Monday, December 29, 2014

Great Expectations Aren't Always Good

I didn't post last week, figuring people would be too busy to read it during the holidays, and I probably would have done the same thing this week except that interesting topics just keep coming up.  The one that most caught my eye was a study on patients' unrealistic expectations.

The study, by Hoffman and Del Mar, was a meta-study reviewing the research on patients' expectations about both benefits and potential harm of interventions.  As might have been expected, patients have an overly optimistic view: in 65% of the studies where data was available, the majority of patients overestimated the potential benefits of their treatment.  Similarly, in 67% of the studies where data was available, 67% found that the majority of patients underestimated the potential harm.

The authors noted: "Overly optimistic intervention expectations by patients and the public are undoubtedly contributing to the growing problem of over diagnosis and over treatment."  No kidding. 

In an accompanying commentary,  Deborah Korenstein, MD, calls patient perceptions "the Achilles heel of high value care," cautioning that the study "makes it clear that we must better equip patients to understand the potential benefits and harms of medical care so that they can make the best decisions and improve the value of their own health care."  She concludes that "the effort has to start with us," that is, with physicians.  

None of this is surprising.  For example, a study of cancer patients in 2012 found that 69% of patients with advanced lung cancer, and an even mote astonishing 81% of patients with advanced colorectal cancer, did not understand that the chemotherapy they were receiving was not at all likely to cure their cancer.   Even more disturbing, patients who rated their communication with their physician high were most likely to have over-optimistic expectations.  They may be comfortable talking with their physicians, but perhaps they're not really listening -- or the physicians are not being as blunt as they could be.  

It's not like patients and physicians are talking openly with each other anyway.  The Open Notes Project is getting lots of deserved plaudits for its effort to allow patients to see their own records, but it is dismaying that we need an initiative to do so.  On the other hand, a recent survey found that nearly half of patients don't want their doctors to see all their health information either.   

Lack of openness goes both ways.

In another illustration of the problem, Kenny Lin, MD, wrote a recent post False alarms and unrealistic expectations in preventive care that recaps the dubious data on the value of many common preventive exams and tests, while highlighting the difficulty in trying to change patients' expectations for them.  He fears that the main goal of allowing these unrealistic expectations to persist is financial -- that is, the financial interests of physicians and the associated supply chain.  He acknowledges that "false beliefs meet the psychological needs of patients for hope and safety, as well as for action, agency, and a sense of control.  They enable clinicians to feel they are making a difference; even physicians who know better order unnecessary tests to please their patients."

Sometimes these false beliefs do serve good purposes.  A patient's positive attitude has long been known to impact their response to illness.  Placebos are an age-old part of a clinician's bag of tricks, and science is starting to help us understand them.  Recent findings have shown that they produce measurable changes in the body, even in the brain (e.g., Parkinson's symptoms).  Landmark research by Ted Kaptchuk, et. al,  back in 2010 found evidence not only of the placebo effect, but that placebos had a positive impact even when patients knew they were "only" receiving the placebo.  

In another intriguing study, Kaptchuk gave asthma patients inhalers, two different placebo interventions, or no treatment, and found that only the ones with inhalers actually improved lung function.  However, the patients who received the placebos reported the same subjective improvement as the inhaler group.  They felt just as good, even if their lung measurements said they shouldn't.

Kaptchuk -- an acupuncturist by training yet an associate professor of medicine at the Harvard Medical School -- has made placebos so mainstream that he now heads up the Program in Placebo Studies & Therapeutic Encounters (PiPS), hosted by Beth Israel Deaconess Medical Center.  

One of the most intriguing findings from the placebo research is that, well, presentation matters.  Karen Jensen, also of Harvard and PiPS, has shown that patients look for clues about what to expect, and those clues may be non-verbal -- the physician's demeanor or facial expression, the decorations in the exam room, etc, As she says: "Everything that has to do with the elaborate ritual of delivering care could be a target to enhance the placebo effect,"  E.g., it is not just the pill but how the pill is prescribed.

Still, placebos and positive thinking only go so far.  As Kaptchuk says: "Sham treatment won’t shrink tumors or cure viruses."

Or can they?  The hottest area in oncology these days is immunotherapy -- getting the body's own immune system to attack the tumors, rather than relying on radiation or chemotherapy.  A new class of drugs are, in essence, releasing the natural brakes on the immune system.  Right now, we need drugs to accomplish this, but recent research has demonstrated that, amazing as it sounds, a person's mind can actually trigger gene expression.  So far it has only been tested triggering genes in mice, but perhaps we're not so far away from releasing those immune system brakes in ourselves.

Advocates of biofeedback must already be celebrating.

It's fun to speculate about literally thinking ourselves to good health, just as it is nice to imagine nanobots doing all the hard work.  Those days may come, and sooner than we think, but for now we're stuck with our existing health care system, and that system is built on physician-patient interactions.  

It's easy to see why those interactions are fraught with inaccurate patient expectations.  One of the biggest problems, of course, is that for most interventions, the supporting data is woefully sparse or inconclusive, especially in the context of a specific provider's performance with specific set of patient characteristics.  Even if a physician takes the time to share the data, and the patient has the aptitude and inclination to understand it, they may not be much better advised than uninformed patients.  

Whenever I think about shortcomings in our health care system, I often think of Congress.  Its approval ratings are at all-time lows, but the fact is we've elected them, or through our apathy allowed others to do so.  Similarly, we've allowed our health care system to be a medical care system, and abdicated much of our own responsibility for our own health to our health care providers.  As a result, when something happens to us, we have these unrealistic expectations about what they can do for us.

It's on us to take better care of ourselves.  It's on us to do better research on our treatment and provider options, and to demand better data.  It's on us to insist on frank and open communication with our physicians and other providers  -- even if that doesn't fit within the 15 minute appointment window they might have slotted for us.  

We should never take hope out of care, but we can do better about making it informed hope.

Wednesday, December 17, 2014

The Convenience Truth

The U.S.  Mint reports that it now costs 1.7 cents to make a penny; nickels are slightly better, costing "only" 8 cents to make the 5 cent coin.  This is economics the way health care practices it.

According to Christopher Ingraham of the Washington Post, we could save $100 million annually by eliminating both coins.  Or we could change the metal composition of the coins to make them cheaper, but that would create havoc with vending machines.  So we just blithely chug along, using coins that few of us would miss and whose costs exceed their value, mostly because we've always had them and the businesses that revolve around them don't want to change.

See how this is like health care?

