I, Dr. Robot

Admit it: when J&J announced that its Ethicon division was teaming up with Google on surgical robotics, didn't you imagine that Google wanted to do for surgery what they are trying to do with (self-driving) cars?

I know I did.

For better or worse -- more on that later -- their ambitions are more constrained, at least for now.  It appears that Google's initial contributions will focus on using its expertise in improving the video feeds surgeon use, in and developing algorithms that add value to the images.  Wired, for example, says Google intends to "do things like highlight blood vessels and display critical information on screen."

They also cite a J&J spokesperson adding that perhaps Google's algorithms might also highlight the best places for incisions, based on the individual patient's medical history: "sort of a Google Maps for surgery," in Wired's words.

The Wall Street Journal similarly says that: "Google reckons it can use its machine-vision and image-analysis software to help surgeons see better as they operate or make it easier for them to get information that’s relevant to the surgery."  Google also told them that, "software could highlight blood vessels, nerves or the edges of tumors that are difficult to see with the naked eye."

Well, that's more like a rear view camera than a self-parking car.  Google could just give its newly patented "smart" contact lens to surgeons if that's all they are bringing to J&J.

Kevin Fogarty of Computerworld, for one, is underwhelmed by the announcement, saying that "Google's contribution will be things it is already good at, not the kind of really new capabilities robot-assisted surgical systems actually need."  As the title of his piece says, they're bringing vision to robots that need help with touch.

Touch is a surprisingly hard problem to solve.  There is work being done on it -- haptic feedback, as it is sometimes referred to -- to create what is sometimes called the "Tactile Internet."  The possibilities such breakthroughs might open up are mind-blowing.

Robotic surgery itself is nothing new.  It has been around about 30 years now, and is most often used for laparoscopic surgeries, especially for things like prostate removals.  The long time leader is Intuitive Surgical, Inc, with their da Vinci surgery product, which can cost $2 million per robot and perhaps $3,500 more per procedure than non-robotic laparoscopic surgeries.

With those kind of high capital and per-procedure costs, one would like to think there would be big improvements in outcomes and/or safety, but that does not seem to be the case.  A 2013 study in JAMA found little added benefit to robotic surgery, despite clearly higher costs.  Moreover, a Kaiser Health News special report that same year raised questions about whether anyone -- patients, providers, or regulators -- are getting the right information.

Some critics worry that the manufacturers spend more time creating consumer demand than training surgeons to use their equipment.  As one ENT told Healthline, "Intuitive are probably the worst at doing this and probably the most responsible. Their direct-to-consumer marketing is just criminal. Their lack of training, in my opinion it borders on criminal."

Yikes!  No wonder that robotic surgery was listed as one of ECRI's 2015 Top 10 Medical Technology Hazards (as it also was in 2014).

Robotic surgery started with the surgeon present, but by 2001 had already moved to telesurgery, where the surgeon was in a different location.  "Operation Lindberg" made international news in 2001 when surgeons in New York successfully removed the gall bladder of a woman in France.  Other such remote surgeries have followed.

The next logical step  would seem to be robots operating independently, starting with routine surgeries but over time graduating to more complicated ones.  Perhaps an autonomous robot would do just as well, or better.  Better vision, ability to make more precise incisions, faster reflexes, more massive and real-time knowledge base, maybe even a wide array of built-in attachments.  Perhaps humans just slow things up.

We shouldn't assume that the purpose of robots in surgery is simply to enhance our capabilities.

If we're going to have robots in health care, though, surgery may not be the area of most need.  After all, there are plenty of surgeons (although not well dispersed geographically) and we probably do too much surgery already.  On the other hand, one health care professional that we do not have enough of is personal care workers, and that shortage is only going to get worse.

Fortunately, robotics companies are already on it.  Toyota, for example, has a whole "family" of partner robots, including ones for health care  Disney even had an animated movie last year -- Big Hero 6 -- that featured such a robot.  That movie was set vaguely in the future, but let's hope the robot of personal care robots is not so far off.

