What to Expect When You're Connecting
What to Expect When You're Connecting includes interviews with a wide range of industry subject matter experts who share their journey, advice, and the mistakes they've made along the way in IoT. If you're adding connectivity to your products for the first time or seeking to optimize and scale your existing connectivity operations – welcome to the conversation.
What to Expect When You're Connecting
Integrating LTE-M Smart Buttons to Track Medication Use (guest Dr. Nagesh Kadaba, RxKeeper)
In this episode of 'What to Expect When You're Connecting,' host Ryan Carlson interviews Dr. Nagesh Kadaba, founder of RxKeeper. They discuss the innovation behind RxKeeper, a device designed to improve medication compliance through the use of LTE-M cellular smart buttons. The conversation covers the origins of RxKeeper, its development process, and the challenges faced in creating a simple yet effective solution for medication adherence. Learn about the device's ability to track medication usage, the advantages of using LTE-M technology, and how it is making a difference in the healthcare space. Tune in to hear insights on the future of digital health and connected products for IOT professionals.
00:00 RxKeeper with Nagesh Kadaba
00:54 The Inspiration Behind RxKeeper
01:36 Innovative Design of RxKeeper
02:35 Evolution of the Product
03:23 Simplifying Medication Management
08:18 Clinical Trials and Patient Outcome
14:27 Provisioning and Distribution
24:45 Technical Challenges and Solutions
28:06 Transition to AWS Server
28:26 Implementing Funk for Data Integration
28:40 API and Webhook Setup
29:07 Future Plans for Integration
31:29 Soracom Integration and Benefits
34:42 Closing Remarks and Future Prospects
35:32 What is Soracom to You?
Welcome to what to expect when you're connecting a podcast for IOT professionals and the IOT curious who find themselves responsible for growing, executing, or educating others about the challenges with connecting products and services to the internet, you'll learn from industry experts who understand those challenges deeply and what they've done to overcome that. Now for your host, Ryan Carlson.
Ryan Carlson:Today on what to expect when you're connecting, we're here with the founder of RxKeeper, Nagesh Kadaba, and it is a device that is using some interesting combinations of hardware and simplifying a process around medication compliance, or at the very least of tracking someone taking medication and knowing when it happens or when it's not happening. So Nagesh, talk to me about RxKeeper and where the idea came from.
Nagesh Kadaba:So it all started with my 92 year old mother and 90 year old mother in law are living with us. And they were, taking 10 plus medications. We both were, busy in our lives and we needed something to remind us to make sure that they are taking the medications on time or taking it at all. And hence the idea started from there and has progressed quite a few iterations. And we are now here talking about the most. Latest iterations that are now placed with clinicians and about 100 patients out in the market.
Ryan Carlson:So there's a lot of digital health and, internet of things that is being brought into the healthcare space. And one of the things I find is that there are some very cutting edge Star Trek level, next generation electronics units, AI, and all of these things. And it's very complex on the back end. And they work very hard to solve from the outside be very simple problems. But what's drawn me to the solution that you've created is that you didn't go the route of over complicating things. You actually went outside of the box in order to build inside of the box. And so to make that little inside joke, make a little more sense, you've taken a enclosure that's got a latch on it, you'd put your medication in it. And then you took one of the, LTE-M cellular smart buttons and you factored it into the design of the box itself. So when the hinge opens, it simulates a button pushes Is that about it?
Nagesh Kadaba:Absolutely. So that's the present, version of the product, just to give you a glimpse of where it started from and, where it is right now. initially, there was no LTE M button. There was no Soracom, when we started working on the solutions like this. we had a choice of going, super heavily engineered product or a simple device. Obviously being a startup, I cannot do a heavily engineered product. So there are, for the people like Phillips and black and Decker and Hiro and those are the folks who are in that field and again, the 90, 10 rule, 10 percent would require a sophisticated product like that. But 90 percent of the folks. who were not compliant in their medication adherence, wanted a very simple device. And so it started off with, a gateway, a Wi Fi sensor, a Wi Fi button, and hodgepodge of things putting together and making it work. Very difficult to send it out and consolidate in a 3PL fulfillment situation but yet, we got a few patients, working on it And then I was desperately looking for something like, how could I run this with a battery operated device and with better penetration and to quote your co founder Kenta, So there's no, the magic of this button is it is simple and it works in many situations as far as your mind can imagine. Similar to that, luckily, I found, that functionality that I was looking for in the LTE M button, and hence, I switched and started using that button. And now, there are multiple verticals that can use this button for both the adherence portion of it, as well as the patient reported outcomes. This is important because Many of these patient reported outcomes are sophisticated apps on smartphones, that require some level of tech savviness to, to, use these, patient reported outcome devices. So again, The LTE-M button provided that ability of pressing, clicking once, twice, or thrice, and then getting basic quality of life questions out from the box to a server where the physician or the provider or the clinician can make decisions, on the outcomes coming out from the box.
