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.

Sunday, October 12, 2014

Paging Abraham Flexner

Those who know who Abraham Flexner was may already suspect, based on the title, where this is going.  Let's start with a thought experiment:

You need to get a lawyer.  You get the names of some suggested lawyers, and check out if they specialize in your need, if they are with a good firm, and perhaps what law school they went to.  The wrinkle is that, in this scenario, there are two different kinds of law schools.  They have similar curricula but are based on different legal philosophies, which may or may not impact the legal advice or services you receive, so knowing which type of law school a lawyer attended is a consideration.

Unlike in the U.S., where lawyers go from law school to practicing (after passing the bar), in this scenario lawyers have to spend several years receiving additional training via extended apprenticeships at large legal institutions.  Despite the fact that these budding lawyers work long hours for modest wages during those apprenticeships, those institutions receive billions of dollars in federal subsidies for this training, none of which either the institutions or the lawyers are expected to repay or even show a quantified public benefit for.

Oh, and I forgot to mention that, for several types of legal work -- say they include property law or intellectual property law -- you won't use a lawyer at all.  You'll use professionals who have trained in entirely distinct programs, are practicing a form of law, yet are not considered lawyers.  Not paralegals, just legal experts with their own domains.

If anyone were to propose such a Byzantium system of legal training and practice, I'm sure the legal profession would be up in arms, suing anyone who had the audacity to suggest such changes.  The rest of us would probably be wondering if whomever had proposed it was high.

As convoluted and nonsensical as this system would appear to be, it is, within my powers of simple analogy, a representation of medical education in the United States.  Thus my call for Mr. Flexner, whose 1910 landmark report on medical education set in motion greatly needed reforms in the medical education of the day.

The distinct types of medical schools are, of course, allopathic (awarding M.D.s) and osteopathic (awarding D.O.s.)  The latter form of practice originally was based on manipulation of bones and joints, but has morphed into education and practice not dissimilar to allopathic.  Osteopathy's cousin -- chiropractic medicine -- still maintains its emphasis on manipulation, and has its own form of education and resulting practitioners (D.C.).

The list doesn't end there.  If you had mental health issues, you might see a psychiatrist (M.D. or D.O.), but you might also see a psychologist (probably Ph.D.).  If you had issues with your eyes, you might see an ophthalmologist, but might also see an optometrist (O.D.).  If you had oral health issues, you may use an oral surgeon, or a dentist (D.D.S.).  Foot problems could be treated by an orthopedic surgeon specializing in foot/ankle, or by a podiatrist (D.P.M.).  If you need a prescription, a physician has to prescribe it but generally can't dispense it, whereas a pharmacist (PharmD.) can dispense but, in most cases, can't prescribe it.

If any of this makes sense to you, it probably is just because we've been raised in a society where "it has always been like this."  That doesn't mean it has to be.  Barbers used to double as surgeons but that's a tradition we managed to do away with.

It's worth noting that the U.S. model where D.O.s have the same scope of practice as M.D.s is only true in 65 countries.  Many countries restrict osteopathy's scope of treatment to forms of manipulation.  I don't know which approach is "right," but if we're going to treat D.O.s like M.D.s, I'm hard pressed to see why there should be two parallel tracks of education.  There have been calls for integrating the two tracks (see, for example, Cohen 2009), to no avail. 

One begins to wonder if the education process has become an end in itself.  Writing in JAMA in 2012, Emmanuel and Fuchs called for shortening U.S. medical education by 30%, noting that it takes far longer to train physicians in the U.S. than most other countries -- roughly 14 years in total here but several years shorter in Europe.  Maybe the $100b in annual revenues for U.S. medical schools has something to do with it.

Then there is the $15b in annual graduate medical education.  It's not clear to me why public funds are subsiding GME at all; you don't see graduate legal education subsidies, by contrast.   Earlier this year the IOM called for numerous reforms in GME, but didn't question the underlying premise of why we're doing it in the first place.

Similarly, in 2010 -- the centennial of the Flexner report -- the Carnegie Foundation called for an updated reform of medical education, but its reforms strike me as wanting to do the things we do now better rather than fundamentally rethinking what we are doing. 

If the medical school route is going to end up taking 14 years, maybe those prospective students -- who typically are good in math & science -- might be better off going into computer science.  They wouldn't incur those big medical school debts, wouldn't face the prospect of battling insurance companies, hospital administrators, or malpractice lawyers, and could at least hope to be comfortably retired due to a couple of successful IPOs by the time the medical school cohort is finally starting to practice.  The medical profession should be very worried.

Whether the training duration is 6 years, 10 years, or 14 years, there is still the problem of all the different kinds of "doctors," each with their own training and licensure.  Who is looking after my health comprehensively, not just pieces of it?

E.g., does it make sense that I get primary care for my teeth from a dentist (or, in reality, largely from a hygienist) and for my eyes from an optometrist, but my "medical" primary care from a physician?  Frankly, I think the only people to whom that makes sense are physicians, especially since it is almost always covered by health insurance, whereas we need dental and vision insurance -- which are not nearly as common -- for the other forms of primary care.  We know, for example, that oral health is closely related to general health, but treat them distinctly.

It's nonsense.