The robots may be ready before we are.  A recent survey in the U.K. by The Institution of Engineering and Technology found that only 33% would use a robot to assist an elderly or disabled relative, while 17% would not even consider it.  Interest was lower when considering assistance for oneself.

As someone who has family members in long term care facilities which always seem to be short-staffed, my only question about using robotic aides to help them would be: where do I sign up?

The question is not really robotic technology will get sophisticated enough to add value in health care -- their role in manufacturing has clearly proven their ability to automate extremely complex processes -- as it is when the supporting software (dare I say "artificial intelligence"?) will allow it to operate with limited or even no human oversight.

Harvard Business Review recently proclaimed that "artificial intelligence is almost ready for business," and specifically cites health care as one of the leading applications, such as IBM's Watson.  Pittsburgh's UPMC, University of Pittsburgh, and Carnegie Mellon just announced their big data collaboration, which UPMC CEO Jeff Romoff says could lead to "doctor-less health care," a quote I bet his PR folks were trying to walk back as soon as the words came out of his mouth.  

Oh, there will still be doctors -- but they won't be our only option, for diagnosis, treatments, even procedures and surgeries.  Not tomorrow, probably not next year, but it will happen.

Of course, the licensing cartel will be a problem.  If organized medicine puts up barriers to doing telemedicine even for physicians who have licenses in other states, I have a pretty good idea how they'll respond to robots getting in on the act.  As was true with telemedicine, I suspect that the technical barriers will be breached well before the cultural and regulatory ones are.

If this kind of future sounds impossible to imagine, keep in mind the words of robotics pioneer Rodney Brooks:

In the future, I'm sure there will be a lot more robots in every aspect of life.  If you told people in 1985 that in 25 years they would have computers in their kitchen, it would have made no sense to them.

Looking for the Future in the Past

I don't get smartwatches.

Yes, I know; they're all the rage.  Apple unveiled its Apple Watch earlier this month, to generally good if not entirely ecstatic reviews.  Not to be outdone, Google announced a collaboration with TAG Heuer and Intel for a "Swiss Smartwatch."   Samsung and Sony are close behind with their own versions, and new players like Pebble Time are also throwing their hats -- or, rather, their watches -- into the ring.

Poor Fitbit, which held the early lead in wrist wearables, is now desperately trying to broaden its product line, including the new Surge.  They must feel a little like Garmin or Nikon did when mobile phones began to incorporate GPS tracking and digital phones, respectively, especially after Apple kicked them out of is stores.   Then again, Fitbit snubbed Apple's Healthkit first.

I have to wonder why the focus on the wrist.  It isn't the ideal place to track, say, your heartbeat, your sleep, or your steps, and as a result fitness trackers have been faulted about their accuracy.  Cramming features into a smartphone makes some sense, because they have become so ubiquitous, but I'm not sure who is clamoring to add more features to a watch.  Weren't they supposed to be on their way out just a couple years ago, especially among the younger generation?

The idea goes back to at least Dick Tracy's watch, which was already old when I was young (and that was a long time ago...).  Heck, they're making/remaking movies out of about every comic book hero, but I don't see any call for a new Dick Tracy movie.  Supposedly just for his watch.

We spent the first few generations of cell phones trying to make them smaller, and in the past few years have been reversing that trend, to the point where the distinction between a large mobile phone and a small tablet have become trivial.  Now we're trying to put more information on watches whose faces are even smaller than cell phone screens used to be?  This is progress?

In an so-to-be era of The Internet of Things, in which virtually anything can be a sensor or even a computer, are watches the best device to be either?  It's as if Timex and Casio, not to mention TAG Heuer, are conspiring to create a demand so that they don't go the way of Kodak.

Now, I have to admit, when mobile phones first included cameras, I was skeptical, so perhaps I'm similarly just missing the wow of the smartwatch.

