Monday, October 16, 2017

Elon, Do We Have a Disaster for You!

One of the most interesting twists resulting from Hurricane Maria striking Puerto Rico was Elon Musk's offer that Tesla could help Puerto Rico solve its energy crisis, with a long-term, 21st century fix.  After all, its electrical grid was devastated, with almost all the power wiped out.  It didn't help that even prior to this disaster its system was antiquated and in badly in need of repairs.

It is telling that we don't have similar offers to rebuild the Puerto Rico's health care system, which is similarly devastated.  Or, for that matter, our system, which is its own kind of disaster.
Mr. Musk was asked on Twitter if Tesla could help Puerto Rico using solar and battery power, and he responded in the affirmative, saying it had done so on smaller islands but faced no scalablity issues.  Next thing we knew the Governor of Puerto Rico and he were talking.  Now Tesla is starting to deliver their battery systems to the island, so we'll see.

The appeal is obvious.  The island has a perfect climate for solar power.  Rebuilding the power plants and power lines is a daunting task, especially for an island that is essentially bankrupt.  Solar is renewable, oil and coal are not.  And, being a tropical island, Maria is not the last strong storm that will strike Puerto Rico, so future outages are inevitable.  Solar/battery at least decentralizes the grid, lessening how wildspread such outages might be.

Maybe it is a marketing stunt on Mr. Musk's part -- if so, you have to give him credit for it -- but the idea has merit.  A disaster like Maria is a once-in-a-lifetime opportunity to try bold new ideas instead of blithely rebuilding what was there before (let's hope Houston does the same with its zoning and floodplain issues).

Meanwhile, Kaiser Health News reports on the toll Maria has taken on the island's health system and residents' health, both now and for some time to come.  Relief workers are doing the best they can, but there's no easy fix for the underlying problems the system was already facing, like high prevalence of chronic conditions, funding shortfalls, and an ongoing brain drain of health professionals, all exacerbated now by lack of clean water, adequate supplies, and shelter.

Still, even Elon Musk isn't bold enough to offer to rebuild their health care system, much less ours.

Sometimes disasters do make us rethink our health care system.  Katrina, for example, has often been credited with creating the impetus for electronic health records (EHRs), since it destroyed countless paper records, wrecking havoc on care for thousands of patients.

But we didn't pay enough attention to even that very visible crisis.  We do have a lot more EHRs now, but less than 30% of hospitals self-report being interoperable, and half of physicians' time is supposedly spent on their documentation efforts.

The records themselves remain largely physician-centered and exclusively medical, although Epic, the nation's largest EHR vendor, is finally saying they will move to a "comprehensive health record" (CHR).  "Because healthcare is now focusing on keeping people well rather than reacting to illness, we are focusing on factors outside the traditional walls, Epic's CEO told HealthIT News.  Rivals say they are doing the same.

I'm glad that in 2017 EHRs vendors are finally realizing there is health outside a medical facility.

It shouldn't take a hurricane -- or an earthquake, or a bickering Congress -- to realize that we have an in-progress disaster with our health care system.  Sure, health care hiring is booming and hospital/medical construction is everywhere, but those are signs of the disaster, not of the robustness of the system.

We spend way too much on medical care, we get too much unnecessary care, we are subject to too many medical errors (including deaths), and we suffer from too many lifestyle diseases, such obesity and diabetes.  Our longevity is embarrassing -- and declining.

We give tax breaks to "non-profit" hospitals regardless of how they use those breaks, and to employer health plans, which end up disproportionately benefiting the middle and upper class.

We finally managed to give health coverage to millions of previously uninsured Americans, but now those gains are under attack, while half of the poor and near-poor remain uninsured.

We bounce from one new dietary finding and/or fad to another, while eating too many processed foods and not nearly enough healthy foods.  Meanwhile, few of us get enough exercise, and we spend too much time on our various screens.  Our social networks are increasingly online rather than in-person.

There is not nearly enough "health" in our health care system, just ever-more "medical."

If all that isn't a disaster, I don't know what is.

Let's say we were starting from scratch.  Let's reset what our health care system could be.  Let's say we didn't have all these hospitals, hadn't trained any physicians, hadn't deployed any medical devices or used any prescription drugs, although we could start with the knowledge of what each of those could accomplish.

Would we remake the system as it is, or would we design something new?

