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.