It's not that I think they are a bad idea.  If you want to wear one, more power to you, and I hope it helps you with your health goals.  My problem with them is that I think they are an example of our trying to create the future by looking in the past.  PCs, laptops, and tablets are other examples.  They're very sophisticated and grow ever more powerful, but have we seen any ideas for them that Alan Kay or Doug Engelbart didn't propose over forty years ago?  Or, to use a more familiar example: I know Star Trek: The Next Generation was set in the 24th century, but it was filmed in the 1980's, and its fans are  convinced the iPad borrowed a lot of features from STNG's tablets (just as the 1990's flip phones supposedly were inspired by the communicators of the original Star Trek).

Shouldn't we be developing truly new technologies and uses for them?

I can't help but think about EHRs in this context.  Health care providers insisted on being subsidized for what would be normal business process improvement investments for any other industry, and settled for technologies that weren't what they really needed.  What we got for all the federal spending were products that physicians don't really like, that more often hinder than help with patient care, that patients rarely have access to, and that can't easily share data.  They, and especially their interoperability, were supposed to lead to better patient care and reduced costs, but those promises haven't been realized.

A new study in the Journal of the American Medical Informatics Association  suggests that, at least when it comes to PCMHs, we may be working from the wrong health IT toolbox.  We need tools that are more collaborative, more interactive, and more proactive.  Our provider-centered EHRs aren't cutting it.

Congress is already starting to ask what it has gotten for its $35b HITECH investment, even holding hearings to demand answers.  Yes, sure, some of this is partisan bickering, a way for Republicans to take potshots at an Administration-led initiative, but EHRs used to have bipartisan support and now have fairly bipartisan disappointment.

We don't even have an agreed upon way to figure out if providers have the same patient, much less share their data about that patient.  CHIME just put out a $1 million prize to someone who can solve this problem.  The financial services industry solved similar customer-identification problems decades ago, without prizes or government mandates.  They did it because it made business sense.

Not so in health care; not yet, anyway.

In theory, that kind of change will happen once we make that big move to "value-based" care, but as long as our baseline is our current level of spending, I'm skeptical.  We need approaches that attempt not just to reduce increases in spending but that aim to take big chunks out of spending.  There's no shortage of waste, duplication and unnecessary care that could be eliminated, not to mention the huge saving opportunities in keeping people healthier in the first place.

Smartwatches, EHRs, or proton beam therapy, to name a few examples, are not likely to help accomplish that.

Readers of previous posts may remember that I am fascinated by virtual reality, holograms, and artificial intelligence (yes, I realize that they, like tablets, also were featured in various Star Trek series; what can I say; I'm a sci-fi geek).  I want to see those kinds of new technologies in health care, not a smartwatch.  Technologies that help change how we think about "health" and how we treat problems with it.  I challenge health care technology gurus: show us something not just that we haven't seen before; show us something we hadn't even thought of before

As Alan Kay famously said: "The best way to predict the future is to invent it."

Better Health Takes A Village

Achieving better health, like many aspects of life these days, is rapidly becoming more social.

I'll start with the example of Facebook's apparent value in hospital ratings.  A recent study in The Journal Of General Internal Medicine found a correlation between hospital Facebook ratings and readmission rates as reported on Hospital Compare, which may come as a surprise to some.

The authors refer to using social media to track public opinion as "sentiment analysis."  They further note:

While we can’t say conclusively that social media ratings are fully representative of the actual quality of care, this research adds support to the idea that social media has quantitative value in assessing the areas of patient satisfaction – something we are hoping to study next – and other quality outcomes."

One can argue that readmission ratings themselves are at best an imperfect mechanism for evaluating hospital quality, but since a recent Health Affairs article found that four of the most commonly used hospital rating approaches -- US News & World Report, Consumer Reports, Healthgrades, and The Leapfrog Group -- didn't agree on what the top hospitals were, even using supposedly objective measures, maybe social media ratings are as good as we should expect.