Ryan Carlson:So I think it's important to, for our listeners to understand the contrast here. I've seen medication dispensing units where you set them up somewhere centrally in your home, maybe in the kitchen or a bathroom, you plug them into the wall. They're going to have rotators. They're going to drop pills down. They're going to count things. And then they're going to send a notification to an app. You look at the notification on the app. It's going to ask you a whole series of questions about how you felt, symptoms, and then, how are you feeling might be an open text field or you're picking things and so there's just all these moving parts, but when someone is sick or they have a chronic condition, or certain socioeconomic or, different rural patient populations, it's a big ask to have the gateway, the wifi the mobile device, all of those different moving pieces, it's hard to follow that many steps
Nagesh Kadaba:absolutely true. So the same moving pieces that you mentioned, as and when you go in the super rural areas, it becomes harder, to get your 4G signals. It becomes harder to make sure that, the medication reminder device and your communication device are in proximity to make that connection and to send the data out. And also involved, quite a few steps for the patient themselves, to set it up a nd start using this system. So in contrast, this product, and I'll just show it to you if I can, is a standalone plastic, box. It's got a, a reminder and an alarm on the device itself. It's got a temperature sensor to make sure that you're not keeping it in the sun and keeping it in a safe place. And it's then it's got a, a sensor built into the box itself. Which will send the data out every time you open the box. Very simple, you get this box, keep it on your medicine counter or kitchen counter, wherever you're keeping your present medications, and start using the box. It is ready to go, right out of the box. Again, a few more puns intended over here. The box works out of the box,
Ryan Carlson:so one of the things to qualify here is that one, this is our first interview with anyone who's been using a smart button for a solution like this. And the button is something that is just that it is got batteries in it. It has got a cellular radio in it on the LTE spectrum. And so the buttons got even a plugin on there where you can put like an external sensor or doing other things. That's it. But really it's just a button so you can press it one click and you can do two clicks or you can do a press and a hold. And those are three different commands, all with the same big button on one of these smart buttons. So they can be programmed to do anything. What I find you interesting and unique is that you turned those button presses into another feedback mechanism. Can you talk me through how people share how they feel when they take their medication?
Nagesh Kadaba:Sure whole issue came up, so there, there are two verticals that I was approaching. One is the Medicare RTM program, Remote Therapeutic Management Program which is a Medicare reimburse program which allows, in, certain fields. of medicine, critical care management, to allow the patient to use a medication adherence device. So in that situation, the button is, has multiple uses. So in, in the RTM situation, there is a switch. Which opens and closes, that sends the data out of the button, saying box was open. The box was closed at a certain time. And then once it's out there up in the cloud, we can make any decisions. We can use AI i. If needed, we can use, nurses, remote nurses watching with alerts. So we have multiple ways of communicating from, the server. Once the data is out, From the same button, you can also get. in a different vertical, which is the clinical trials vertical, where it is important for medication adherence. Obviously, there's a huge percentage, 30 to 40 percent dropout of clinical trials midway. And every time there's a dropout, it's 20, 000 plus per patient to get back on and get the clinical trials, progressing. So it's a very expensive, situation where Clinical trials needs the compliance and the adherence, but also they were expected, the patients, they're sick themselves and quite sick when they're on clinical trials, but expected to have a sheet of paper, write down the time of the day, and then write down how they're feeling. Now, what's that? What's the side effects or not? How are they feeling? So what's their mood like? So they were supposed to keep a log on that paper log was brought back on a monthly basis to the central location, and it was key entered. And then a electronic patient reported outcome was created after all these steps. So what happens with a button like this? The questions are simple, but the data, clinical data is pretty strong for making decisions for the drug makers and for the clinicians in the clinical trial ecosystem. So that's what it does both. It does the open and close for the adherence portion of it, and it does the clicks for the electronic patient reported outcomes.