In a previous post I enumerated several things about our health care system I was dying to redesign, and in another I gave some specifics about how a re-engineered system might work.  Even those, though, didn't start from entirely scratch, still focusing more on the medical than on the broader health perspective.

We should be spending more on our health needs -- broadly defined -- than on our medical care.  We should be more worried about if people are going to the park than if they are going to the doctor's office.  And when we do get medical care, we should make sure it is care that has solid evidence of working, rather than too often accepting care that might work.

Elon Musk has his hands full saving humanity, not to mention helping Puerto Rico, so we probably can't count on him to offer to reinvent our health care system too.  So who will it be?

Tuesday, October 10, 2017

Let's Hope This Bores You

I think I know what is wrong with health care: not enough people are bored. 

These are stressful times for health care.  There's a never-ending stream of innovation, constant pressures about costs, concerns about the quality of care, conflicting research findings, ongoing uncertainty about how we should finance what coverage for which people, and new business models and organizational structures. 

There's too much to take in, and everyone in health care is working too hard, too long.  Honestly, who has time to be bored?

But that's a problem. 

We usually think of being bored as a bad thing.  You don't often find people saying they're looking to be bored.  You don't find many activities that bill themselves as being boring.  In our always connected, 24/7 culture, being bored is seen as some kind of a failure: isn't there another notification on your phone, another email you could read, another update you could post, another task on the to-do list that you could try to cross off? 

But being bored, as it turns out, is closely connected to being creative.  Psychology Scott Barry Kaufman writes:   "In recent years, neuroscientists have discovered that we tend to get our best ideas when our attention is not fully engaged in our immediate environment or the task at hand."  He was writing about executives needing more alone time, but the point is to distract the brain in order to allow those creative juices to flow.

Earlier this year Wired reported on two studies relating to boredom.  One found that subjects who had just been doing boring tasks like copying numbers from a phone book did better on creative thinking tests than a control group.  The second found that subjects who had to watch a dull screensaver did better on an associative word test. 

"Boredom becomes a seeking state," said one of the lead researchers.  Another of the researchers worries that: "We try to extinguish every moment of boredom in our lives with mobile devices," thus eliminating "useful, productive monotony." 

Similar, a 2014 study found that bored people are more likely to have "divergent thinking styles...Thus, boredom may encourage people to approach rewards and spark associative thought." 

We're even so scared that our children will become bored that we hyper-schedule them, give them interactive devices, and structure their free time.  Dr. Helen Street says: "A child’s school life is more structured than ever and from an earlier age than ever before....As a result we are seeing a massive creativity deficit in kids."

Imagine what is happening to even-busier adults.

Albert Einstein famously spent several years as a patent clerk, reviewing ideas far removed from the spectacular physics that he was developing at the same time.  He was busy but not so busy that his mind couldn't break free of conventional ways of thinking. 

Author Jordan Rosenfeld wrote in Quartz about retraining her mind to be bored, suggesting:

  • Get in the habit of "spacing out;" 
  • Resist the urge for constant communication;
  • Face your feelings, rather than trying to avoid them.  

Certainly many activities in health care are boring, or at least mundane.  Processing claims, coding bills, updating patient records in EHRs -- not anyone's idea of a good time.  But neither are they tasks that allow for much spacing out, for associative thought that can lead to creative ideas.

Instead, we try to force creativity.  We hire consultants to tell us their ideas, we pour over research to see what ideas other people have, we conduct "brainstorming" sessions, we go on retreats with exercises designed to spur teamwork and new ideas. 

It's not impossible that creative ideas come from all that; it's just not very likely.  It's more likely that we just get iterations and variations of existing ideas.     

Creativity can't be forced, but it can be encouraged.  A previous post talked about the value of "wrong thinking" and "dumb ideas."  Another post talked about the importance of failure as the price of success. 

You have to give people the time to think freely and the support when that freedom doesn't always pay off. 

People say that health care is too important to try creative ideas that might be risky.  People's lives are at stake, after all.  We have to be careful what we try, how we try it, on whom we risk it.  Perhaps that is true, but the end result of that kind of caution is a health care system that costs too much, delivers too little, and that makes no one happy. 

