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Joseph Kim:
Welcome to Clinical Research Confidential. On this show, we highlight and demystify the inner workings of this greatly misunderstood activity called clinical research. Now, why is clinical research important? Well, it’s the basis for nearly every modern remedy for sickness and a growing method to build trust and solutions meant to optimize health, but it’s not for the faint of heart. And so on this show, you’ll hear what it really takes to succeed in the clinical research game. I’m your host, Joseph Kim, and I’ve spent over 23 years in the clinical research industry, now serving as the chief strategy officer for ProofPilot. Get ready for some adventures as we look into the underbelly of clinical research.

Joseph Kim:
And today I’m here with Gabriela Asturias, who is a young entrepreneur studying and creating a very interesting business model around mental health. Now, most people might think about the show in terms of researching actual drug interventions, but lots of times medicine and care is a lot more than the intervention. And we’re going to hear from Gabriela in terms of how she’s helping the world get triaged to the right algorithm of treatment, particularly in mental health, which is so hard to make sense of in this world. Gabriela, welcome to the show.

Gabriela Asturias:
Thank you for having me, Joe.

Joseph Kim:
Of course, before we get into your, and MiResource, which is an amazing company and we want to tell the whole world about it, tell us a little bit about your background, because it seems like you were always interested in science and medicine as an undergrad at Duke. Is that correct?

Gabriela Asturias:
Yes, well, even before Duke, I would say, I was born and raised in Guatemala. And I think the one constant in my life that I’ve known is that I love science. I love the scientific method and the structured way at how we can go after an idea and validate it and generate evidence for it, and then how other people can replicate that and also test what we’re proposing I think is very elegant, and I’ve always really enjoyed applying it to everything from like a science fair when I was a kid to then doing more formal research when I was in undergrad. So medicine is actually a passion that came from me later in life when I was in undergrad. And even as I’m going through med school, I’m more and more realizing how much I enjoy it, but what I’ve always known I’ve loved is science.

Joseph Kim:
So it looks like you did end up going to med school at Stanford and you’re a trained physician. Did you end up ever practicing or did you just start to pivot right back into science?

Gabriela Asturias:
Well, I’m now at the tail end of the medical school, actually, so I’m yeah, I’ve been able, Stanford is very flexible. I’ve been able, I was able to part-time one of my years, so that became two years that was part-time. So I was working the other part of my time in MiResource and all the different research efforts that we’re doing. And then I went back full time, then I took some time off, so I’ve been juggling med school and MiResource, but I am interested in specializing in psychiatry, and hopefully, one-day blending practice with also research and the work we’re doing in MiResource.

Joseph Kim:
Well, Gabriela, it’s hard enough for people to just go through med school. The fact that you’re juggling MiResource, your company, and med school is pretty heroic, so kudos to you. Tell us about MiResource. What does it do today?

Gabriela Asturias:
Yeah, so MiResource was started by Mackenzie Drazen and I, and my co-founder had a very personal story related to mental health, how she got introduced to this problem. Her sister suffered from depression and an eating disorder, and she lost her sister to suicide when she was very young. And I think part of what my co-founder was frustrated with and why she came to me when we were undergrads at Duke was it’s really hard to start searching for care, and sometimes even if you do get connected to some form of mental healthcare, it might not be in the right stage of what you need. Because the interesting thing about mental health is not just about the kind of provider or program, which really depends on like the severity of your presentation at that point, but also like the frequency of engagement with that care. And so really understanding the level of care and what kind of care you need and also how frequently you should be engaging with it to really get through rougher periods is a hard thing to determine, and it’s something that most people don’t know. I definitely didn’t know before I became a part of this field. And I think for families, when a family member is diagnosed with severe mental illness, it’s very difficult to predict what is the right choice of treatment for them. And it’s a huge burden already dealing with the knowledge that your family member is sick and finding ways to support them, but also figuring how to navigate a system is just another layer of struggle and stress on a family and on the person themselves. So I think what we’ve been both obsessed with fixing is how do we help people navigate the system and understand how to approach the system. And that’s really at the core of the business. Now, practically speaking, what does the business do, we help health institutions connect their members or patients to mental healthcare. Right now, we’re working with payers because we believe that at the end of the day, if you can’t afford the care, it’s not really access. And there’s a lot of conversation around out-of-pocket care, out-of-pocket expenses for mental healthcare, and I think that can work for certain people and for certain levels of care, like the lower acuity, maybe like a therapist that you don’t need to see so frequently, but when you start mixing psychiatrist medication prescriptions, or even a therapist that you need to see more frequently, or higher levels of care, very few individuals can actually afford all of that out of pocket. So insurance plays a huge role in whether people have access to care. And especially mental illness is not linear, you can be doing fine with a therapist and maybe you also have a psychiatrist once a month. You may then have a crisis and then you may need to go inpatient and then step down to a program and then you can go back to outpatient care. And that kind of fluctuates in mental health, and that’s why insurance is so important for all of this to get approved, to get reimbursed for it. And what we’re really focused on is empowering insurance to do a better job of how they connect their members to all the levels of care that are right for that person at that point in time.