I find it amusing when providers object to consumer ratings on the basis that they are subjective.  In the first place, they've had decades to come up with more objective measures that consumers -- or even other professionals -- can use, without noticeable success.  In the second place, consumers seem to be pretty happy with such "wisdom of the crowd" ratings, as used by, say, Amazon or Yelp.  The traditional pat response to such examples is that health care is "different."  Perhaps it is, but that distinction may be vanishing faster than health care experts like...or realize.

Sentiment analysis is anything but sentimental.  IBM is trying to help businesses understand public perceptions of them by analyzing Twitter, just as Nielsen is realizing it needs to co-opt Twitter's chatter about TV shows in order to stay relevant in TV ratings.   Health care talks a lot about Big Data, but may not fully realize the potential in the non-clinical sources of that data, such as social media.

Use of social media isn't all about ratings.  Social media and use of communities have been seen as a promising tool for helping people with chronic conditions for some time.  Cancer patients and survivors have a plethora of support groups and communities, Weight Watchers now uses meetings (in-person or online) as one of their key weight management tools, and the America Diabetes Association sponsors multiple communities to assist diabetics and their families.

Last year, the eHealth Initiative published A Report on the Use of Social Media to Prevent Behavioral Risk Factors Associated With Chronic Disease, covering both its promise and challenges.  While they acknowledge definitive research on its impact is yet to come, the key to its promise comes from the fact that: "Health behavior is fundamentally influenced, shaped, and defined by social networks composed of friends, colleagues, family members, caregivers, and others."

Unfortunately, that's not how medicine has usually been practiced.

The granddaddy of patient sharing sites is probably PatientsLikeMe, which began primarily as forums for patients with specific conditions, and now is a for-profit company that earns its living by sharing its member data with health researchers plus pharma or medical device partners, who don't seem to mind if that information is subjective.  Walgreens, for example, is going to use patient feedback from PatientsLikeMe to replace, or at least supplement, those nearly incomprehensible prescription side effect warnings.

Smart Patients offers a similar service to PatientsLikeMe, while Apple just announced ResearchKit, allowing Apple users to make their health data available to researchers, such as for clinical trials.  We're just starting to scratch the surface.

Even physicians are getting into the act of collaboration.  Figure1 has been described as "Instagram" for physicians, allowing them to upload photographs and patient information in order to get opinions from other physicians.  SERMO positions itself as a "virtual doctors lounge," allowing physicians to crowdsource tough cases (although I'd be curious to learn how much of that goes on versus, say, complaining about insurers).  They claim 300,000 members, all physicians, and competitor Doximity claims even more, so there obviously is significant demand for this kind of virtual collaboration. 

Health care is patting itself on the back for Open Notes, which is slowly allowing patients to at least view their own health records, including doctors' notes.  They claim 4.8 million members have such access.  I admire the initiative, but someone wake me when such sharing is the norm, instead of the exception.  I'll only start to get excited when patients' records become truly collaborative -- and it is the patient deciding what is shared, and with whom.

If the EHR industry isn't careful, it's going to get supplanted by a sharing approach.  Facebook could do it, or Google, but it would be very different than traditional medical records.  Think it couldn't happen?  Ask the taxi or hotel industries.

Collaboration will really get interesting when it gets involved more directly into processes of care.  The Wall Street Journal recently profiled how some hospital ICUs are allowing patients and their families to participate more directly in what is happening to the patient during his/her stay.  Think how much more powerful this approach will be when -- not "if" -- it allows patients in an ICU to communicate with each other about common issues/questions, or even with patients in other ICUs with similar conditions.  Or allow them to ping doctors in other locations to participate in their care.

The Journal article also discussed making the various processes of care more transparent, as well as tracking progress of tasks.  E.g., not just using checklists but sharing them with patients as the tasks are happening.  Patients in many health care settings spend much of their time waiting, not knowing what is happening next or when.  Forcing the provider to disclose what is supposed to happen, when, and by whom would force radical changes that should benefit the patients.

