMR
eRx flow
4. Doctor knows where to find it
and Rx it
5. Rx magically goes to pharmacy
6. Wholesalers get medicine to
pharmacies
7. Patient knows to pick up
medicine at pharmacy
(1) (2)
(3)
(4)
(5)
(6)
Unique
Identifier
(7)

23.
When a new digital therapeutic is cleared,
the system doesn’t just work
Unique
Identifie
r
(1) (2)
(3)
(4)
(5)(6)
1. Connected medicine /
digital therapeutic approved
2. Connected medicine does
not get unique identifier
code
3. Connected medicine does
not shows up in EMR eRx
flow
4. Doc does not know where
to find it and Rx it
5. New: Patient needs to
create account
6. New: Patient has to get kit
individually fulfilled and
set up
7. New: Data has to get back
to the patient’s provider
(7)

24.
We are building new rails one step at a time

25.
Attempts at new flows: Provider enrollment / monitoring
● No simple way for clinicians to refer a patient for a connected medicine and no easy way to get data
from the connected medicine back into the physician’s EMR
● Adds work for the clinic staff but no traditional reimbursement for physicians or clinic staff to enroll and
monitor patients
● Transition to value based payments has been slow, making it difficult for physicians to purchase
additional services
● Best enrollment conversion, engagement, retention and clinical outcomes
Physician identifies
patient and ‘prescribes’
connected medicine
Clinic staff creates
account and sets up
connected medicine(s)
Patient uses connected
medicine and is
monitored by clinic care
managers
26
programs

26.
Attempts at new flows: Pharmacist enrollment / monitoring
● Pharmacists are an underutilized resource but have similar enrollment conversion, engagement,
retention and clinical outcomes to provider enrollment/monitoring
● Time consuming and resource intensive for pharmacy with no reimbursement for pharmacists time
● Pharmacists often had to select patients from a list, determined by payer or healthcare system
● No easy way to get data from the connected medicine back to pharmacist
Pharmacist identifies
patient for connected
medicine
Pharmacist creates
account and sets up
connected medicine(s)
Patient uses connected medicine
and is monitored by pharmacists
or other care managers
3
programs

27.
Attempts at new flows: Direct to patient (DTP)
Optional
Patient marketed
to online
Patient enrolls online and
connected medicine / sensors
shipped to patient’s home
Patient uses connected
medicine and is optionally
monitored by care managers
● Highly scalable method to acquire patients and connect their medicines
● Patients don’t pay (yet)
● Lower engagement, retention and clinical outcomes compared to physician- or pharmacist-driven
programs
● Difficult to link patients acquired via DTP back to physicians, care managers and payers
● Currently US only; legally ambiguous in EU
12
programs

28.
Attempts at new flows: Payer direct to member
● Very ineffective strategy with low enrollment rates, low engagement and subpar clinical outcomes
● Payers tend to focus on a small number of very sick and expensive patients, who are challenging to
enroll and engage, leading to low conversion (typically only 1-2% of a given list)
● Payer care managers perform worse than provider care management, presumably due to lack of
existing relationships with patients
● This strategy completely excludes physicians from patient identification and management
Payer creates list of
most expensive patients
Propeller markets directly
to patients ships sensors
to patient’s home
Patient uses connected
medicine and is monitored
by Payer care managers
9
programs

29.
We believe the answer is going to be a more
traditional provider / payer flow
Reimbursement for
device and set up time
Reimbursement for physician /
clinic time for ongoing
monitoring and outreach
Physician identifies
patients for
connected medicine
Patient enrolls in clinic, in
pharmacy or via home delivery
Ongoing service and
monitoring
$