So, be willing to be bored.  Make time for it rather than letting every minute get filled.  Be open to flights of fancy that come from some good old associative thinking.  Stop trying to go from point A to point B and think instead about different kinds of destinations, using different modes of transportation.  Spend less time worrying about what has to be done and more time wondering what might be done.

I truly hope you weren't, in fact, bored reading this, but if a good idea or two came while you were, it will have been worth it.

Tuesday, October 3, 2017

Putting Our Health Before Their Dollars

You have to give CVS credit.  In early 2014 they announced that, as a health company, they would stop selling tobacco products in their stores, despite the estimated $2b in sales those represented.  Sure enough, by September of that year those products were gone.  A follow-up study suggested that many of those shoppers didn't just buy them elsewhere but actually reduced their consumption, with a significant number ceasing to buy them at all.  Credit to CVS.

This year CVS is doubling down, beefing up its selection of healthy food options and health-focused products, while moving candy and junk food to the back of the stores. "Pharmacy is the heart of our business and our focus on providing care to patients and customers defines everything we do in our stores," said their Pharmacy President. 

And yet, in those stores, right by those pharmacies, you can still find plenty of dietary supplements, including vitamins. 

This is not to fault CVS, at least not solely.  After all, other retailers with large pharmacy businesses -- e.g., Walmart or Walgreens -- never even stopped selling tobacco products.  Of course, they sell supplements as well.

It is no wonder: supplements are big business.  The industry itself says it is a $37b industry, although estimates range widely.  At least half of Americans take some kind of supplements, with use among people 60 and over even higher

Supplement use is so mainstream that we not only tell our physicians about using them, they are our leading source of trusted information about them.

The question is not whether supplements are mainstream.  The question is whether they should be.

Just last month a police officer died after taking kratom, an herbal supplement.  Kratom is banned in 6 states, and the DEA tried to ban it nationally, citing 15 deaths in three years.  That ban died due to intense lobbying by, believe it or not, the American Kratom Association.

The problem is that the supplement business is not what one would call heavily regulated.  It barely is regulated at all.  The FDA does not approve dietary supplements.  Companies making/selling them are responsible for ensuring their products are safe and that any claims about them are not false or misleading, but the FDA does not verify either safety or effectiveness. 

In theory, the FDA is allowed to inspect manufacturing processes and maintain adverse event reporting, and can take action if problems are discovered, but there is severe doubt about how well it can perform these tasks.  The FDA's Office of Dietary Supplements has a $5 million budget and about two dozen employees, to oversee an estimated 80,000 - 90,000 products on the market. 

It's not a fair fight.  Supplement manufacturers don't have to prove their products are either safe or effective, but to remove a product the FDA has to demonstrate it poses a "significant or unreasonable risk of illness."

This matters.  The U.S. Poison Control Center gets a call every 24 minutes, on average, related to dietary supplement exposures.  One study estimated there were 23,000 ER visits annually, and 2100 hospital admissions, due to supplements.  The number of deaths associated with them remains in dispute, although a rare FDA ban -- of ephedra, in 2004 -- drastically cut the number.  Shamefully, the industry had fought that ban, but ultimately lost in federal court. 

Part of the problem is that we don't really know what is in supplements.  In 2015 the New York State Attorney General's Office found that only 21% of ingredients listed on various store brands were actually in the products.  Another study looked specifically at one specific product -- "red yeast rice" (I am not making that up) -- from 28 manufacturers and found that the key ingredient varied wildly in dosage and wasn't even present in some versions. 

Keep in mind that there really is very little data that supplements -- even vitamins -- actually have a positive effect.  One study found no impact of vitamins or mineral supplements for cancer or heart disease.   Another study focused on antioxidant supplements taken to lessen risk of Alzheimer's or dementia, and similarly found no impacts.  Indeed, multiple studies have found at best no positive impact and sometimes negative impact.

S. Bryn Austin, a professor at Harvard's School of Public Health, pretty much summed up the industry, telling Business Insider:
Consumers should expect nothing from [supplements] because we don't have any clear evidence that they're beneficial, and they should be leery that they could be putting themselves at risk.  Whether it's on the bottle or not, there can be ingredients in there that can do harm.
And yet supplements are discussed one-in-four primary care visits, with at least 79% of physicians admitting that they have recommended them at some point.  Over half of physicians take supplements themselves.  Some physicians are even selling them directly, which has its own host of ethical and legal questions


It really shouldn't be a surprise that we fall for the supplement hype.  We like quick and easy solutions.  We are a nation of fad diets.  We'd rather get vitamins from a pill than from eating a balanced diet.  We'd rather take weight loss supplements than eat less and exercise more. 