I thought of this when I read a New York Times profile of BetterWorks.  Although The Times headlined the approach as using "computer games" to manage employees, the keys are really transparent tracking of tasks and social media collaboration from other employees (e.g., they can give "cheers" or "nudges") to help employees improve their performance.  It may have some aspects of gaming, but it sure sounds a lot like what continuous quality improvement programs are supposed to do   I would love to see some health care organization implement BetterWorks or a similar approach.

Imagine if patients also got to weigh in.

Social media, patient (or provider) sharing and collaboration, and other 21st century social strategies won't, in themselves, ensure our better health, but it's hard to see that they won't be part of the process towards it.

The Sky Is (Still) Falling

Everyone seems to be writing about the Apple watch, which had its dog-and-pony show this week, but I'll leave that to others for now.  Instead, I want to talk about why it seems to be so hard to fill health care jobs.

Gloom and doom abound, as they have for decades.  The Association for American Medical Colleges (AAMC) just reported that by 2025 we'll face a shortfall of between 46,000 and 90,000 physicians.  Even more startling is that the shortfall is expected to be even larger for specialists than for primary care physicians.  Their 2010 projections predicted a shortfall of 130,000, so perhaps we should take these new projections as progress.

Similarly, a report by Georgetown's Center on Education and the Workforce predicts we'll face a shortfall of nearly 200,000 nurses by 2020, through a combination of newly created jobs and jobs open due to retirements.  According to the report, nurses account for nearly thee out of every five health care jobs.

Not to be left out, the American Association of Colleges of Pharmacy predicts a shortfall of 157,000 pharmacists by 2020, while HRSA projects a shortage of 15,600 dentists by 2025.  I suspect that it wouldn't take a lot more effort to find ominous projections for other health care professions.

I look at the explosive growth of retail clinics, or the increased emphasis on population health management and patient-centered-medical homes, all of which seem to require at least nurses, if not nurse practitioners, physician assistants, or even physicians, and the shortages seem to be understandable.

Still, I'm wondering: in a supposedly capitalist economy, why would there be these kind of shortages?  After all, these are relatively well-paying jobs, in one of the largest sectors of the economy and one of the few that promises to continue to have steady growth.  Shouldn't people be rushing to fill these jobs?

People in these professions might cite factors such as dealing with the competing demands of government, third party payors, and patients themselves.  As enviable as their salaries might appear to many other workers, many of these professionals have faced pressures on their earnings.  Plus, there is the economic burden -- both due to direct costs and due to missed alternative opportunities -- posed by the long period of education and training (up to 14 years in total for some physicians).  All these may be daunting to potential entrants.

Perhaps part of the answer was given, oddly enough, by the Supreme Court in a recent case, North Carolina Board of Dental Examiners v Federal Trade Commission.  It found that licensing activities can have the effect of being anti-competitive.

I mentioned the case in a recent post.  In short, it revolved around the Board's efforts to keep teeth whitening services limited to dentists.   The Supreme Court found that such state licensing boards were subject to antitrust suits unless any anti-competitive actions are specifically sanctioned by the state, and were under "active supervision" by the state.

This case seems somewhat far afield -- teeth whitening?  Dentists? -- but the implications are not trivial at all.  Rebecca Haw Allensworth and Aaron Edlin wrote an op-ed last week applauding the ruling, noting that 30% of the U.S. workforce is now subject to occupational licensing and that such licensing can have the effect of limiting competition.  The duo had previously written an in-depth analysis of the licensing mania -- Cartels By Another Name: Should Licensed Occupations Face Antitrust Scrutiny -- that was cited in the SCOTUS opinion.

Their use of the word "cartels" should not be taken lightly.

Their analysis listed the various licensing boards in Florida and Tennessee as examples, and it should come as no surprise that they include not just ones for dentists but also physicians (both M.D. and D.O.), nurses, pharmacists, chiropractors, podiatrists, and various other health care professions, not to mention cosmetologists and barbers, among others.  Health care has a lot of silos, each of which guards its own domain tightly and some of which occasionally try to encroach on others'.