30.
We are at the precipice of scale. What is changing?
The respiratory drug delivery sector has proven the ability connect medicines, improve outcomes
and conduct successful pilots in the healthcare system. Broad scale is the next step. There are a
number of positive developments in the market that make us very optimistic that scale is coming.
Can we make a
tech product that
positively impacts
important clinical
outcomes?
Can we prove
outcomes in RCTs
and real-world
clinical programs?
Can we
successfully run
pilots with leading
healthcare
organizations?
Can we scale
within leading
clinical
organizations?
Can we achieve
ubiquitous
payment /
reimbursement?
Can we own
financial and
clinical risk around
asthma and COPD?
We are here
$

31.
The landscape for connected medicines is evolving
INTEGRATED
ADD-ON
DIAGNOSTICINTEGRATEDADD-ON

32.
Device architecture and supply chain optimized for scale
Cost Adoption Model
ARCHITECTURE
COGS
VOLUMES
PLATFORM CUSTOMER

33.
Significant improvements in technology are
impacting device performance
Chip / Firmware
Optimization
Connectivity
Protocols
Sensor
Development
Battery
Optimization

34.
Connectivity options to improve pairing
What is changing: Connecting directly to the
cloud

35.
Connectivity options are increasing
What is changing: Connecting directly to the
cloud

36.
Connecting directly to the cloud

37.
● Understanding user & therapy challenges
● Demographics & design features
● Human factors & customer engagement
● Training & onboarding
Leveraging user-centered
design to effectively utilize
connected medicine data

38.
New distribution infrastructure
New products, services and capabilities are making it easier for physicians to order connected
medicines, get patients enrolled and get data back into the physician’s EMR.
Lobbying for drug-
like IDs to include in
eRx lists
New tools to order
connected medicines
from the EMR
Health Systems are
investing in centralized
enrollment services
The ability to integrate
seamlessly into multiple
EMRs is getting easier
Unique
Identifier

39.
New payment and reimbursement
Advances in US and global payer policies point to imminent integration of connected medicines in
traditional healthcare delivery models.
National commercial
coverage of CGM tools
New CPT codes for
digital monitoring
As of 2018, nearly all
commercial payers, covering
∼200 million lives now
reimburse for CGM
monitoring
Effective Jan 2019, CMS will
launch 3 new RPM codes
developed by AMA’s Digital
Medical Payment Advisory
Group
2018 CMS announced
Medicare coverage for CGM
monitoring.
2017, NHS reimbursements
for selected digital tools
Effective Jan 2019, Cigna
expands Omada Health’s
Diabetes Prevention
Program to all national and
regional employer clients
Public insurance
coverage of digital
health services
Payer coverage of
Digital Diabetes
Prevention Program
CPT 99453
One time setup
CPT 99454
Device/service (monthly)
CPT 99457
Physician interpretation
(monthly)

40.
Bringing
technology
closer to the
medicine
Technology is now being
embedded directly into medicines
and drug delivery devices to
create line-extension or de novo
products.
Teva’s Digihaler
Proteus’
ingestible
sensor

41.
Pharma is embracing digital
Pharma is clearly embracing connected medicines, digital therapeutics and digital more broadly. All are still
piloting and doing sub-scale programs, but the pace of activity is increasing quickly
Biopharma Digital News
GSK / BI / Novartis / Orion Propeller
Development and commercial deals signed in 2014 (Boehringer Ingelheim),
2016 (GSK), 2017 (Novartis), Orion (2018)
Novartis Pear Therapeutics
2/28/18: Announce collaboration to develop digital therapeutics for
Schizophrenia and Multiple Sclerosis
Otsuka Proteus
11/15/17: Received FDA approval (NDA) of digital medicine (pill with
embedded sensor)
Novo Nordisk Glooko
7/17/17: Announce partnership to develop and market app for diabetes
management
Roche MySugr 6/30/17: Roche acquires MySugr (popular app for diabetes self management)
Bayer BetaConnect
5/30/17: Beyer gets FDA approval (sBLA) for BetaConnect (connected
betaseron pen injector for MS)
Sanofi Verily 9/12/16: Jointly create OnDuo joint venture with $500M investment
Teva CareTRx
9/27/15: Teva acquires Gecko Health for its respiratory CareTRx platform
and apps
AZ Adherium
8/19/15: AstraZeneca invests $3M in Adherium and signs commercial
agreement

42.
New models are leveraging subscriptions and mail order
Companies like Truepill have created medication delivery by API, to easily create a new
product or experience that includes Rx medicines. Initial applications are built on re-branding
generic medicines for ‘lifestyle’ diseases.