Joseph Kim:
Yeah, really interesting. This thing, this with drugs and other molecules, the dose is everything, right? It’s going to be x milligrams of this, but mental health, there’s not a dose per se, and it sounds like there’s all these different modalities to deliver care. Can you help us understand the different categories? Because you sort of rambled off a couple of these things. Help our audience understand like what? How do you classify the kinds of mental healthcare that’s out there?

Gabriela Asturias:
Yeah, so starting from a lower acuity, for example, we have everything from apps. People engage with bots nowadays or different apps or even taking like a journal app and like writing down or meditation apps. All of these tools that help like mental health maintenance that everyone can benefit from, although you can use every day or so often, that will be like, for me, the lowest level. And then we have therapy that can, is always part of treatment, and I think what changes is the level of frequency and also who’s delivering it. And so there’s different, people who are trained to deliver therapy. There’s professionals like social workers, there’s different kinds of licensing for therapists that can then a master’s or certification that allows them to then provide psychotherapy. We have clinical psychologists, we had a PhD in our training to do this in that way. So with therapy, you also have different psychotherapies. Some are very indicated for certain conditions. And in other conditions, there are many that can work. So it’s not just about getting a therapist, but also getting one that’s trained and what’s the best for your condition. And then we have psychiatrists, psychiatrists, and other, well, there are other professionals that can do medication management, but the main one being psychiatry. They are the ones that can kind of prescribe medication, manage, manage side effects, and they help you go through that process. Some of them also do therapy. And so these are all kind of the outpatient providers, that means that you live in your home, you may go to work or not or school, and you then engage with care with a certain frequency. Some people, weekly, bi-weekly, monthly, depends on your level of severity and also how long you’ve been in care. Then we have the next levels that are, some of them, you can still either are the highest level to contrast would be inpatient. So that is when someone is in an acute crisis that can be, for example, after a suicide attempt or someone who’s going through a manic episode or someone who’s experiencing psychosis or an exacerbation of depression or maybe depression with psychosis. Either way, is someone whose function in life is very impaired and they’re not being able to meet their goals, and they may need more acute care, 24/7 care. Those people would be admitted inpatient and they would get a team-based approach that includes a psychiatrist, some form of therapy. Where I work, we do occupational therapy, we have a psychologist also that works with patients. We have the psychiatry team, we have social worker as well, so it’s a more involved care and we’re kind of a 24/7 care model. The next level would be a residential program where you go live somewhere, the rules are a little more relaxed and you have more free time, maybe more access to your devices, depends on the program, and you’re still getting like kind of this like 24/7 approach, and you have all these professionals at your disposal, but maybe instead of seeing a psychiatrist and a psychologist daily, you see them every couple of times a week. So it, the frequency starts diminishing as you go down and level of care. And after residential program you have, and here I’m doing like broad categories, there’s more of us to all of this, but then you have partial hospitalized programs and you have intensive outpatient programs. These are programs that you live at home, but you go almost daily or every few days for a long period of time to the program. So it’s a really good step-down model because you’re someone who was in an inpatient and then you live in a place where there’s a safe environment where you have all this care options available, then you get to go home, and it’s kind of like rehabilitation model where we’re like easing you in back into your life, but you still have very frequent care and then slowly go to outpatient. And so these are the complexities of mental health, right? And like knowing the level of intensity, and that’s why I was giving the analogy like or the most important thing to consider with all of this, more than all the nuances I described, is it’s about the frequency and how many professionals you need in your care team working with you, for your goals. And I think that’s what changes as you go up on a higher level of care. And we’re really focused on this in MiResource because that’s how we started. We started with a family who had a family member with severe mental illness, who didn’t know that all these levels existed, who started at too low of a level for what that person needed, and that led to bad consequences. It took too long to get the person to the right level of care. And so, at my research, we’re obsessed at understanding where are you right now. How is this affecting your level of functioning, your ability to engage with people around you? How are you perceiving the world? Are you being able to work or study or complete your passions or activities that you want to do in your day-to-day life? And based on how much you’re being affected by it, we want to make sure we’re getting the right people to your team. We’re recruiting the right team to get you to feel better, and that’s really what we’re trying to build in MiResource.