And we fall for placebos of all sorts, mainstream and alternative, while allowing use of prescription drugs and medical devices that are not nearly as safe or effective as we think.  Supplements aren't an outlier; they fit quite nicely into the rest of our health care system. 

Part of me feels that if people want to spend their money on products with no validated efficacy, that's their choice, as long as those products are marketed accurately (which is a big caveat).  If they want to go to GNC, a health food store, even to the junk foods section of a drugstore to buy them, well, it's their money.

Just don't pretend they belong in the pharmacy.

A larger part of me, though, wishes that, rather than embracing supplements due to their popularity, "mainstream medicine" should be even more vigilant about requiring evidence for use of any treatments -- prescriptions, devices, procedures, tests, or supplements.

When CVS -- or other pharmacies, doctors, hospitals, or other health care professionals-- start only selling or recommending treatments that have proven value, then I'll believe they're putting our health above their dollars.

Monday, September 25, 2017

Patients Are Not Consumers...But Who Is?

It has become an article of faith in some health policy circles over the past 20 years that the "solution" for our health care system's woes is to make us better health care consumers -- the so-called consumer-driven movement.

After all, we've known for at least forty years that increased cost-sharing does influence how much health care we consume, so, in theory, higher deductibles and coinsurance, plus better cost/quality information, should give us the right incentives to shop.

Most health care professionals are equally convinced patients aren't, and are never going to be, "consumers" in any meaningful sense.  Health care is too scary, relies on too much specialized information, and is too often "consumed" at times when we are least able to make thoughtful decisions.

So far the evidence that health care shopping works is skimpy, and I've often wondered why.  I've come to realize that it is not just a health care problem.

We're just bad consumers generally.

Oh, no, you might say.  We're a nation of consumers!  We love shopping!  We're the home of the mall, of Walmart, of huge grocery stores, of Amazon!  Shopping is as American as mom and apple pie.

Well, if health care has shown us anything, it is that just because we spend a lot of money on something doesn't mean we're good consumers.

Take one of the most common consumer products over the past thirty years, the personal computer.  Through luck or shrewdness, Microsoft managed to ensure that most of the early computers ran on a Windows operating system, buggy though it was, and we didn't demand better.  It wasn't the best OS available then and it isn't now (although it has improved), yet Windows remains by far the dominant operating system.

Well, then, consider mobile phones, specifically smartphones.  We love our smartphones even more than we ever loved our PCs, and Apple has certainly raised the bar for the entire market with its iPhones.  Here, certainly, is a case where we've acted as good consumers.  

Or maybe not.  Last year Apple made around 80% of all smartphone profits, despite only having around 15% of market share.  That is not a sign consumers are demanding better value.  Apple is now rolling out iPhoneX starting at a cool $1,000, and preorders for it are already depressing orders for other models.

If it is new and flashy, we want it.

Then there is the quintessential America product, the automobile.  Once upon a time, U.S. manufacturers dominated not just the U.S. but the world.  They got cocky, gave us ever more expensive and lower quality cars, and assumed we'd just keep buying them.  They didn't introduce car safety features like seat belts or air bags because we demanded them or because they wanted to improve their vehicles, but because lawsuits and consumer gadflies like Ralph Nader forced them into it.

Higher gas prices in the 1970's gave foreign car manufacturers the chance they needed, and they've been taking market share ever since, to the point when it's fairly even.  We now have better choices, safer vehicles, and -- thanks to the Internet -- virtually all the information anyone could want to shop for the best vehicle.

So what do we buy?  Year-in, year-out, the top three selling models in the U.S. are huge, gas-guzzling, expensive pickup trucks (Ford F-series, Chevy Silverado, and Dodge Ram).  

It's not that so many of us are farmers or construction workers.  We buy them because we like who we think that makes us.  You don't have to watch too many car commercials to realize they're appealing to our desired self-image rather than encouraging us to shop smartly.  And it works.

Most of us don't like our cable companies, but most of us tolerate old technology, subpar customer service, and paying for channels we never watch.  Few people consider flying a fun experience these days, but airlines continue to shrink legroom, tack on ancillary fees, and reduce choices of flights.  Yet we keep flying. 