What made me think about this was a recommendation from Britain's National Institute of Health and Care Excellence (NICE).   They now say that midwife-led birthing units are safest, and advised more women to consider them for low risk pregnancies.  They believe this could account for as many as 45% of live births.  Moreover, they think home births are just as safe as births in a hospital.  The Netherlands is considered the leader in home births, at a little under 25%, although that rate has been dropping in recent years.  The U.S. has 1.36% home births

Although I don't have any first hand evidence, I'm willing to bet that Dutch women aren't built any different than U.S. women, and don't love their children any less.  The non-hospital birth rate in the Netherlands versus the U.S. must be due to cultural and structural differences, not medical ones.

The literature -- often drawn on Netherland's data -- generally supports the NICE recommendation, but not everyone is convinced.  A lot of factors come into play, not just the specifics of the pregnancy itself but also how midwives are trained, how far the home or birthing center is from emergency services, and so on.  It would be very easy to weigh all the factors, and conclude that even a relatively small increase in risk is not something you'd want to take for your own baby, and opt for the "traditional" OB/hospital delivery.

This is where the penny analogy starts to really apply.  These decisions on risk reduction are not without financial consequence.  A vaginal delivery with no complications averages about $10,000, whereas a birthing center costs under $2,500, according to Childbirth Connection.  I assume home delivery is less expensive.  As NICE's Dr. Mark Baker said about hospital births: "Yes, it's a very expensive way to deliver healthy babies to healthy women.  Saving money is not a crime."

Sadly, I can't even imagine a public body in the U.S. making such a bold recommendation.  I can't even imagine having a productive discussion on this topic in the U.S.  Just try and see how quickly it leads back to "death panels."

In a piece for The New York Times, professor/physician Aaron Carroll notes that the ACA-created Patient Centered Outcomes Research Center is explicitly prohibited from considering cost effectiveness.  Its website says: "We don’t consider cost effectiveness to be an outcome of direct importance to patients."  


Dr. Carroll uses the clever example of a pill that would extend your life one day, but cost $1 billion, versus a pill that cost $1 million but might extend your life 10 years.  We think we know how to decide about the former -- I hope -- but decisions on choices like the latter get murkier (e.g., Sovaldi...).  And it's always easier to keep paying for things that we've historically paid for, even when their value becomes more questionable.

In theory, value-based purchasing will help us address these decisions.  In practice, though, most of the value-based purchasing arrangements I am aware of -- and that certainly is not an exhaustive list -- reward providers whose outcomes are simply what we'd hope for, may penalize them slightly for disappointing results, and are indifferent about if the care could have safely been done elsewhere for less.  Does anyone think there is a health plan in the country which would dare reward midwives for the savings they provide through home births, or penalize OBs for hospital deliveries?  The data say we should, but I think I can safely say we won't.

There is a way out of this mess, but it may not be what you think.

I'm beginning to think that trying to reshape our health care system through value-based purchasing, cost-effectiveness, or even greater transparency may not work.  The "killer app" may not prove to be any of those high-minded strategies but rather a much more basic one: convenience.

Indeed, one of the earliest urgent care chains attributes its inspiration to the example of McDonald's.  We are, after all, the nation that invented fast-food, decided even that wasn't fast enough and so invented drive-throughs, which we use for over half of our fast food.  We liked the convenience of them so much that we've extended the approach to banks, car washes, pharmacies, even weddings and  funeral homes.  The concept of drive-throughs itself is rapidly being supplemented and even superseded by mobile apps, allowing consumers not to even have to get in their car.

Health care cannot ignore these consumer demands for more convenience.

Walgreens' chief medical officer recently noted that: "The idea of convenience ... is really becoming a dominant theme in health care."  It's no coincidence that Walgreens has been investing in in-store clinics, has a 24/7 Pharmacy Chat option, and just rolled out a direct-to-consumer physician virtual visit app, similar to American Well's Amwell service.  Not to be topped, Kaiser is now offering EMT home visits, in addition to its array of in-office and virtual visit options.  

Our traditional approaches to care delivery have revolved around convenience for the providers, not the consumers.  Many people still like to see their doctor in person, and to go to the hospital when they have serious health issues.  Thus, hospital births.  The rise of urgent care and  ambulatory surgical centers illustrate consumers' appetite for lower cost, more convenient options -- even though not everyone is convinced these options are as safe.  Perhaps home births will end up following this pattern as well.

Many consumers, especially younger ones, find ridiculous the notion that they have to call for an appointment that may end up weeks away, go to an office or facility that may not be close, only to wait there with sick people, and perhaps be sent to some other office or facility for more services.  They'd rather get their care via their mobile devices and/or in their home, and the technology is increasingly allowing that for many health concerns.  Not everything, mind you, but more than we realize now.

We've come to recognize that health care is one of the few industries where technology typically not only doesn't lower costs but usually adds to them.  Maybe, though, expecting providers whose revenue is at stake to focus on cost-effectiveness is asking too much of them.  Focusing on convenience shouldn't be.

It may not initially be about cost -- smartphones are more expensive than the mobile phones they are rapidly displacing -- but once consumers start opting for more convenient options, it's hard to see that costs won't plummet, as the traditional care silos start to fall.

Focusing on convenience is simply a way to make sure we're focusing on the consumer (AKA "patient").  Isn't that supposed to be the point?

Monday, December 8, 2014

Borrow From the Best

If imitation is, as they say, the sincerest form of flattery, health care should be doing a lot of sweet talking.

I was amused -- no, make that intrigued -- to see that the Defense Department recently released an RFI, asking both defense contractors and non-traditional vendors to help them dream up new defense technologies.  "I'm game for anyone," deputy assistant secretary Stephen Welby claimed at the press briefing.

Mind you, this is the Defense Department that already has DARPA, whose track record of technological innovation includes stealth planes, GPS, and -- in case anyone had forgotten -- the Internet.  But DOD still thinks they need help in developing "...novel or unconventional applications of technology in ways that would provide significant, enduring capability advantage..." to quote their RFI.

Health care needs more RFIs like that.

I was primed to react to the DOD RFI by an article in the Harvard Business Review: "Health Care Needs Less Innovation and More Imitation," by Anna Ross and Thomas Lee, M.D.   As they say:
Health care is infatuated with innovation.  We're awash in innovation conferences, organizations proclaiming innovation as a core value, newly minted Chief Innovation Officers, prizes for best innovation.  We think innovation is great, but there's a downside.  When organizations overemphasize innovation, they can miss out on the power of imitation -- copying existing approaches that actually work.  Providers need to actively seek out good ideas that have been tried and refined, bring those ideas home, and adapt them for local use.
They propose -- "our tongues only partially in cheek" -- an International Institute for Imitation, where Chief Imitation Officers could find good ideas to borrow.  They cite several examples of successful imitation, although the examples where health care organizations have borrowed ideas from other health care organizations are more convincing than the ones borrowing from outside health care.