Joseph Kim:
Yeah, I mean, my head is spinning after you, like, laid out even a simple terms, those different levels of mental health resources. And my first job out of college was as a social worker, and so I dealt with some of those low-level things and I ended up doing some research with molecules. And so there was more molecule pharmaceutical-based treatments, but yeah, there’s, there’s a whole host of things. I can’t imagine how hard it is for somebody with mental health trying to navigate that. So in terms of like, how do you relate to a specific diagnosis? Because you’re not diagnosing people, it sounds like. You’re doing something very different, which is equally important, which is helping them understand how to then seek the right frequency sequence and intensity of treatments that are already out there. So yeah, tell us about the relationship between a diagnosis and then what you might do.

Gabriela Asturias:
I think in mental health, for all intents and purposes, a diagnosis is a way for care providers to conceptualize your presentation, which can include the present and the past and a way for them to speak with each other and also think through what’s the right medication for you, like what class of medication should we try. In some cases, what kind of psychotherapy is the gold-standard for your condition? So it’s a common language that allows care providers to then decide what the intervention is going to be. But I think when you’re thinking of level of care, and I will say we actually do ask questions like certain symptoms for a common comorbidity so we can make this distinction of where to send you or like what kind of care you need in your team, what we should recruit for you and how frequently you should see them. But we try not to diagnose because at the end of the day, you will be diagnosed in these settings. You will be, these providers, once you connect effectively with care, like whether we get you to a therapist or we get you to a psychiatrist or we get you at a higher level of care, there’s people there that their sole focus will be to diagnose you if it’s applicable, because everyone can benefit from therapy. You don’t need a diagnosis like a DSM5 or ICD10 diagnosis. You can set your own goals for therapy, right? Like you can work on grief when you lose a loved one, going through a divorce, either yourself or maybe your parents, or going through difficult times with academic concerns or job stressors. So there’s many reasons to interface the mental health system that are not necessarily diagnosable. For the ones that are diagnosable, once we connect you, those professionals will be having a longer interaction with you and we’ll be able to give you an effective diagnosis, because with mental health, the more and more I learn about it in the field, it’s not just about how you are in one instance. I think to really formulate a good diagnosis, you need more exposure with the person, you need collateral information, you need to know a little bit more about their past as well. And I feel like it’s something that’s a little more complex than that can be done in the right setting. And it actually doesn’t, knowing or not knowing your diagnosis, it doesn’t really hinder our ability to identify the right care for you. Now, if you’ve been diagnosed in the past and you want to give us that information, we definitely, that definitely helps us also identify the right care for you, but we’re not making that a requirement because we want our system to work for everyone. If you’ve never interacted with a mental health system or this is the first break episode of psychosis, for example, or the first time you experienced depression, and you don’t even know what you’re feeling, you just know something is off, we want to be able to speak to you in a way that you can communicate that something’s off without having to use this terminology that doctors use to conceptualize a presentation of a patient.

Joseph Kim:
Yeah, I love it. You really just trying to understand the person and their behaviors and limitations first, get them set up in the right direction so that they can actually put a name to it, and then finally get the help they need, brilliant. So listen, all of this sounds obviously good. How do you know that it actually works?