OK, but surely the success of Walmart and Amazon proves we're good consumers, taking advantage of low prices and comparison shopping?  Don't count on it.  Even at these low-cost merchants, there still are plenty of markups on most items (think Air Jordans really cost $150?).  And Amazon illustrates how prices for the exact product can still vary greatly -- yet some people still pick the higher priced options.

If there is anyplace we might be expected to act as good consumers, it might be at the grocery.  We all shop there, and our lives literally depend on our choices.  Any illusions one might have about how wisely we shop there should be dashed by the cereal aisle, which is filled mostly with overpriced ways to repackage sugar.

So where, exactly, are we acting as good consumers?

The fact of the matter is that we are not rational consumers.  There is a raft of research literature on this point.  Psychologist Peter Noel Murray, Ph.D., calls it "the myth of the rational consumer."  We like to tell ourselves -- and anyone who asks -- that we're making sound, rational purchase decisions, but much of our purchase decisions are driven by influences that we may not even be aware of.

In the end, Dr. Murray says: "It is the consumers’ perceptions of emotional payoffs that cause purchase behavior."

We're aware of how badly we consume health care services because the health care system is so bewildering, and because our encounters and health insurance premiums are so expensive.  If we used more legal services, we'd be talking about the arcane legal pricing structures and how ill-equipped we are to shop for those services.

The question isn't why we're not better health care consumers, but why we ever thought we'd be better at shopping for it than anything else.

That being said, there are people who do try to shop prudently, and would probably do more in health care settings if they had better data and more options.  We may not be actually getting better deals at auto dealers -- their profits don't seem to be suffering much from all our supposed hard bargaining -- but more of us at least can leave there feeling we tried.

We can at least hope for that much, even in health care.

Tuesday, September 19, 2017

Not Just Better Tech, Nicer Tech

We are surrounded by our technology.  We're glued to our smartphones, and when we're not on them we're looking at our tablets, computers, televisions, or gaming systems.  We're turning our cars into mobile technology platforms and our houses into "smart" homes, complete with Internet-of-Things (IoT) connectivity and always-on-call virtual assistants like Amazon's Alexa.  Most of our jobs are increasingly infused with technology, even ones historically considered low-tech.

We're addicted to technology, but we're not all that happy with it, and nowhere is this more evident than in health care.


For example, a recent post-mortem of HITECH, by John Halamka and Micky Tripathi looked at the "miraculous" success of the program in moving health care providers to electronic health records (EHRs).  Still, the authors admitted: "Along the way, however, we lost the hearts and minds of clinicians.".

In their great analogy, "we gave clinicians suboptimal cars, didn't build roads, and then blamed them for not driving."

Indeed, EHR tasks are said to consume half of primary care physician's time, and nearly two-thirds of health care professionals in another survey said the ROI on EHRs has been terrible or poor; only 10% rated it positive.

As Jody Medich warns in Singularity Hub, our interfaces are killing us.  According to Ms. Medich, The "human-machine-interface" (HMI) we've been relying on is all-too-often based on a time when we sat at a desk, looked at a terminal, and did things like math.  It wasn't intended for now, when our computing devices are with us everywhere and expected to be always-on-call, for a variety of everyday tasks and in ways that we can immediately process.

Our cars as mobile technology platforms are a good example: driving at 70 mph, is not the best time to have to look at verbal information on a small screen or at confusing icons.

Ms. Medich believes we are about to go into an era of cognitive or perceptual computing, which "recognizes what is happening around it (and you) and acts accordingly...This means technology will be everywhere, and so will interface."

David Webster, a partner at design firm Ideo, frames the coming technology revolution differently.  He writes: "The key is to design experiences around emotional value rather than rational value."

That may be the problem; our technology has always been written by hyper-rational coders, aiming at "rational" tasks, while much of what we do every day is driven by more emotional reasons.  .

Mr. Webster gives the health-related example of a "smart" scale that chided a woman for gaining a few pounds -- not realizing she was four months pregnant.  Getting such alerts can help motivate people, but they need to be appropriate and in context in order to be effective.

Just ask any health care professional about "alert fatigue."