The question that the members of the various Boards in every state should be asking themselves is: if we had to go to court, how many of our licensing requirements could we prove were strictly to protect consumers' best interests?

Think about, say, requirements that physicians licensed in one state can not "see" a patient in another via a tele-visit without a license from the patient's state, that a nurse practitioner must be overseen by a physician, or that a pharmacist can't prescribe (as they can in some countries)?  There certainly are arguments Boards could make for such restrictions, but let's hope the burden of proof for them is higher than "well, they're not physicians."

A lot of our health care licensing serves to mask the facts that (a) we don't really know how to measure quality, or value, (b) much of what is done is not based on empirical evidence (or, in some cases, has actually been shown not to work), and (c) we don't do a very good job of monitoring performance.  Having the requisite education, passing a initial examination, and doing some continuing education are used as proxies for actual evidence of providing value.

If I'm on that jury, such proxies would not suffice.

The various projections of shortages suggest not that we need to pump more money into the training and support of the existing professions, but rather than we're approaching the problem from their standpoint, instead of rethinking how we can provide health care services and support differently.

I would argue we need to see several things:

• Performance-based licensing: make the Boards require proof of unique value in return for any licenses that restrict others from performing certain services.  "Only we should do this" is not sufficient.
• Revamp medical education: as I've written before, our approach to medical education is too disjointed, too academic, and too long.  It's no surprise prospective applicants are not rushing to get trained.
• Health versus medical care: Our health care system is really a medical care system, too often addressing health issues only after they've manifested.  We should be catching problems earlier, helping people manage more on their own, and supporting them with professionals trained specifically to do lifestyle coaching.
• Be more open to new types of providers: I'm not just talking about so-called physician extenders.  I mean truly different kinds of approaches, like tinkering with the microbiome or gene therapy, that may be best suited for scientists who may not be physicians.  I'd go so far as to advocate a role for artificial intelligence in certain circumstances, and believe those circumstances will rapidly widen as AI learns more.  These new types of providers must still prove their value to be licensed themselves.

If the sky is, indeed, falling, let's be clear upon whom it is falling.  In any event, we probably shouldn't be standing still.

Cutting the Cords

I've been reading about various ways consumers are starting to "cut the cord" from many traditional sources of services, and I keep wondering: what's the equivalent in health care?

Let's look at some of the trends:

1. Landlines: Mobile phones (increasingly smartphones) are pretty much universal; a year ago Pew said 90% of adults had a mobile phone, and 58% a smartphone. As a result, landlines may be on their way out; already some 46% of U.S. households don't have a one.  Two-thirds of those 25-29 are exclusively mobile.  
2. Mobile carriers:  Mobile carriers have to look at the landline trends with both glee and dread, the latter because they may be next.  Ryan Knutson of The Wall Street Journal recently recapped his attempt to rely solely on Wi-Fi only service, which he deemed "definitely doable." So doable, in fact, that there's already a market.  In January Cablevison announced their low cost Wi-Fi only service, and Comcast has hinted it might not be far behind.  Companies like Republic Wireless are already offering Wi-Fi/cellular hybrids that are priced lower than most wireless carriers, a path that Google just announced they will follow
3. Cable: Streaming may be the new cable for watching TV or movies.  Many predict 2015 is the year that significant numbers of households will start getting rid of cable service in lieu of OTT (over-the-top content) options, which are starting to include such premium content as ESPN, HBO, and Nickelodeon.   Amazon, Dish TV, Hulu, and Netflix are all eager to replace your cable TV service.
4. Taxis: It's likely you've heard of Uber, and if you are under 30 and/or live in a large metropolitan area, you've probably used it instead of a taxi.  Uber claims it is a technology company, not a transportation company, an argument the taxi companies find frustrating in their attempts to equalize regulation.  Amazingly, Uber is already projected to be worth at least $40b and may be soon worth as much as $80b.  In some markets, like its home of San Francisco, it's already bigger than the entire local taxi industry.
5. Hotels: Airbnb is taking the hotel business by storm, doing for it what Uber is doing for taxis.  Airbnb's most recent investment round values them at $20b, and their million rooms is more than any of the traditional hotel chains.  Heck, even Warren Buffet recommends using them.