Gabriela Asturias:
Yeah, so we were talking earlier that one of the, this is the core of the business, right? Like how do we get people to the actually correct care? What do they actually need today? And that’s really the reason we started this, and so that’s kind of like the passion side of the business. And we recently won a grant from the NIH, it’s called an SCTR Grant, which is an amazing funding mechanism they have that helps small businesses do research that then is translated and implemented commercially. And so we’re working with the Child Mind Institute, they’re our partner in New York, and their research team and our engineering team and our research team are all working together in this grant. And what we’re really trying to test is if the set of questionnaires we’re asking to predict the right level of care for someone, if that can be as good as gold-standard. So answering the question, how do we know that it works? And so what we’re doing is we’re building a data set right now with different partner universities, because MiResource, when it started about 4 or 5 years ago, we did mental healthcare for college campuses. So we have about 65 partner universities and a couple of them are enrolled in this study and we’re building a huge data set. And so we have different questionnaires that the students are filling out, and the interesting thing about our study is that it’s all online, it’s all through the university, and we really take participants with all levels of severity of care. And the great thing of partnering with universities is that you fill this questionnaire and then they actually do talk to a case manager in the university and they are getting connected to care and the university uses our system. So it’s not just us getting information from these people, but they will finish the loop and we’ll get connected to care and they’re helping us build this data set. And then what we’re going to be doing is we’re attempting to train a machine learning algorithm to take this data and then predict what level, what kind of care does this person need at this time point. And then once we do that, we’re going to compare that to gold-standard. Now, gold-standard is interesting for triage because there’s no, there’s different gold-standards, so I think right now it’s more like clinical decision-making, but social workers are actually a huge part of it and we are testing it out with social workers. We’re testing it out with psychiatrists, case managers, and insurance companies, and we’re also testing it against what’s called a low-cost protocol, which is something that some insurance companies and even doctors use as guidelines to know where to refer someone, like what level of care to refer someone to. And so what we’re trying to see is can this algorithm predict the level of care as good as clinical decision-making and the low-cost protocol, and so we’ll be able to answer the question. Does this work?

Joseph Kim:
Yeah, well, I love what this research actually looks like because you’re not testing a specific thing on a person. You’re gathering all this information, looking at the outcome, and then you’re training a machine to then to recognize patterns here so that you can repeat that. Am I hearing this correctly?

Gabriela Asturias:
Yes, and then the goal would be, so in the training phase, we want it to be as good as these clinicians. And so the clinicians are also going to look at the data and they’re going to make a decision. So both machine and clinician are looking at the data and are making a decision and we want the machine to be as good as the clinicians and also as a low-cost protocol, so we’re running two different tests. And then ultimately what we’d love is for this to be offered through our site for people to just fill out these questions and then we can just guide you. There’s no reason to wait or to make an intake appointment with someone else. We just can predict what that gold-standard would tell you and tell you where to look for care. And so the way we envision this rolling out is you go to our site, we ask you questions about how you are doing. I don’t want you to tell me, oh, I’m looking for this or, we don’t want to put the burden on the person looking for care because there’s already so much of a burden, I mean, just the mental illness itself. And even if you have family members or loved ones helping you through it, it is a stressful time, especially for those first-timers that have not interacted with the system. And there are just so many things you have to be thinking about, can I even afford this? How is this going to impact my life? There’s just so much you’re thinking about that we want to make it as easy as possible for the person that’s going through this, and we’re going to only ask you questions that you can answer. Things like, how are you feeling today? Like, are you depressed, are you anxious? And we’ll put different scenarios and you’ll tell us how you’re feeling. We’re going to ask also about like function like, are you being able to get out of bed and either go to school or go to work, or I don’t know, if you have some activities you like to do at home or take care of your kids, for example, understanding not just how you’re feeling and your symptoms, but how is this affecting your life, your relationship with other people, your ability to do things that matter to you? Have you ever had past treatment experience? Like have you ever received any kind of treatment? So asking all these questions that you could technically answer about yourself, and then we take all that information and the ideas that the machine learning algorithm could then predict, okay, it sounds like at this time point, this person sounds like they’ve been diagnosed with this, they’ve gone through this in the past and that right now they’re doing a little worse and they might benefit from this level and this level of care and this frequency. And so what we’ll do is in MiResource, we’ll offer you the right care. So we’ll tell you, look, the team you need right now focusing on your goals to get you where you want to be is this. So here we have some results and you can start seeing results. So it’s not just telling you what you need, but also like literally getting you options that you can afford, because it’s in network with your insurance, and then you can further refine that search. If we’re talking about outpatient providers, a therapist, or a psychiatrist, you can tell us, hey, does identity matter? Does gender matter to you? Does sexual identity matter? Does ethnicity or even language? You can filter by that, you can read about that person, how they introduce themselves, and then you can make a choice, but you’re shopping within the right bucket. We already told you, hey, this is the right care you need at this time point and you’re shopping within that, but you can further personalize it and have like an agency over who you get to see, for example, for programs, different consideration because you’re going to work with so many people, you’re in a program. What matters to people is actually like the facilities, especially if you’re living somewhere. How is it going to be like to live there? Am I going to be able to exercise? Am I going to have to access to my personal devices? Am I going to have Internet? Am I going to have this kind of, some people even like certain kinds of therapy and they want to make sure that’s available to them? So it’s a little bit more about, how is my life going to be when I’m there? And we also allow them to filter by that and answer those questions when they’re choosing a program. And our whole philosophy is, take the burden off of you from the things that we should be figuring out for you. But then once you’re already there, we already get you to the right care team, giving you back the agency to say, well, these things matter to me, so I want to find someone or a place, in the case of programs, that really is aligned with what matters to me and what I want to get out of it. So that’s our hope. This is the vision that we see for the research. And since we have the SCTR mechanism, which I definitely highly recommend to any small business listening, because it’s just a beautiful mechanism that allows you to collaborate with a research team. Like I said, our partners are the Child Mind Institute and then we can take all of that and actually apply it and make it available to people to use and have a benefit from it directly, from building it in research, and making it available to people. So it’s very exciting.