I've written numerous posts over the past few months about how technology companies are becoming interested in health care -- e.g., AmazonFacebookGoogle -- but also expressed my concern that many of these outsiders are less interested in revamping health care than getting their share of the $3 trillion health spending.   If we're going to imitate, we need to make sure we're picking the right things.

One example of imitation is health organizations bringing in experts from retail industries, hoping to improve their patient/member experience.  Disney is often cited as one of the gold standards.  After all, Disney manages to take a hot, crowded, expensive experience and make people love it.  No wonder health care organizations think they can learn something.

The online version of customer experience that health organizations are now aspiring to imitate is Amazon.  Whenever I read about health care organizations wanting to create an "Amazon-like experience" (and President Obama helped get that particular ball rolling, bragging about before its disastrous initial roll-out last year), I think about why that is unlikely to happen.

Here's an example of the problem.  If my car was damaged I'd probably get a estimates from a few auto body shops, hopefully at least one of which my auto insurance will agree to pay in full.  I'd expect my car to get fixed on schedule and for the quoted price.  If it happened like it happens in health care, it's unlikely I could get an estimate in the first place, and when it came time to pay I'd probably get lots of bills -- from the auto body shop, from each of the mechanics, some for any diagnostics performed, and so on.  My health insurance might decide not to pay for some of these, claiming they weren't "necessary," or make me pay extra for anything it didn't consider part of its network.  What a mess.

When even auto repair looks consumer-friendly by comparison, you know health care is badly in need of reinvention.

The influx of different technologies and customer orientations certainly is welcome, but at best they paper over some of the underlying major problems, and I'll highlight a few:

  • Billing: Transparency is heralded as a way to help consumers make better choices.  There are no shortage of vendors in the space, and even some research suggesting it can help.   More transparency is needed, but the problem is that the underlying pricing structures make no sense.  They're based on wildly inflated charges that bear no relation to either actual costs nor the numerous negotiated rates.  Even worse, they grow ever more granular, whether based on CPT codes, DRGs, or other mechanisms.  There are thousands -- tens of thousands! -- of them, few of which carry any real meaning to consumers and which are rarely disclosed until long after the service is rendered.  Even if a provider's fees were made perfectly transparent, consumers still would be at a loss to understand them.  
  • Comparability: Let's pick on health plans, although I could do the same for providers' services.  It's not so hard to compare cost-sharing provisions like deductibles, copays, coinsurance, out-of-pocket limits, and premiums, and if you are relatively healthy that may be enough.  But if you have a chronic illness or suffer some major acute episode, things like how health plans define "medically necessary" or "experimental treatment," what's on their formulary, even which providers are in their provider network may be even more important.  It is hard to find and compare health plans on any of these prior to enrollment -- and health plans can change them with no warning during the plan year.  
  • Episodes of care: It's pretty rare that an encounter with the health system results in seeing only one provider, or only once.  A doctor's visit may led to the pharmacy or lab, an ER visit may include out-of-network physicians, and hospital stays end up with bills from a surprising number of providers, both during and after the stay.  Patients rarely know exactly what they are "buying" or from whom they are buying it, much less what it will all cost.     
We have armies of billing experts on the providers' side trying to maximize their revenues, countered by armies of claim examiners on the health plan side trying to combat those efforts, while experts on both sides fight over contractual language like Talmudic scholars.  None of this helps the consumer -- the patient/member -- and very little of it is understandable to them.

Yes, I know smart people on both sides are working on approaches like bundled payments and value-based purchasing, but I fear that even these may end up so technical that only those experts can understand them.

Health care is very complex; I get that.  But so are lots of things, such as computers or cars, and buying them is much easier than buying health care.  We shouldn't accept that this has to be the case. I think the winners in the health care wars will not necessarily be the ones with the coolest technology or the friendliest customer experience, but those who have the easiest-to-understand products and pricing.

If we want to borrow from other industries, technology is nice but simplicity would be better.

Tuesday, December 2, 2014

Cutting More But Not Saving More

There's an epidemic in American health care, and I don't mean the commonly lamented ones like obesity, diabetes, or even Ebola.  It's surgery.

It would be easy to think I am referring to cosmetic surgery.  After all, according to the American Society of Plastic Surgeons, there were some 15.1 million cosmetic procedures in 2013, more than double the number in 2000.  One can question what all those cosmetic procedures say about our society's values, especially with some of the stranger procedures being done or the reasons for wanting them (selfies!) but at least cosmetic surgery is usually patient-driven and paid for out-of-pocket.

No, I'm concerned about the increase in supposedly medically necessary surgeries.

What started me thinking about this was an article in The Wall Street Journal detailing the increase in women with early stage cancer in one breast who are having both breasts removed.  The proportion rose from 2% in 1988 to 11% in 2011.  For most women -- unless they have a BRCA genetic mutation -- the double mastectomy doesn't appear to improve chances of survival.

Experts speculate that women may be making the decision out of fear or anxiety rather than objectively looking at their risk, but it still make one wonder why that percentage is rising so fast.  Is breast cancer more scary than it used to be?

Breast cancer is a very emotional diagnosis, and I can't really put myself in those women's places.  If it was just this trend, I'd leave the topic alone, but there are sizable increases in many other types of surgery as well.  Here are some examples:
  • Cesarean sections:  In 1996, the C-section rate in the U.S. was 20.7% of all births; in 2011, it had risen to 31.3%, after reaching a high point of 32.9% in 2009.  In 1965 it was 4.5%,  The WHO recommends that the rate should be no more than 15%.  Many blame the dramatic rise on mother's requesting C-sections, more medical need for them, or physicians performing them out of malpractice concerns, but Childbirth Connection disputes all those arguments.  
  • Spinal surgery for spinal stenosis:  Use of spinal fusion increased 67% in Medicare patients from 2001 to 2011, according to a report from the Dartmouth Atlas Project.  Even more telling, rates for spinal decompression vary eight-fold across the U.S., while rates for spinal fusion vary fourteen-fold.  It would appear something other than medical necessity is in play.  
  • Knee replacements: These have soared from 250,000 annually fifteen years ago to over 600,000 in 2012.  The fastest growing population is not the elderly but those 45-64, whose rates have increased 205%, versus "only" 95% for the 65+.  According to a study by researchers at Virginia Commonwealth University, as many as one-third of knee replacements may not be appropriate.
  • Heart Stents: Over the past 25 years, annual use of stents to help narrowed coronary arteries has grown from virtually none to over 500,000.  Even the AMA and the Joint Commission think that is too many, reporting that 10% may be inappropriate and another one-third are questionable. Nortin Hadler, a professor of medicine at UNC, told Bloomberg News: "Stenting belongs to one of the bleakest chapters in the history of Western medicine,"  
  • Bariatric surgery: In 2000, there were only 36,700 bariatric surgeries, versus an estimated 179,000 in 2013 (although that number may have peaked at 200,000 in 2008 and 2009).  Evidence for its effectiveness is mixed, with some studies indicating that the surgery may not have the long term positive impact on costs and longevity that many expected. 
I'm sure more clinically oriented readers can come up with other examples; the list is meant to be illustrative, not exhaustive.