Ryan Carlson:And one click would be feeling fine, two clicks would be feeling okay, and press and hold would be, I'm not feeling well at all.
Nagesh Kadaba:Exactly,
Ryan Carlson:Okay. And then that probably, because it's all in that box, when on that clinical trial, they open the box, they take their medication at that time, they're asked to then, Give their feedback right on how it is that they're feeling.
Nagesh Kadaba:exactly. And it's totally dependent on the clinician. They can open the box and take it in the morning, and they don't need to click the buttons. They need to, only click it in the evenings. So you'll see what the effect of the medication was in the morning and how they feel in the evening before they take the medication. So you can decide, whichever way, the procedures are, for getting clinically relevant data, for every particular situation. Absolutely.
Ryan Carlson:one of the things I typically like to find out is like what manual process. Your products are typically replacing now with the clinical trials. You already answered that one, which is it's a pen and paper, right? It's a highly manual process. We see this in convenience stores and, even janitorial, where it used to be like writing down when a job was done on the inside of a little sheet or a clipboard someplace, and now they've got. Buttons or they even have like tracking tags that automatically log like, Hey, staff already came in, came through here and it checks it off in the system. But with, the medication management, I'd imagine the manual alternative is exactly what we already think it's, you have to. You're relying on your ability to both remember to take it and providers don't even know, even if you did set a timer on your phone, there's no way to know as a provider that the medication was even being interacted with, right?
Nagesh Kadaba:Absolutely. Absolutely. So there are two things with reminders. One of them is the reminder happens exactly at 9 a. m. every day. You get into a reminder alert fatigue, so you start neglecting those alerts just because it's coming every time. Now, with the way the RxKeeper container is designed, it does reward you. Say if it was at 9 o'clock, the alarm was set at 9 o'clock, and you took it at 855, it does not remind you at 9 o'clock. So there itself, you have some kind of a reward, for being in compliance. So that, that is a pretty useful, tool to make sure that the patient doesn't get into alert fatigue.
Ryan Carlson:just like waking up before your alarm in the morning and you get to avoid the loud jarring one. Instead, you can just slowly wake yourself up. If you get up a little bit before your alarm, I get that
Nagesh Kadaba:Exactly.
Ryan Carlson:alarm fatigue. I'd never thought of that. But that's actually a thing, right? That's something that we almost come to dread, especially when it's not an activity that we're looking forward to, or it's something that creates more work or friction in our day.
Nagesh Kadaba:The whole reason for putting that alarm goes away because you start ignoring it just because you know that it's going to do that at nine o'clock. So let me ignore it. So the whole reason for that work process is, negated, in that situation.
Ryan Carlson:so one of the biggest challenges with connected products is the actual putting them out into the field, setting them up, getting them into the hands of users, talk to me about system that you have in place to streamline the distribution. and provisioning of a device that's supposed to be simple to use, but is it simple to set up?
Nagesh Kadaba:Great. That's another huge step that happened from version one of the product where the provisioning had to be done with Wi Fi and Bluetooth and gateways. A massive process which had to be done in house, in the warehouse, and then shipped out. And hopefully everything will work after it's shipped out. And it needed power for the gateways once it's at the patient's home. A funny story about a gateway in a patient's home. The multiple patients called me and told me that device is going to pull a lot of power. And they cannot afford the cost of a gateway device attached to power. And again, these are very old people, very sick people and, economically disadvantaged, but even that small plug, they think that it's going to suck out the power from their home. So that itself moving away from, especially for that class of people. Away from a power device to a battery operated device like the LTE M was a huge step. So that's number one. The moment it becomes one single device, and then all the provisioning is done by just one click. So if you get a thousand LTE-Ms it comes with everything registered on your Soracom's website and all you do is just click once and all those thousand devices are now registered to your group or to your account. And once that's done, you have nothing more to do online. All you have to do is now somehow associate that button to this box. So each box will have the same code that's on the button, stuck with a label in the box and on the device. and on the shipping box itself. So when the patient gets the box or when the provider gives the box to the patient, they associate that code, which is the Soracom IMEI number to that patient. And that's about it. So no one knows there is no association of the patient itself in the box. in the EHR system where they associate the code to the box.