Joseph Kim:
Very exciting. Let’s talk about some maybe potential unintended consequences. Might there be a legitimate fear or can you allay some of these fears that, well, now you’re taking the job of a good clinician to do this sort of work, or is it more so that you’re actually preparing potential patients much more quickly so that you can skip a couple of steps and get to treatment faster?

Gabriela Asturias:
I would say the latter. I think in my own experience working in the hospital or outpatient clinics in mental health, oftentimes the intake appointments are, you’re right, the burden does fall on the clinician. And I think that sometimes makes it that accessing care is delayed because the wait times to get into an appointment are just so long in some parts of the country, extremely long. And it’s really worrisome because most of these requests can be time sensitive. I mean, not all of them, but, you know, I mean, you can’t be waiting for months sometimes, in some cases, not even weeks or days. So I think the fact that this country is just so hard to get care and that appointment is purely to route you to care, because you don’t really start care at that point. It’s purely to route you and then you get to start. So I think, by being able to remove that burden from the system and help route people to care, I hope that also frees up time in our limited supply of mental health options that we have for people so that they can focus on getting the right patients for their level and just start getting treated. Now, that doesn’t mean that intake is eliminated completely because any time that you get referred, especially outpatient providers or even in programs, they will, providers will do an intake to understand like your story and also to be able to understand like what kind of work they will do with you and what goals to set for therapy in the terms of, in terms of programs, a lot of them do require intake just to make sure eligibility is met. And we, what we’re trying to do is making sure that there’s less futile attempts. So when you actually go and contact a program, we have all their eligibility criteria front and center for you. So you’ve already been able to see that and you already indicated for a program. So in a way, like hopefully that means that more intake appointments will be successful because you’re already, there are some prep work beforehand. Today it’s actually a little, it’s less clear how to prepare. What does it even mean to try to get into these places? That being said, programs have websites and you can technically look for it, but you need to know how to find all these programs. So I think that’s what makes it a little hard also. So we’re just trying to centralize information. So I think takeaways, I really do hope that this reduces the burden in clinicians and having to help route people for care and gives them more time to do intake appointments with patients that are right for them, and so they can get started on treatment and for programs to get requests from people that meet eligibility criteria and make sense for that level of care from the get-go. And there’s also another element that a lot of outpatient providers sometimes get patients that are better suited for a program, and they, it takes a really long time for them to scale up to the right level of care, and that can lead to worsening outcomes. The other thing is most clinicians don’t have a network of programs just lying around that they can send this person to. So sometimes when you go through an intake and they say, actually no, you need a higher level, they may not even be able to help you get that higher level. So it just becomes a very disappointing process for people to be like trying things out and navigating all these things. So hopefully with MiResource, we’re able to eliminate those burdens. And one thing I haven’t added, which actually exists today, all of the providers and programs that are in our system have the ability to refer their patients. So if I’m a psychiatrist with MiResource, for example, and I see a patient, I’m like, you know what? You need a higher level of care. Like, at this point, I don’t think what I’m giving you in the frequency I’m able to provide, it is not sufficient for how you’re feeling. So I think you should get into an IOP program, for example. I could go as a provider into MiResource with you. We can even search together and I can actually do an effective referral for you, and that comes from a clinician that is saying this is indicated. So I think that’s really good that it’s not just not only for the patients but also for the providers. They can also help use MiResource to refer people to the right level of care and make sure that there’s no disruptions and people aren’t left without care for periods of time.