Why is this happening?  There are lots of possible explanations, starting with the fact that we're simply not very good about evaluating risk.  Our brains evolved to deal with a different set of risks than surgery.  Those same brains also evolved to focus on immediate gratification over long term benefits, so when faced with a choice of surgery versus lifestyle changes or treatments that might take longer, well, it's easy to go for the perceived quick fix.

It doesn't help that there rarely are meaningful data on the risks/benefits of the surgery, the specific surgeon, and the non-surgical options.  It's hard to make informed decisions without the right information.

Another reason for the increase in surgeries could be simply because we're developing new and better ways of doing them.  Cataract surgeries are on the rise, but would anyone want to go back to how they were done in the 1960's?  Anyone not want to have minimally invasive options for a host of procedures?  There are truly marvelous surgical approaches available, requiring incredible skills from our surgeons, and it almost seems like a waste not to use them.


Finally -- and there's no avoiding it -- there is the money.  Surgeons tend to be among the highest paid physicians.  The Wall Street Journal exposed significant financial conflicts of interest for spine surgeons back in 2010, which the recent Open Payments data released by CMS have only made more troubling -- and not limited to spine surgeons.  We like to think we're not getting surgery because the surgeon stands to make a lot of money from it, but we'd be foolish to think it doesn't factor into the recommendation.

In a previous post (Mistaking Failure for Success), I had suggested that we should look at hospitalizations as a sign of failure, arguing that each admission should be accompanied by a review of what could have been done to avoid it.  I propose that we should view surgeries in the same way.

Certainly some surgeries are inevitable -- if you are shot or are born with a hole in your heart, chances are you better have surgery -- but I'd be very curious about what percentage a careful analysis might find actually are truly necessary.  A 2013 USA Today study estimated 10-20% of surgeries in some specialties might be unnecessary, and I'd bet a more in-depth review would produce an even larger share.

Any way you look at it, there's more cutting going on than there should be.

Mayo Clinic co-founder Charles H. Mayo once (supposedly) said: "It is the surgeon who benefits most from elective surgery."  That sure sounds like a recipe for an epidemic of surgeries.  More and better data on risks and benefits would be a good start to addressing the issue, so that we could at least try to make rational decisions.

I suspect, though, that we won't make real progress on avoiding unnecessary surgeries until they go from being a revenue source for providers to being a cost center.  If we were paying providers to keep us well, not to do more things to us, surgery might not be as attractive to them.

As surgeon Norman M. Kenyon once said: "The hardest thing about being a surgeon is knowing when not to do something."

To be fair, I could have equally discussed the large increases in procedures (e,.g., colonoscopies) or imaging (e.g., CT scans), for much the same reasons.  Doing more, not necessarily better, seems to be the hallmark of our health system.

Maybe we should spend less time worrying about Ebola and more time worrying about these health system-induced epidemics.

Monday, November 24, 2014

A Hologram Might Be Worth a Million Numbers

I saw a fascinating article about how Fidelity, through their research arm Fidelity Labs, has released a virtual reality tool to portray financial information in a more visual manner -- not even using numbers.  I immediately thought about how this approach could apply to health care.

The Fidelity tool -- which can be viewed using virtual reality goggles or as in simulated 3-D on a browser -- is pretty cool.  Stocks are buildings, the height is their price, the size of the base is the trading volume.  Weather reflects whether markets are up or down, day/night indicates if markets re up or closed, and so on.  You can build your own "city" or neighborhood based on your portfolio or stocks/sectors you are following.

Fidelity got interested in this after Facebook acquired virtual reality company Oculus earlier this year (for a very real $2b), figuring Facebook might have some hint of where consumers were headed.  To date, virtual reality has been mostly thought of in terms of gaming, but Fidelity is thinking out of the proverbial box.

Financial information certainly can be very dry and numbers-laden, but I think health care can make a case for the title of most confusing.  Lots of confusing language, lots of data that sometimes is information and sometimes just adds to the noise.  Think of your medical record (if you've ever been able to see it) or a set of lab results.  Now add all the data that is or is soon going to be added to your information via wearable or remote monitoring devices, and the sum total is certainly a situation that is crying out for better visual representation.

Yes, I know that many of those fitness devices, as well some lab results, may come with charts or graphs, but people who don't like numbers may not like charts and graphs much better.  And that's still just a slice of our health information.

We know understanding health care data is a problem.  In a recent study, The University of Michigan found that people with low literacy and numeracy skills were less than half as likely to understand their lab results -- and even among those with higher such skills, only 77% were able to.

All that health care data is crying out for visualization.  Visualization of Big Data is becoming a hot trend generally.  From an evolutionary standpoint, humans aren't very good at making sense of numbers, but we excel in looking at patterns -- and pictures.

To help address this, University of Michigan has a "Visualizing Health" initiative.  They've created a gallery of of recommended ways to graphically represent health information that they've validated through user testing, and are making them available for free.  It's a great project, but looking through their 54 examples, I think it is just a first step.

GE Healthcare has their own data visualization effort, and I'm sure there are others.  Still, more and better charts and graphs are nice, but Fidelity has raised the bar.

I'm thinking holograms.

To some, holograms are still the stuff of science fiction, but they're becoming more mainstream and they've already started to be used in health care.   Last year, Realview Imaging showed how holographic images could be used to assist surgeons in cardiac surgery, allowing the surgeons to view, touch, even mark the 3-D images generated from ultrasounds and X-rays.  Realview just went through a $10 million investment round and expects to be in the commercial market by 2016.

I want to see a holographic medical record.

Think about it.  The current generation of EHRs isn't wowing anyone.  Health future Joe Flowers recently suggested that they are so flawed that we should just ditch them and start over again.  No wonder, because, as best I can tell, they did for medical records what 1990's websites did for paper: they simply made the content digital, added a few links and a modest amount of interactivity.  We called that "brochureware" then and I'm not sure EHRs have done much more for the old paper records.