Ryan Carlson:You're using the unique IMEI number as the unique identifier for the device and you're tying that to the practice and that practice uses it to, to attach it to their patient. And so when they get their data report, is it all flows through the button to Soracom to your system off to the end provider. It's one. Continuous ID
Nagesh Kadaba:Exactly. Exactly.
Ryan Carlson:that's actually not tied to any patient information or protected health information at all.
Nagesh Kadaba:Very true. Very true. And that was very important for a startup to make sure that we are HIPAA compliant, but we wanted to make sure that the data goes from the box to the cell tower, from the cell tower directly to your server to the server at the provider site. So making that, change to a single system, our fulfillment and provisioning went down from 15 minutes per setup, per device down to three minutes. So that's a huge burden that's removed from our side before the device Gets to the patient, or the provider.
Ryan Carlson:and it's not just time I'd imagine that because it's one component, it drastically reduces the potential for. human error or just putting the wrong device next to the wrong thing or forgetting a cable or a power supply or, again, things happen, right?
Nagesh Kadaba:Absolutely.
Ryan Carlson:so you had mentioned something that I think those of us at Soracom take for granted is the loading of things into the system. So where, whereas with many carriers, you might buy a bunch of sims or devices with sims, And then you get to find the IMEI number and you have to upload spreadsheets or manually code in a bunch of things into your console. Whereas what you were referencing was you can just go to purchase history, you find the order of buttons you put in and say add to account and it just pulls them all over and they're all active. So it's a huge time saver that I think I take for granted all the time. But our customers, to keep reminding me this is a really big deal because it's a really painful little task.
Nagesh Kadaba:Absolutely. Massive. deal. And, it, it is, it's make or break, in, in many cases, as far as fulfillment goes and provisioning goes.
Ryan Carlson:So with the hundreds of units that you have out there, what do your users have to say about it? What do patients and what are providers feedback look like?
Nagesh Kadaba:So the patients, I gave you one example of a patient who was using the version one, of the gateway, base system. So that was one example. The other example is, I do not get 4G signal. They don't say 4G signal, but they don't get signal on their gateway devices, because they are in a basement and there is no window, and, it's probably, in a shadow of another large building or a mountain and they absolutely don't have 4G signal. And so they try moving the boxes around and then we'll have to get the boxes back. In those situations, in exactly one of those situations, we sent out an LTE button version of the RxKeeper container, and it works flawlessly because of a technical reason. It is LTE M, and LTE M has far more penetration into the buildings and into the structures than a 4G would.
Ryan Carlson:If that's people that are setting them up and trying to use them, just switching to LTE-M is one of the advantages. How about from, the actual practical application, the medication management or the data that's being received from it? Is there been any feedback that you'd be willing to share
Nagesh Kadaba:Sure. In the present, deployments, there is always a nurse station involved. Medicare pays for that whole system where the provider prescribes a medication adherence system in the, two verticals, musculoskeletal and respiratory chronic care. So in any one of those verticals we would have a There's a nurse station that would monitor the box opening and closing, and also be in constant touch with the patient the moment they miss their medication. So the provider is also aware of what's happening. But the nurse's station is in direct contact with the patient, as well as asking for refills, and how they're feeling and have an ability to take those notes down. And so the Medicare reimbursement, these are the three players, in that, ecosystem.
Ryan Carlson:for people or for patients that need to take medication in order to get better or for the outcomes that they're looking for, rather than having them in inpatient or in the clinic? What's interesting as we've been hearing in the telemedicine space, this is having this remote nurse station monitoring. What could be dozens or even hundreds of different patients, depending on the level of how the frequency of touch points that are required is so much more cost effective than having people in the actual practice itself. So it's really cool to see these diagnostic tools. That are being covered now by your health insurance day in order to help people be able to stay safe at home where they're at lower stress, where there's less chances of even just getting injured coming into a practice. So we hear a lot of this in the connected health space is how getting these solutions into people's homes is becoming more and more important in achieving the outcomes that we want.