Mr. Webster goes on to say:
The fundamental role of designers is to use creativity to bridge the gap between rational and emotional—to make new technology engaging and appealing by having it meet humans on their terms. We’ve found the best way to get people to integrate new products or behaviors into their lives is to connect with them emotionally, which encourages adoption.
If there is any sector that needs to think about the emotional, it is health care.

People turn into patients when they enter health care settings.  They turn into patients once they're diagnosed with a health issue.  As patients, they're forced to rely on health care professionals, they're bombarded with unfamiliar jargon, they're often asked uncomfortable questions or put through unpleasant treatments and/or procedures.  They may be scared, worried, angry, uncertain, or even delighted (a new baby!).

Talk about emotional.

Much effort has been put into giving patients access to their heath records, yet Ambra Health reports 31% of consumers can't easily access them, and other research suggests that well below 30% of patients with such access actually access them.  And how many understand them?

Meanwhile, we're also collecting data from other sources, such as wearables.  We're able to track our steps, monitor our blood pressure and heart rate, measure our blood glucose levels.  We can see all those resulting numbers, and get alerts about them.  But more numbers are not what we need.

We're already floundering in data we don't easily understand and we're making it worse.

If health care was strictly rational, placebos wouldn't work and we'd be eager to replace our human doctors with artificial intelligence (AI) ones.  But they do and we aren't.

EHRs shouldn't be data collection vehicles for clinicians, and they shouldn't be primarily data reporting mechanisms for them, or for us.  We are not data and our health can't be reduced to it.

Similarly, it's very clever to create "dashboards" for our various health information from our many devices, but we care less about what the numbers are than what they mean for us.

A previous post argued for the importance of data visualization, pointing out: "Let's face it: most of us are not good with numbers.  Most of us don't think in numbers.  Most of us think in pictures."  Rasu Shrestha, MD, MBA, the UPMC chief innovation officer, gently disagreed, saying that most of us think in stories.

Pictures or stories -- either way, if we want tech to be effective, it has to engage us emotionally, not just rationally.

In a Wall Street Journal opinion piece, Mark P. Mills -- a senior fellow at the Manhattan Institute and engineering professor at Northwestern -- says the cyber age has hardly begun, as we have yet to truly integrate software into hardware "so that it becomes invisible and reliable."

Further, "the U.S. now stands at the equivalent of 1920 for ubiquitous cyberphysical systems," he believes, and "the dominant players of the cyberphysical age have yet to emerge."

Our 1960's/1970's approaches to technology have been very successful, but it is now the 21st century and it is past time for the next era of technology.  Whether that is cognitive computing, emotional design, or cyberphysical -- or a combination of all three -- our technology needs to and is going to act very different.  It needs to "know" us and react to us appropriately.

We are building technology with ever-higher IQs, when what we really need is technology with EQ.

Where better to start than in health care?

Tuesday, September 12, 2017

The World Is Not (Going To Be) Flat

Too many of us have come to believe that the world is flat.  No, I'm not talking about the Flat Earth Society or the random celebrities who purport to believe it is (although both are troubling).  I'm talking about the rest of us, who increasingly see the world through the prism of our various screens, be they smartphones, computer screens, or TVs.  Americans admit to almost 11 hours of screen time daily, and one has to suspect that is understated.

That's going to change.  Soon.  And digital cinema camera maker RED may be showing us how with its new Hydrogen One smartphone.

In a partnership with Leia Inc., an HP spin-off, RED announced the Hydrogen One, which it claims is "the world's first lightfield "holographic" smartphone."  It is expected to be on the market in the first half of 2018, and will retail for $1,200 ($1,600 for the titanium version).  

Their press release says: "The Hydrogen program will feature stunning holographic content and 3D sound for movie viewing, interactive gaming, social messaging and mixed reality."  That's all very nice, but it is the holographic display that has people's attention (well, that and the price).

RED's background has been in cameras, aiming to "build the world's best cameras," which began with 2007's RED ONE, a breakthrough 4D digital camera (they now claim products with "8k resolution").  Leia has similarly grand ambitions, stating that:
Our proprietary Diffractive Lightfield Backlighting (DLB™) solution adds nanostructures to a conventional display and gives them almost magical properties while preserving their standard imaging capabilities.
Got that?  A 2015 Leia video helps illustrate their display:
OK, so it's not quite like the holograms we expect from science fiction television shows and movies, and content is going to be an issue for some time, but it is at least a break from the flat screens we're used to, even with 3D renderings in 2D.  And they're not alone.