43.
Going out on a limb with a prediction:
1 million patients
Using connected medicines
by the end of 2022 (3 years)
What will the world look like
with ubiquitous use of
connected medicines?

44.
Patient journey with connected medicines
A patient meets with her doctor,
who evaluates her.
Her doctor selects the appropriate therapy,
and she leaves with a prescription.

45.
Patient journey with connected medicines
The patient goes to the pharmacy
and picks up her Rx.
Her doctor selected a connected medicine, so
her medicine comes connected and with an app.

46.
Patient journey with connected medicines
As she goes about her normal life, she
uses her medicines as she normally does.
She also receives a software-based
intervention, and starts to improve.

47.
Patient journey with connected medicines
Meanwhile… Many patients have been prescribed connected medicines that are
delivering data back to physicians, hospital systems and payers

48.
Patient journey with connected medicines
Healthcare providers and care managers use the data from connected medicines
to risk stratify patients and prioritize outreach.

49.
Patient journey with connected medicines
Patient returns to her doctor and they
review data on adherence and disease
status from her connected medicine.
Her physician uses the data from her connected
medicine to get her to the right therapy regimen.
Disease severity and
level of control

50.
Connected medicines present new opportunities for patients,
healthcare providers and payers
Patients will have more
therapy options, will get to
the best therapy regimen
faster, and have better
control of their health.
Care teams will have
better data on how
patients are doing, and be
able to offer better
solutions to their patients.
Payers and hospitals will
lower utilization and costs,
and have data on which
therapies are most useful
in which patient groups.

51.
Quiz

52.
To date, how many sensors for inhaled medications have
been deployed worldwide?
Quiz - Question 1
A) Under 100,000 sensors B) 100,000 - 250,000 sensors
D) 500,000 - 1,000,000 sensorsC) 250,000 - 500,000 sensors
E) Over 1,000,000 sensors

53.
What is the biggest barrier to adoption of connected medicines?
Quiz - Question 2
A) Physicians are
hesitant to adopt new
technologies
B) Lack of reimbursement
for devices and
physician time
C) Lack of ability to order
connected medicines
from the EMR and get
data back into the EMR
D) Regulatory challenges
and concerns

54.
How many patients with respiratory disease will be using
connected medicines by 2024 (5 years from today)
Quiz - Question 3
A) Under 500,000 patients B) 500,000 - 1,000,000 patients
D) 2,500,000 - 5,000,000 patientsC) 1,000,000 - 2,500,000 patients
E) Over 5,000,000 patients

55.
In what year will we pass 1 million patients using
connected medicines, worldwide?
Quiz - Question 4
A) 2020
(next year)
B) 2022
(3 years)
D) 2030
(10 years)
C) 2025
(5 years)
E) It will never happen

56.
What is the most important measurement a sensor
needs to make when a patient is using a connected
inhalation device?
Quiz - Question 5
A) Compliance to dosing
regimen (Date and
time of administration)
B) Inhalation technique
(inspiration rate)

57.
When designing or selecting a connected device,
identify what key feature you would like to see added to
the inhaler.
Quiz - Question 6
A) Dose counter B) Audible feature
D) Flow measurement /
inspiration rate
C) Visual feature
E) Angle of inspiration

58.
When designing or selecting a connected device which
of the following criteria plays the biggest role in the
selection process?
Quiz - Question 7
A) Cost of device B) Regulatory pathway
C) Sustainability D) Device functionality /
features

59.
Q&A