Nagesh Kadaba:Absolutely. And then you should contrast that with what was happening before. So all these situations existed a decade ago, two decades ago, three decades ago. So in those situations, what happened was the same nurse's station. It's to pick up the phone and call every patient and say, okay, did you take your medication? And guess what? After the third call, they stop picking up the phone. Patients, they're dealing with their chronic care and their life and a call coming on every day. to remind them to take the medication, especially after a hospital visit, is, it's doesn't work, for what it was designed for. And they stop picking up the phone. So in a situation like this, where it nudges, there's an alarm on the box. It's a pretty irritating alarm. And it will only stop after you take it, and it won't ring if you've taken it before the alarm. So that itself is a small factor that nudges the patient to take their medications, on time. And then if they don't do that, then the nurse's station follows up with a call. So now what you've done is you have reduced the burden on the nurses themselves, with a automated device. And any form of automation like this will reduce the burden in patients. Different parts of the ecosystem.
Ryan Carlson:Let's talk about making products. So as an engineer, what is the hardest part about making a connected product?
Nagesh Kadaba:Oh the hardest issue is communication. How do you communicate the data out of your device? And how to do it without any customer interaction. That is huge. As you understand that, initially there were Bluetooth products. You had to pair the Bluetooth products to your app, you had to run an app. Your Bluetooth products only worked within 10 meters of your phone. If you've taken your phone downstairs, there's no communication, there's no data then came the Wi Fi products, which, you still have to pair your Wi Fi product to your home network and then again, be in the vicinity of maximum 10 meters to collect the data. So with all those restrictions, and all of them were powered devices. So if you lost power for any reason. You have no data coming out from your devices. So the whole issue about having a battery operated cellular device, was a huge jump, that didn't exist. It, even now there are very few companies that can have the chip. To make sure that a battery operated cellular device exists. And then once the data is out, how that data is moved with simple, well documented APIs to any system, any EHR system, any platform. So having that in place, Many people did jump around those hurdles because, there were non standard APIs that people wrote, custom APIs. So those were the biggest, hurdles that for an engineer, any connected device situation.
Ryan Carlson:I think what's interesting, you're talking about routing of data. Yeah. is, one of the things that happens to be one of the areas that Soracom really puts a lot of emphasis on is the ability to securely route or reroute data or even split data feeds. So you've got data that's pointing to your servers right now, but you could just as easily group a deployment of buttons or boxes at this point and point that data to wherever you want without having to need access to the box itself. You can route those changes you using what we call a unified endpoint, but all the devices just talk to one thing and then you get to route that endpoint wherever you want, which is pretty cool. Whether it's their cloud platform, cloud infrastructure, a virtual private network, where, people are going to be hosting their own EHRs or practice management systems. So maybe they're going to be piping it in that way. So I think there's a lot of flexibility where you're at. You're just responsible for getting the data. From these remote places and getting it into a normalized standard format that can then be directed to how they want to consume it. Since we know that there's over 250 different EHRs on the market, just in the United States alone.
Nagesh Kadaba:Exactly. Yeah. I had an option When I started experimenting with the, button, for using Harvest and, what's the, there's another tool. You had Harvest and then you had another tool to visualize the data.
Ryan Carlson:Harvest and Lagoon
Nagesh Kadaba:Lagoon. and Harvest. So we started with that. Once that was done, I moved away from it because I was using it to test it, to see if the heartbeat was there on the button and if the data was coming out of the button as designed. Once that was done, I needed the data to come in directly into my AWS server. And Funk was the ideal way to do it. Beam could have been one, too, to get it into. But Funk was ideal because it came into our server and We had well defined API. So I have two APIs, as you see in one of my documents. One is an API that comes out. It's a webhook from our server. So it's button to Soracom AWS server. And then we use Funk from there to our server and then we have a webhook for people who do not have the ability to take Funk data indirectly, but for people who can take Funk data directly. We'll just group them together and just send them a funk link and a short description of how I integrated the Funk into AWS server with a lambda function. We'll do the same thing with any of our mutual customers going forward.
Ryan Carlson:And everyone's using something a little bit different, whether it's going to be an API driven doc dot chrono, or you're going to be doing like a big Athena health or an Epic integration, who knows?