Apple, for example, has filed a patent application for "interactive three-dimensional display system," according to CB Insights.  Holus has a Kickstarter campaign for its "interactive tabletop holographic display." while Holoxica claims "several generations of holographic technologies, which span from static images to motion video displays with interaction."

There are published papers in Nature and Optics Express that promise, respectively, "Holographic displays generate realistic 3D images that can be viewed without the need for any visual aids" and a "360-degree tabletop electronic holographic display."

Writing for NPR last month, Glenn McDonald asserted that for true holographic displays, we're not quite there yet, but "we're getting awfully close, though."  He cites a laser display from the University of Rochester and a laser-plasma approach from Aerial Burton as examples.  Other versions are still, he believes, more like optical illusions of "genuine" holograms.

If we only think we're seeing a hologram, does it really matter, as long as we do see them?

The point is, holographic displays are not only feasible with existing technology, but are starting to be commercialized.  RED may have gotten a jump on the market, and may be early in what the experience can yet deliver, but its state-of-the-art will not remain the state-of-the-art very long, nor will they be the only ones.

There will be some fast followers, and they will, indeed, follow fast.

It won't just be about smartphones.  Anything that uses a screen could be augmented, or replaced, by a holographic image.  I've written before about the coming world of "ubiquitous computing," where your device could be just about anything and your display show up anywhere you desire.

You may not care about a holographic display of text, for example, but you might about images, especially if they are interactive.

Entertainment and gaming, of course, are two industries where holographic displays should find early uptake.  Health care, on the other hand, is rarely a fast follower of new technology, but the industry needs to be thinking about the possibilities.

Health care is about people, but it is full of words and data.  Your medical chart is full of words you don't know, drugs you can't even pronounce, numbers that have no obvious meaning.  Health educators do their best to come up with illustrations, simplified explanations, videos, and visual aids, but most of us have health literacy levels well below our general literacy.

Even health professionals struggle to take in all the information, and that problem will grow exponentially as that data does, such as through sensors in wearables and elsewhere.  We need more pictures, and some of those pictures should be holograms.

Picture a hospital room, with the poor patient hooked up to various monitors (all beeping away constantly).  A doctor or nurse coming into the room has to look at the screens and try to make sense of what they are saying about the patient's health.  They may be very good at it, from years of practice, but perhaps it doesn't have to be so hard.

A holographic display -- perhaps of the patient, or trend lines -- could help more easily illustrate problem areas or indicators that are trending in the wrong direction.  It doesn't have to be holographic, of course; it's just that we are visual beings.  A holographic image might make the situation more real and the comprehension faster.

I long for the EHR that is based on holographic displays, allowing the clinician to not only visualize a patient's history and current status but also interactively annotate them.  The display could also be much easier for the patient to view and understand, as well as allowing for on-the-spot visualization of any diagnoses or proposed treatments.

If, as the saying goes, a picture is worth a thousand words, then a holographic display might be worth ten thousand words of medical jargon.

Augmented reality (AR) and virtual reality (VR) are equally exciting, but, to the extent that they require us to view them through devices, may have different uses.  At some point, though, the three technologies may, for all practical purposes, merge into a unified "hand-free" interactive experience.

So, kudos to RED and Leia for showing us the way forward with smartphones.  The future of holographic displays can't come fast enough.

Tuesday, September 5, 2017

Health Care's Juicero Problem

Bad news: if you were still hoping to get one of the $400 juicers from Juicero, you may be out of luck.  Juicero announced that they were suspending sales while they seek an acquirer.  They'd already dropped the juicer's price from its initial $700 earlier this year and had hoped to find ways to drop it further, but ran out of time.

I keep thinking: if they'd been a health care company, they not only might still be in business but also would probably be looking to raise their prices.
Juicero once was the darling of investors.  It raised $120 million from a variety of respected funding sources, including Kleiner Perkins, Alphabet and Campbell Soup.  They weren't a juice company, or even an appliance company.  They were a technology company!  They had an Internet-of-Things product!  They had an ongoing base of customers!

Juicero's founder, Doug Evans, saw himself as a visionary, telling Recode: "I'm going to do what Steve Jobs did.  I'm going to take the mainframe computer and create a personal computer.  I'm going to take a mainframe juice press and create a personal juice press."