Joseph Kim:
Yeah! So yeah, from a dollars and cents perspective, which is important, it’s not everything, but it sounds like you’re taking away, you might be taking away a little bit of revenue, but it’s low-value activities, right? And oftentimes the conversion from an intake to entering a program isn’t that great. So it sounds like you’re taking away some burden, which might be some revenue, but it also means you have a better conversion of somebody coming in, matching to the right care provider or care program, and then moving forward much more quickly versus having a clinician or a patient. Kiss a lot of frogs before they end up finding the right match.

Gabriela Asturias:
Yeah, and I hope this doesn’t impact patient outcomes because, at the end, that’s the most important thing for us.

Joseph Kim:
Yeah.

Gabriela Asturias:
I think it is important to recognize that someone who has a mental illness having to try so many different things until they get care, can definitely exacerbate symptoms and also make them feel more discouraged and sometimes stop looking for care altogether, and that is a really big problem the system has right now. And that is one of the things we hope to impact and we’ll keep measuring to see we accomplish that.

Joseph Kim:
Yeah. Final question, with regard to your research, after you collect all this data, you’ll be working with very different kinds of people than you maybe thought of when you thought about research when you first went to school, right? When you think about human research and medical research, you think about doctors and clinicians, but you’ll be working with a whole different kind of profession to do all this machine learning. Tell us about like how that lands on you and how you found these other folks to work with and what you’ve learned being exposed to these kinds of topics.

Gabriela Asturias:
Yeah, the research question for this grant has been literally present in my co-founder’s mind and my own since we started the business. And I think it wasn’t until my co-founder was actually in a dinner with Arnold Klein, who’s our PI from the Child Mind Institute, and sharing passions, realizing, wow, we both really want to solve this problem. So we found a really good match in them, and through them, we’ve been able to identify good machine learning data, data scientists. And so it’s done a really good collaboration where we have on their end a lot of clinical advisors, we have the machine learning specialists, and then we also have some help from their engineering team and then our engineering team also. So because we found such a good partner, we were able to then go and identify people that have different skill sets that could come in and help us make this grant even a reality. So yeah, I mean, you’re right. Working with researchers and healthcare professionals, very different than working with engineers and data scientists, and machine learning specialists. So that’s always something to learn and grow from every single day.

Joseph Kim:
Yeah, I mean, from the early days of psychology and psychiatry, it’s funny how far we’ve come and you’re truly on the cutting edge of this by combining full human care and understanding of the person with all these high-tech machine learning engineers and data scientists. I wish you all the best, I think what you’re doing is really hard to do, but certainly needed. Tell everyone where they can find you and more about your company, MiResource.

Gabriela Asturias:
Yeah, they can look at our public website that is available to everyone, MiResource.com, and they can look for me on LinkedIn as Gabriela Asturias, and I’m also all over social media. My Twitter handle is @GAsturias.

Joseph Kim:
Gabriela, soon to be Doctor Asturias. Mucho gusto. It was really great meeting you and learning about your history and your company and where you’re headed. Thank you so much for spending time with us today.

Gabriela Asturias:
And thank you so much for this opportunity, Joe. I love sharing what we’re doing and I’m very passionate about what this could do for the field.

Joseph Kim:
Thank you for tuning into Research Confidential. We hope you enjoyed today’s episode. For more information about us, show notes, transcripts, and resources, please visit ProofPilot.com. If you’d like to debunk a clinical research myth, share some war stories, or maybe just show our audience what kind of heroics it takes to pull off gold-standard research, send us your thoughts, episode ideas, and more to Help@ProofPilot.com. This show was presented by ProofPilot and is powered by Outcomes Rocket.

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