No wonder they're so clunky.

On the other hand, imagine if your doctor comes into the exam room and instead of holding a paper chart or tablet with your record, her smartphone projects a holographic image of a human body.  Of your actual body, if preferred.  That scar on your knee, all your X-rays and CAT scans, your balky shoulder, your asthma -- all those are represented in the image.
The doctor can view and update a current snapshot of your health, go back to a previous version and contrast, add or listen to verbal notes.  She can zoom in to specific organs or other body parts in order to highlight specific areas of concern.  When she takes your vitals, they automatically get uploaded into the record.  The hologram can take advantage of Fidelity-like symbolism to give a literal picture of your health, down to lab results, Fitbit readings, and even your own subjective comments (e.g., the image gets blue when you are depressed, or degrees of red indicate where and how much pain you are feeling).

Advances in haptic technology may mean that anything your doctor feels when examining you (like a lump) can be uploaded to your holographic image -- and that the image itself has tactile qualities.  The "hands-on" advantages of the exam can be fed directly into your record, with no manual input (pun intended).

Rather than you feeling that the doctor is reading the record when he/she should be paying attention to you, the record would become interactive with the exam, in a way that is both highly visual and available to both of you.  It also would become another tool for the doctor to explain to you any diagnoses or recommended procedures; she can touch and manipulate the image to show you exactly what is going on or will happen.

That's an EHR that could add to, rather than detract from, the clinical experience.  Equally as important, it is an approach that consumers would probably be more willing to use on their own in managing their own health.  That Big Data that everyone expects us to be collecting about ourselves would become not just more numbers or charts but part of an interactive display of...well, us.

One way or another, better visualization of health care data is going to be essential if we don't want to get lost in all the data.  I sure hope health care doesn't come late to the party, like it did to digital information.  Holographic technology isn't the complete answer, but it is here and will soon find applications throughout our daily lives.  It will play a more important role in health care, and I can't think of a better place to start than revamping our idea of what an EHR is.   You can't tell me that the folks at Realview aren't already thinking about health records.

I just wonder if the people at Epic or athenahealth are.

Tuesday, November 18, 2014

Who Ya Gonna Call

Imagine, if you will, a health care system without doctors.

On first blush that concept doesn't make sense: what would a health care system be without doctors?  But I would argue that the notion is not all that far-fetched, and, even more, that we need to be open to ideas like that if we really want to change our health system.

Let's start with the basic assumption that, within a few years, we'll be able to track our health at virtually a molecular level, in real-time or close to it.  That's one of the goals of Google X's Life Sciences team, using something they call nanodiagnostics.  They envision a swarm of nanoparticles swimming around in your body, detecting diseases in their earliest stages, and connected to wearable devices so we can act on the information they glean.  Instead of waiting for diseases to manifest, we'd be able to catch them in their formative stage and head them off.

It's not just Google that sees this future; researchers elsewhere, such as at Northwestern and Vanderbilt, also see exciting opportunities in nanoparticles.  The Northwestern research, for example, helps identify circulating cancer cells faster and more easily.

Just think: we wouldn't need a physician to give us their best guess at a diagnosis; we'd actually know exactly what was wrong.

Well, even if we could replace physicians for diagnoses, we'd still need them to treat us, right?  Not so fast.  Take another hot field: the microbiome.  We're finding out that our bodies have a lot more bacteria than "our own" cells, and that what is going on with those bacteria has important implications for our health.  Imbalances in them have been linked to a number of common maladies, including allergies and other auto-immune disorders, cancer, and obesity.  If we can figure out how to address those imbalances, much of what ails us could just go away.

I always think about the example of stomach ulcers, which used to be blamed on stress and diet, when in fact it turns out that most are caused by a bacteria infection.  We were thinking about it wrong and treating it incorrectly, and I suspect that the more we learn about our microbiome, the more examples like this we'll find.

The microbiome is already a serious field of research.  The NIH Human Biome Project -- whose mere existence should illustrate how quickly the field is becoming mainstream -- is funding a number of demonstration projects.  MIT and Massachusetts General Hospital (MCH) just announced the launch of their joint Center for Microbiome Informatics and Theraputics.  The field is starting to generate significant investment.

Deloitte estimates that in 2010 consumers were already spending some $56b of their own money on "nutrition/supplements," despite the alarming lack of evidence of their benefits.  Imagine how much we'd be willing to pay to be able to manage our own microbiome.

So I'm wondering; if good health is about manipulating our microbiome, do we still rely on physicians -- or perhaps microbiologists instead?

Then there is gene therapy.  This effort to replace defect genes is still in the experimental phase, but is showing promise.  For example, there is an Alliance for Cancer Gene Therapy that hopes to fix the root problem -- defective genes -- without the need for traditional medical interventions like surgery, chemo, or radiation, each of which has its drawbacks.

Similarly, a company named Spark Therapeutics has just received an FDA "breakthrough-therapy" designation for a gene therapy that addresses a group of eye diseases called inherited retinal dystrophies (IRDs).  Fierce BioTech notes a number of other companies are also making big bets in gene therapy.

When gene therapy reaches a more mainstream status, should it be physicians who oversee it, or geneticists?

Well, certainly we'd still need physicians to do surgeries and other procedures, right?  Perhaps, but many of those, while technically impressive, can actually be viewed as markers of failure -- failure to diagnose earlier or treat more conservatively.  That's not through anyone's fault, as the techniques for earlier detection and less invasive treatment haven't always been there, but they may be available in the not-so-distant future.

Why get a hip transplant or go through back surgery when, say, our ability to regenerate bones or nerves might make those approaches obsolete?  Indeed, in a hundred years -- or hopefully less -- much of the current practice of medicine may look as archaic as medieval medical practices do to us.
The question is, will we be ready?

All is this not meant to bash the medical profession (although when I read about things like pain doctors routinely testing Medicare patients for angel dust simply because they get paid for the expensive tests, it's hard to refrain).  My big concern is how limiting the "practice of medicine" to the medical cartel can stifle disruptive innovations in health care, by forcing them to funnel through the established practitioners.  It's ostensibly for patient protection but often looks more like protection of income (see Stay Off My Turf).

Telemedicine should be forcing us to rethink our historical criteria from where we receive our care, just as physician alternatives and even advances in artificial intelligence should also be forcing us to rethink our reliance on physicians.  Instead, we're trying to make the new options conform to the old rules.