The market seemed promising.  All those people willing to pay $5 for a cup of Starbucks or $200 for their own Keurig would certainly see the value in their own juicer, especially with Juicero's own, IoT-connected Produce Packs.  Indeed, Juicero claimed to have sold over a million of the Produce Packs alone.

The ridicule started almost as soon as the hype.  $700 -- even $400 -- for a juicer?  Even for Silicon Valley, that was a bit much.  Mr. Evans was replaced as CEO last fall, but their woes continued.  The negative publicity probably reached its nadir in April, when Bloomberg reported people could produce almost as much juice almost as fast just by squeezing the Produce Packs directly.
Moral of the story: if you want to introduce products that have minimal incremental value but at substantially higher prices, you're better off sticking to health care.

Take everyone's favorite target, prescription drugs.  The pharmaceutical industry has learned how to play the system for higher prices, and profits.  They can take existing drugs and tweak them to justify higher prices, or even buy rights to existing drugs and jack up the price, as we saw with Daraprim ($13.50 per tablet to $750) and EpiPens ($57 to over $500).  Former Turing Pharmaceuticals AG CEO Martin Shkreli, who raised the Daraprim price, may be hated for his actions but he's not alone.

Consider this: studies suggest that only about 10% of new drugs are actually clinically superior to existing treatment options.

As Donald W. Light charged in Health Affairs, "Flooding the market with hundreds of minor variations on existing drugs and technically innovative but clinically inconsequential new drugs, appears to be the de facto hidden business model of drug companies."

As with prescription drugs, we regulate medical devices looking for effectiveness but not cost effectiveness -- and we don't even do a very good job evaluating effectiveness in many cases, according to a recent JAMA study.

And, as Elisabeth Rosenthal pointed out in her remarkable An American Sickness, medical device manufacturers have figured out how to game FDA regulation by claiming products were "substantially equivalent" to existing devices; "The surprising result is that today there is generally far less careful scrutiny of new devices than new drugs."

Take robotic surgery, hailed as a technological breakthrough that was the future of surgery.  A robotic surgical system, such as da Vinci, can cost as much as $2 million, but, so far, evidence that they produce better outcomes is woefully scarce.

As Dr. John Santa, medical director at Consumer Reports Health said, "This is a technology that is costing the heathcare system hundreds of millions of dollars and has been marketed as a miracle -- and it's not."

It is, of course, much more expensive.  

Proton beam therapy?  It's one of the latest things in cancer treatment, an alternative to more traditional forms of radiation therapy, and is predicted to be a $3b market within ten years.  The units can easily cost over $100 million to buy and install, cost patients significantly much more than other alternatives, yet -- guess what? -- not produce measurably better results.

The number of proton beam centers is growing rapidly, of course -- especially in the U.S.

But, in our health care system, with its crazy-quilt system of financing and delivering care, we don't need new drugs or fancy new devices to cost us more.  We pay more for pretty much everything than pretty much everyone else.

Last year Vox used 11 charts to illustrate how much more we pay for drugs, imaging, hospital days, child birth, and surgeries than other countries.  Their conclusion, which echoes conclusions reached by numerous other analyses: "Americans spend more for health care largely because of the prices."

We not only don't get a nifty new juicer from all of our health care spending, we don't even get better health outcomes from it   

Health care's "best" Juicero example, though, may be electronic health records (EHRs).  Most agree on their theoretical value to improve care, increase efficiency, and even reduce costs.  But after tens of billions of federal spending and probably at least an equal amount of private spending, we have products that, for the most part, frustrate users, add time to documentation, and don't "talk" to each other or easily lend themselves to the hoped-for Big Data analyses.

Many physicians might, on a bad day, be willing to trade their EHR for a Juicero.

Jonathon S. Skinner, a professor of economics at Dartmouth, pointed out the problem several years ago: "In every industry but one, technology makes things better and cheaper.  Why is it that innovation increases the cost of health care?"

Essentially, he believes, our health care system pays for too many things that are of too little value, because, "unlike many countries, the U.S. pays for nearly any technology (and at nearly any price) without regard to economic value."

So we can make fun of Juicero all we want, but when it comes to overpriced, under-performing services and devices: health care system, heal thyself first.