I don't have any quick fixes to any of this, but I'm pretty sure it is a problem.  I'm also sure that the various educational institutions and corresponding professions would fight vigorously to preserve their turfs.  It's naive, but I wish we could all step back and ask the simple question: what is best for the patient?  If we were starting with no preconceptions, but with the knowledge and capabilities we have available, how would we choose to train and organize the health care professions that we license to use them?

To fix things we'd need someone like Abraham Flexner but on steroids.

Monday, October 6, 2014

Dr. Facebook, I Presume

Reuters has reported that Facebook is planning to join the rush by tech giants (e.g., Apple, Google, Amazon, Samsung) to get into health.  I'm not sure if I "like" Facebook's rumored move but I'm sure going to comment on it.

As was true with the reports about Amazon, details are sketchy at best.  Reuters' sources suggest that Facebook is interested in "support communities" to connect users with specific conditions, and may possibly also offer some "preventive care" apps.  Earlier this year Facebook had bought activity diary app Moves, signaling its interest in health.

The support communities would be a logical brand extension, and are undoubtedly being done informally within friend circles to some extent already.  There are countless such online communities, the granddaddy of which is probably Patientslikeme.  Patientslikeme has successfully monetized its patient communities, allowing patients to let researchers to use their data via various collaboration tools, so Facebook may figure they can do even better.

Of course, just because Facebook may want to jump into a new field doesn't guarantee their success.  Anyone use the Facebook phone?  I thought not.

Partly because of Facebook members' concerns about protecting their privacy,  Facebook may release its first apps under a different name and/or allow members to use the service under aliases.  Facebook just unveiled its new ad platform that will gather data on what members do even on other sites, so I'd say the privacy concerns are legit.  Moves, for example, has already changed its privacy policy to allow it to share data with Facebook and Facebook companies.  Facebook will quickly find that privacy is even more paramount when it comes to health information.

Anyway, I think it's great that Facebook is interested in health.  Companies with expertise outside health can help bring new thinking into our rather in-bred health care system.  As I wrote in Getting Our Piece of the Pie, though, I worry that the tendency will be for them to be co-opted by the existing players rather than overthrowing them.  Health care may not be as easy to fix as it looks.

Since I'm still waiting for Amazon to call about my suggestions for their entry into health, I'm free if Facebook wants to pick my brain.  Here are a few ideas:

  • Support communities: this actually is a good idea, but much lies in how it is done.  I'd suggest creating a second, pseudonym-version of a member's profile, which can join specific support communities.  Regular friends could -- at the member's option -- see any updates or comments the member said in those communities.  
  • Updates: for years CarePages has allowed patients and their family to update their extended circle about a patient's condition and progress.  Many hospitals use CarePages as part of their digital strategy.  Frankly, I'm not sure how CarePages has survived in a Facebook world, but consciously adopting a similar strategy or even buying CarePages might be a smart move for Facebook.
  • Advertising: OK, let's face it -- whatever Facebook does in health, they're going to find a way to advertise on it.  Maybe we should give in to the inevitable and focus on what that advertising is.  If it is simply selling health-related products that patients may or may not need, shame on them and on us if we fall for it.  If Facebook wants to be more strategic and, say, match up top-ranked providers with patients in need, then that would be progress.  I've proposed this kind of "provider exchange" before, especially for Amazon, but maybe Facebook can get there first.
  • Provider messaging: Facebook has shown considerable interest in messaging, what with Messenger and WhatsApp.  They're even talking about using it for mobile payments.  Patient-provider messaging would be a very logical entry point for Facebook, competing with American Well and other current services.  
I want to loop back to privacy and to putting members' interests first.

The recent release of information (Open Payments) of financial ties between providers and drug/medical device companies is both eye-opening and instructive.  According to the CMS database, in just the final five months of 2013 some $3.5b was paid to providers.  This is with one-third of the data removed due to some provider matching problems.

Most providers didn't get very much money, but a number got well in excess of $100,000. The Wall Street Journal reported at least 2 physicians earned over $4 million in that five month period.  You can't tell me that level of payment has no influence.

True to form, the AMA issued a statement supporting transparency and opposing "inappropriate, unethical interactions," but cast doubt about this particular effort at this time.  They want to help CMS make improvements "to ensure the data is presented in an accurate and informative way to help patients understand and interpret the information correctly."

Yeah, thanks for that, but I think we get the picture already.

The size of these payments -- call it close to $10b on an annual basis -- is tiny in comparison to our overall health spending, but I look at them in the same way I look at political campaign contributions, which are small in comparison to government spending but which certainly seem to buy outsized influence.  Many voters have lost confidence in their elected officials, in no small part because of this lobbyist influence, and if health care providers aren't very careful the same will happen with patients.

The lesson in all this is that, whatever Facebook does in health, it absolutely needs to demonstrate that they are putting their members first, not just using them for its own monetary gain.  We don't need more players whose motives and financial motivations are unclear.

For years, Facebook's mantra was "move fast and break things," which, honestly, is exactly the attitude I think health care needs in order to innovate.  Their new mantra -- "move fast with stable infra[structure]" -- is not as catchy, but perhaps it is designed in part to assure the more staid health care community that patients and their data will be protected.  We can hope, anyway.

So if Facebook does enter the health space, what leading companies from outside health care would be left on the sidelines...and which will be next?