Yes, I know the AMA just approved the interstate compact proposed by the Federation of State Medical Boards to facilitate more interstate licensing for telemedicine, but even that proposal reduces the degree of difficulty from, say, a 9 (on a 1 to 10 scale) to maybe a 6 or 7.  It is a compromise that might have been progressive in the 1990's.  Not in 2014.

It is the kind of inertia that typifies our existing health care system..

With all the new kinds of approaches, I'll be happy if they still have to go through FDA approval, so that we still require some (relatively) objective testing about efficacy and safely.  What I don't want to see is their falling through the rabbit hole into our crazy Alice-in-Wonderland health care system, which is what I fear happens if we require that only physicians can dispense them and expect them to be covered by health insurance.  That's the wrong way to go.

When Google starts selling their nanoparticles, and they or someone else starting selling a maybe home 3D printer to produce the necessary corrective actions that the personal health AI prescribes, I hope they're selling them direct-to-consumers.  More importantly, I hope that the medical-industrial establishment doesn't succeed in demanding control.

I have no doubt that there are still going to be physicians in our future health care system.  However, if we truly want innovation in our health care system -- and it's not like anyone is particularly happy with our current one -- then we have to stay focused on our health, even if it means displacing the central role physicians have always played.

As entrepreneur Elon Musk says, when it comes to innovation, start from "first principles."

Tuesday, November 11, 2014

The Future Is Still Not Here

US News & World Report had some fun looking back at what experts in 2004 predicted for health care in 2014.  Not surprisingly, they found that we're not quite there yet, but might be by 2025.  The future, it would appear, is always ten years away.

Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:
2004 prediction: In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.

To be sure, there have been several important changes in our health care system over the past ten years.  Some of the more important ones would have to include:
In terms of realizing those predictions about controlling costs, improving customer service, reducing medical mistakes, or addressing malpractice concerns: well, not so much.

The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014.  Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes.  Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.

If this is progress, I'm not sure we can take much more of it.

By way of contrast, think about the technology world in 2004:
Why isn't health care seeing those kinds of radical changes in the landscape?

Certainly there have been plenty of important clinical innovations -- new treatments, new devices, new drugs, new techniques -- in the last ten years.  Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have,

Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people.  By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).

I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.

The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future.  Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed.

Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits?  I'm willing to bet that the technology for those will exist, and that consumers would be very interested in using them, but I wouldn't risk much money betting that our moribund reimbursement and regulatory mechanisms will embrace them, or that providers would jump on those bandwagons either.

Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush (e.g., Fitbit, Jawbone, Apple Healthkit, Microsoft Health, Google Fit).  I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data.  By 2024 we should be using real-time data to prevent hospitalizations (e.g., as Sentrian claims it can already do) and other acute episodes, but who will pay for, and act on, the monitoring and interventions?

One company -- Pact Health -- has already figured out a way to use results from activity trackers to adjust coverage, such as raising and lowering deductibles.  It is a solution imperfectly crafted on top of a normal health plan, but at least it's a start.  Too bad existing federal and state requirements for health coverage don't directly allow for such innovative approaches.  That's a problem.

Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth.  That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.  

All those ACOs and other integrated health systems aspire to be Kaiser, but, as I wrote about previously, the Kaiser model may be more the past than the future.  After 70 years, they hold dominant market position in California, but it is their only market where that is true.  Their enrollment growth since 2004 averages a paltry 1.5% per year, and, for all their integration, their costs and cost increases really aren't any lower than competitors.

If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.

I've made some predictions about the future previously (Living in a Jetson's World),  but what I really hope for is a system that doesn't just look like today's health care system modestly improved.  I'm hoping for changes that seemingly come out of nowhere to radically reshape the system.  Maybe that's gene therapy or nanotechnology (or, better yet, nanotechnology delivering gene therapy -- as is already being piloted).  I don't know what they'll be, but someone is already working on them.

Whatever the changes are going to be, I worry that if they go through our existing delivery and financing mechanisms, they'll suffer the same fate as telemedicine -- slow, halting, incremental adoption that at best integrates with instead of reshaping.

As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it.  I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.

Let's not wait ten years.

Tuesday, November 4, 2014

Stay Off of My Turf!

The obvious thing to write about would be the announcement of Microsoft Health, but I thought I'd switch gears by focusing on a seemingly unrelated topic: America's slow yet expensive Internet. 

Bear with me and I promise to loop this back to health care.

The Open Technology Institute just released its Cost of Connectivity report for 2014.  It concludes that "customers in the U.S. still tend to pay more than their peers in Asia and Europe for comparable broadband Internet service."  Put even more simply, OTI asserts that we're "paying more money for slower Internet access."

Sadly, their conclusions are neither new nor surprising; the problem is well-understood.  The OTI report includes an extensive literature documentation, but here are some similar findings:
  •  Akamai's State of the Internet report has the U.S. slipping to 14th place for average connection speed.  Our average speed is less than half of South Korea's.
  • The Ookla download speedtest puts us in 27th place, right between Finland and the U.K.  South Korea is 3x faster, and they're only 2nd best in the world.
  • Ookla puts us at a dismal 34th place for cost per Megabit per second (MBPS), paying $3.50/MBPS versus only $0.47 in Bulgaria.  At least if measured by relative cost (calculated as cost divided by GDP per capita), we jump all the way to 19th place.
Sprint Chairman Masayoshi Son summed it up aptly earlier this year: "This is the nation that invented the Internet.  How can Americans live like this?"

There is widespread agreement about the reason why we're getting such a poor product: lack of competition.  As Tim Wu, a Columbia law professor and antitrust expert, told The New York Times: “It’s just very simple economics.  The average market has one or two serious Internet providers, and they set their prices at monopoly or duopoly pricing.”

In the early days of the Internet, before broadband, we got by through using cable or telephone lines.  Now that we have moved into broadband, fiber optic is the technology of choice.  But it is expensive to lay fiber optic cables, and monopoly or duopoly providers haven't seen much reason to make that investment. 

Sure, maybe we can squeeze more speed out of copper wires -- as Bell Labs has demonstrated -- but technology isn't standing still; at some point, even current fiber cables will be outdated.  It is a technological arms race that we are falling behind on.

ReadWrite's Adriana Lee contrasted concerted efforts to build out broadband infrastructure in South Korea and Romania versus our rather more laissez-faire attitude approach.   The results?  Well, as FCC Chairman Tom Wheeler said in September, "...three-quarters of American homes have no competitive choice for the essential infrastructure for 21st century economics and democracy."