While Uber and Airbnb avoid investing in their own taxis or hotel rooms, respectively, in health care we're continuing to spend billions to make hospitals nicer, or at least prettier, despite a new study from Johns Hopkins researchers that indicate such new, supposedly patient-centered improvements have little impact on patient satisfaction.  As the study's lead author Zishan Siddiqui, M.D., said: "Hospital leaders will have to stop blaming poor patient satisfaction on aging buildings and units."

Maybe we need an Airbnb for hospitals.

In health care we're also still walking telemedicine just ahead of the sheriff, as the saying goes.  The Texas Medical Board is considering restrictive rules, which telemedicine vendor TelaDoc is fighting in court; new research confirms that state licensing requirements continue to be a burden; the AMA seems more concerned about protecting physicians from liability than in increasing patient options.

Organized medicine is still fighting to avoid cutting that in-person cord.

Roy Smythe, writing in Forbes, warns that health care is going to have to learn to operate differently. He believes health care must embrace "losing potential revenue and being progressively demonetized by technology."  As an example, he quotes Peter Anderson, Chief Strategy Officer for Sutter Health: "lab tests in the future will be home-based, and this will be both more convenient, and much cheaper than the current model"

That's not in the far-off future; Smythe cites Theranos and Diagnostics for All, both of whom are already upending lab testing.  Theranos can perform a full array of tests using just a few drops of blood or other bodily fluids.  DFA has a unique paper-based approach that can be used and interpreted even in the most rural areas, without needing a lab or a trained professional.

It shouldn't be surprising that Theranos is already teaming up with Walgreens to deliver their solution more conveniently to consumers.  Indeed, Tom Greene argues in Venture Beat that retail clinics, such as Walgreens' healthcare clinics or WalMart's primary care clinics, could do to health care what Uber is doing to taxis.  He notes that retailers know a lot more about customer loyalty than most health care organizations, and believes that to succeed health care also "...will have to embrace an Uber-like ecosystem that places a premium on convenience, availability, and access."

That's nice to think about, but I've written before that I worry that new entrants in health care may be more interested in getting their share of its bloated spending than in revamping how the system works for patients.  We really need fresh approaches.

I don't know who the Ubers of health care will be, but when I think about "cutting the cord" in health care there are two cords that I think are going to have to go:

• Third party payments: We've become lulled by the premise that other people -- e.g., health insurance or Medicare -- pay for our health care, and that fantasy has allowed the ridiculous prices and excessive utilization we see in health care.  We do need mechanisms to protect people from truly catastrophic expenses, and to help finance care for low income people, but most health care should be financed directly.  Note to health care innovators: figure out services that provide enough value to consumers that they will pay out of their own pockets for it.
• Practice of medicine regulations:  These exist ostensibly for the protection of patients, and have been part & parcel of health care for so long that we think of them as inviolate.  The fact that they are used, among other things, to prevent patients from doing a video consult with outstanding physicians who happen to live in other states, or even in other countries, illustrates that what they end up doing is protecting the providers who practice nearby.  That is not to say that physicians and other health care professionals don't and won't continue to add value, but we've allowed them to claim that value more on their simply having a license than on any demonstrated results.  That won't work in the 21st century; value may come from non-traditional sources.  Note to health care regulators: let's focus more on actually demonstrating value and less on the type of degree or license the person delivering it has.  

The health care system isn't going to get overturned all at once.  Change is most likely to come first for less complicated conditions and types of care.  And that's OK.  Once consumers see how different health care can be, it's going to be hard to avoid that tidal wave from reaching the rest of the health care system.

Cutting the cord can be scary, but if we do it right it will be liberating.