Nagesh Kadaba:Exactly. Yeah. Having that ability is huge for the engineering house to take a device which is cellular and get the data out of the device to the cloud.
Ryan Carlson:I love that you're thinking about data portability though, because we know in healthcare data interoperability is one of the biggest hurdles facing so many of these different solutions on helping to improve patient outcomes and improving the communication between patient and provider. Is that you're already looking at the, it's not just interoperability, but flexibility in that you've already thought about that secure conduit on where you can easily point the data into another direction, depending on what solution provider you're engaging with. So as a business owner, what was, or is the hardest part about making a connected product?
Nagesh Kadaba:The issue about fulfillment, especially when there are disparate connected devices, for example, a Bluetooth device talking to a cellular device or a Wi Fi device or a ZigBee device talking to a gateway and then sending the data out. And the data that goes out of these gateways, non standard in the sense each entity will have their own APIs. sending the data out into for example, my server. And then once it's in my AWS server, I would be able to then pass it on in some standard form. So having this ability to send the data out and not worry about it till it hits the AWS server, was a huge thing, as a business owner. And that helped all the other issues about. Having an out of the box solution, for the patients.
Ryan Carlson:Take me back to the day when you first decided to evaluate Soracom and tell me what happened.
Nagesh Kadaba:Again, I was pretty lucky to stumble onto it, because this was initial stages. This was about, beginning of the year, and I guess you guys had just announced, the product, but I did not get the announcement you're just coming into, the U. S. market, and I stumbled upon that, and I saw two or three words over there. One of them was cellular. Battery operated buttons and a accessorial input for either a thermometer or a motion switch or a, read switch. So the moment I saw that, I contacted, you guys. And, you just told me to get one of your kits and ordered the kit and within 48 hours. I had integrated button into my platform and it was functioning as my connected gateway solution So that was how fast and easy it was to integrate it.
Ryan Carlson:So how did you initially even hear about the button? Was it on the web or social or
Nagesh Kadaba:It was on the web. So it was a search on the web. And also, I did stumble on Unibiz and what they were doing. With the Sigfox and, in Europe, but then obviously, there is no universe in, sorry, no Sigfox in, in the States. So LTE M was a critical factor to decide that's the way to go. And, that's the end of my talk.
Ryan Carlson:Yeah, did you evaluate any other button solutions on the market?
Nagesh Kadaba:Most of them were, not most of them, all of them were Wi Fi based buttons, from the time, Amazon did their dash button, they were all, either Bluetooth or Wi Fi. And the moment it's Wi Fi, it needed a gateway and, having a gateway increased the complexity and even the gateways. Were unique gateways, which were not standard enough for my data to be pushed to a standard server, in a secure way. That was not even a contender the moment I found a battery operated device that could do exactly that with LTE M with better penetration, into, harder places to get the data out of these devices.
Ryan Carlson:If people wanted to learn more about RxKeeper, where should they go?
Nagesh Kadaba:There we, I do have a website. It's, rxkeeper. com. And, I am doing my rounds, in conferences, in connected health conferences, mobile health conferences. I have a chance to exhibit in some of these startup, venues, within these large conferences. Either my website, or one of these conferences, I'd be more than happy to show you and talk more about, device.
Ryan Carlson:Great. We'll also have your LinkedIn information in the show notes. And that's our time. Thank you for sharing RxKeeper and your journey on taking a more simple approach to reaching entire different patient populations that struggle with some of the existing gateway or 4g type solutions out there and congratulations for being the first of the smart buttons, featured on both our podcast and one of our stories that we share about people that are doing cool things with the button. And you actually get to legitimately say, yeah, my solution is out here to help actually save lives.
Nagesh Kadaba:Absolutely.
Ryan Carlson:It's not just a remember the milk or something along those lines. It's a remember to take your blood pressure medication. Thank you so much for your time Nagesh this has been a really great conversation.
Nagesh Kadaba:Thanks, Ryan. Thank you very much.
This has been another episode of What to Expect When You're Connecting. Until next time.
Ryan Carlson:Nagesh, what is Soracom to you?
Nagesh Kadaba:A hardware and cloud based company for serverless data capture.