The OTI report noted that the U.S. cities with the fastest service tended to either have municipal high-speed networks, or were pilot markets for Google's fiber-optic efforts.  Susan Crawford, a former technology and science advisor to President Obama, told BBC last year:
We deregulated high-speed internet access 10 years ago and since then we've seen enormous consolidation and monopolies, so left to their own devices, companies that supply internet access will charge high prices, because they face neither competition nor oversight.
Hmm, a capital-intensive industry that has rapidly consolidated, to the point most markets have only one or two service providers, and those providers take advantage of their cozy market positions to charge high prices and innovate very cautiously.  It may very well describe ISPs, but it sure as hell also characterizes much of our health care system, especially when it comes to health systems.

You could rephrase the OTI quote above by saying that, when it comes to health care, we're paying more money for worse outcomes.  If you don't believe that, check out OECD or Commonwealth Fund statistics.

The increasingly lack of competition is coming from provider consolidation, with health systems merging or acquiring rival systems, and also buying up physician practices.  I've written on provider consolidation before, as have numerous others (e.g., Delbanco or AHIP).   Much of the consolidation is done in the name of "clinical integration," but there is some pretty good empirical evidence that the main effect is to raise costs (for example, see Robinson and Miller).  It is something that should worry anyone concerned about cost, quality, or innovation.

The aspect of our health care system that most obviously intersects with Internet speed is perhaps telemedicine, which has been fighting an uphill battle for mainstream recognition for much of this century.  It is making progress, but the barriers to more widespread adoption are not technological but rather issues with our 20th century mechanisms for reimbursement and for provider licensing.

The common thread between provider consolidation and provider licensing is, of course, protecting turf.  Providers vow that both are done in the best interests of patients, but that rings hollow to me.

The turf issue reached ridiculous new heights recently when the Supreme Court agreed to hear North Carolina Board of Dental Examiners vs FTC.  Essentially, the Board tried to prevent anyone but dentists from doing teeth whitening.  They claim they were simply protecting their (would-be) patients' oral health, but it sure looks like cartel activity to me.  And I don't think either North Carolina nor dentists are unique in this kind of protective behavior.

George Will says these occupational licensure laws are "...residues of the mercantilist mentality, which was a residue of the feudal guild system, which was crony capitalism before there was capitalism."  Ouch.

I've written previously on both state medical boards and medical education, which control who can do what to us for our health care.  The Supreme Court has already previewed that it has a strong desire that such appropriate health care experts decide health care issues, rather than "bureaucrats," but I just wish I felt more confident that these various professional organizations were, in fact, acting in the public's best interest rather than that of their profession.

If they were, they'd be leading the charge for better performance monitoring and increased focus on patient safety.  Instead, they're being dragging kicking & screaming,

It's not about the patient.  It's about the money.

Rates for long distance calls plummeted in the 1980's, due to telephone companies being required to offer equal access to other long distance providers.  That's the kind of innovation we should be looking for.  It may be easier to see how that might apply to the Internet than to health care, but that's the fun challenge.

We need to be radically rethinking where we receive care; how and from whom we receive that care; how the people giving care get trained, licensed, and overseen; even what "care" is.  Hey, in China they are working hard to integrate Traditional Chinese Medicine with so-called Western medicine; maybe nothing will come of it, but it is far too early for us to have closed minds about what works and what doesn't.

What I'm pretty sure won't work is anything aimed at artificially protecting someone's turf.

Tuesday, October 28, 2014

Living in a Jetsons World

The quote of the week has to go to Deloitte's Harry Greenspun, M.D..  Speaking at WEDI's annual conference, FierceHealth IT reports he said:  "We live in a Jetsons world, but when you go to the doctor's office it's like an episode of The Flintstones."

Millennials, you're going to have to look up those references.  

To be fair, we're not quite in a Jetsons world yet -- anyone driving a flying car? -- but, on the other hand, I haven't seen a tablet at a doctor's office that is literally a stone tablet either.  Still, I wouldn't at all be surprised to find doctors' offices that don't yet have computers, much less tablets, and the number of providers who can easily share patient data with other providers is low enough to remind one of the pre-Internet days.  So, all in all, most of us know exactly what Dr. Greenspun was getting at.

Dr. Greenspun noted that the vast amount of health-related data that is, or soon will be, available challenges both providers and patients about how to best make use of it in a way that will positively impact patients' health.  It's a good problem to have -- we've muddled along too long with only intermittent and incomplete data about what is happening with people's health -- but it is a problem nonetheless.

After all, about one-in-five Americans own a wearable device, according to PwC's The Wearable Future with one-in-ten wearing it daily.  Two-thirds of Americans say would use one in exchange for discounts on their health insurance. Forty-four percent of those without wearables claim that better advice from their provider would be an incentive to use one.  Analysts are predicting crazy growth rates for wearables -- 43.4% CAGR over the next 5 years -- and even if they're off it is clear there is going to be a heck of a lot more tracking.

That's potentially a lot of data, but it's as the old expression says: be careful what you wish for...

The other great point Dr. Greenspun made was that people are only patients in health care settings but are healthcare consumers all the time (or they should be, at least).  I believe Dr. Greenspun was pointing out that there is a lot about people's health that happens outside health care settings -- which is certainly true -- but I'm also struck by the implicit duality in his characterization.  Aren't they always consumers?

I've suggested before (Mistaking Success for Failure) that perhaps continuing to use the term "patient" is part of the problem.  It fosters the illness-versus-health, dependent-versus-responsible, passive-versus-proactive attitude that pervades our health care system.  We need a new word, something that recognizes that we're responsible for our own health, although sometimes we need help -- often a lot of it -- from others.

I'm open to suggestions.

What would care look like in a Jetson's world, hopefully one in which we've decided to really put patients/consumers/people first?  Here are a few thoughts:

  • For one thing, I wouldn't expect to get too much of that care in a doctor's office.  As I wrote in I'll Take My Care To Go, we increasingly expect services to be ubiquitous, and health care is tracking in that direction.  Yes, many people -- especially doctors -- firmly believe in a physician needing to see and touch patients, but with even today's optics and with steadily improving virtual reality for touch (e.g., Nimble VR), physical presence becomes much less important.
  • I also wouldn't expect that you'll be seeing as much of doctors, or, in fact, actual humans for your care, at least for E&M.  I wrote about the use of AI in May I Speak to the Doctor's Computer, and in a Jetsons world I fully expect a large percent of things that currently would require a physician could be dealt with via an expert system using AI.  You wouldn't ever have to wait for them to call back.  Of course, the system would need to know when to triage issues off to human experts (usually but not necessarily always physicians). 
  • Care will become much more proactive.  All that monitoring will create massive amounts of data about what is going on with you and your health, analyzed real-time and producing targeted feedback.  I see much of that feedback coming from -- again -- AI, in the form of a virtual health assistant or avatar.  We've already got Alme from NextIT and Molly from Sense-ly.  These avatars are only going to get better -- not only able to deal with more kinds of problems, but also more tailored to your needs and personality (e.g., some people need to be nagged, some rebel against nagging).  They're not going to wait for you to notice or complain about a problem.
  • We're not only going to get virtual replacements for caregivers.  The Jetsons had a housekeeping robot named Rosie; maybe that will happen, but someone is going to make a fortune by developing a personal care robot.  Hospitals, nursing homes, and assisted living centers struggle to staff their aides now, and the impending aging Baby Boomer demographics will demand we solve the staffing shortfall through technology.  Toyota, for example, is already working on what they call "personal assist robots" for this very purpose.  These will allow people to stay home longer/go home sooner and reshape our concept of "care," not to mention many of our institutional settings.
  • Your health record will, indeed, be yours, in a graphic, easy-to-understand, actionable form that is available on-demand 24/7.  Rather than worrying about providers trying to connect their various versions of your record, which they may or may not let you notate or even view, they will annotate your record, downloading whatever they need from it for their business needs. 
  • We're going to know what care costs in advance.  These shell games that are being used to hide and disguise health care costs (e.g., absurd charge structures, out-of-network billing in in-network settings, after-the-fact medical necessity decisions) are evidence of a very dysfunctional market.  We shouldn't be paying blindly for piecework that may or may not produce good results; we should be paying for actual results.  Frankly, I'm not sure anything we're even testing now will resemble the payment and financing mechanisms we'll find in a Jetsons health care system.  
I only hope I don't have to wait until 2062 to see these changes.

Monday, October 20, 2014

Google Wants to Helpout Your Health

I suppose it was inevitable that I'd end up writing something about Google's interest in health, since recent posts have focused on efforts from Facebook and Amazon, as well as the general gold rush for health IT.  Fortunately Google has obliged me by introducing a neat health-related wrinkle on their Helpouts service.

Google's new service pops up an offer to do a video chat with one of their Helpouts physicians when you are doing health-related searches, in case you want more expert opinions and advice.  It certainly beats getting an ad for a pill or a health aid (although I don't imagine Google will stop presenting those as well).

Let's back up.  For those of you not previously familiar with it (and count me among those), Helpouts is a Google service, launched last November, that allows consumers to connect with applicable experts via live video chats.  Right from the start, they made sure it was HIPAA-compliant and included some physician experts.

The new feature connects the service to search results.  You may not have Google Helpouts top-of-mind when looking for health information, but it's a pretty safe bet that you might use Google search in doing your research.  Pew says 72% of Internet users searched for health information within the past year, with 77% of them starting with a search engine.  Since Google commands about two-thirds of U.S. search results, they undoubtedly answer a lot of health requests -- thus giving them a potentially big market for Helpouts telemedicine feature.  Those Helpouts doctors could be very busy.

"Google Docs" takes on a whole new meaning now, doesn't it?

The telemedicine aspect of Helpouts is not strikingly new.  I've written on telemedicine before, especially about the painfully slow regulatory progress, but it continues to become more mainstream.  According to a recent report by U.S. News & World Report,  about a million patients a year use video services to talk to physicians, and half of U.S. hospitals use some sort of telemedicine, such as video visits or remote monitoring.  There are starting to be plenty of telemedicine options, with more jumping in every day (including a new "virtual health concierge" approach by PlushCare).

What distinguishes Google's effort, of course, that it is pro-active.  It doesn't wait for you to decide things are serious enough to seek out a doctor, but, rather, uses your search activity to trigger the offer of a consult.  I think this will be an important part of our health system's future -- not merely reacting but being proactive.  All these remote monitoring devices are pretty pointless if we don't use them to try to intervene early, instead of waiting for an acute event or an office visit to trigger care.

You have to figure that online content sites like WebMD or Mayo Clinic are kicking themselves for not thinking of this first, or at least not getting their versions in the market earlier.  After all, plenty of shopping sites feature real time chat support, and Amazon offers its cool Mayday feature that connects Fire users to a real person via video.  Surely getting the right health information is more important than picking the right pair of jeans, right?

I have a couple of suggestions, or at least questions, on the new Helpouts feature:

  • It's not clear to me how specific the type of physician available is to the search request.  If you are searching on angina, for example, it'd be nice if you got a cardiologist to talk with rather than a dermatologist.
  • It's not clear to me if the experts are always physicians, or if they triage the experts based on the severity of the information being searched for.  We have this problem that we tend to see physicians as the only authoritative source of information, and that may not always be true.  Rather than starting with the most expensive, least available type of expert, perhaps Google could use their fancy algorithms to match search requests with the most appropriate type of expert, including nurses, nurse practitioners, physician assistants, or pharmacists.
On the second point, I've written before about personal health assistants -- including Better from The Mayo Clinic -- as well as potentially using AI to provide such a service.  I think it'd be even cooler if Helpouts gave you a personal health assistant, starting with an AI agent and progressing to a specific human team if necessary, with physicians available for the most complex needs.  Maybe that's Helpouts 2.0.

Of course, Google's health interests don't end with the current Helpouts approach.  They are already pushing Google Fit as a way for Android developers to connect their health apps, and it'd be a great next step if Google could tie Helpouts to those apps, using the data mined from them to trigger an offer of a consult -- or an intervention, depending on the urgency of the need (e.g., it could trigger a 911 call if your heart monitor indicated a heart attack).

It'd be even better if you could opt-in your own physician(s) and health system to the Helpouts service instead of relying on Google's set of physicians.  That would assume that your providers have the right capabilities, which some might and others will soon develop.  Providing those capabilities might even open a new business opportunity for Google.

As long as I'm already trying to come up with more things Google could do in health, I might as well add that I'd love to see them get into the transparency business.  They try to help consumers find the best prices for other goods, and certainly health care can use all the help it can get in this regard.  There's no shortage of companies already working on the problem, but if any of them aren't worried about what a Google or an Amazon could do if they devoted resources to it, they're being myopic.  At some point the market opportunity will simply be too big to pass up.

Whether Google buys one of the major transparency players or develops their own approach will be interesting to watch.

Google is thinking bigger than these more modest expansions, like their "moonshot" to genetically map a healthy human body, or their new health and well-being company Calico, which has already announced the building of a major research facility.  I like that they are taking the long view, focusing on prevention and cures rather than simply more treatments, but there's still plenty of ways they can help the health care system in the short term as well.

Hmm, Google loves robots: maybe robotic surgery -- or doctors -- is next.