Sunday, August 28, 2016

Octobot to the Rescue!

Acclaimed futurist Ray Kurzweil has a lot of bold predictions (including that computers will become smarter than us within a few decades), and some of his most interesting ones deal with how technology -- especially nanotechnology -- will soon totally revamp how we manage our health, leading to longer, healthier lives and hugely increased intelligence.  Sounds like science fiction, right?

Meet Octobot.

Harvard researchers have unveiled what they describe as the "first autonomous, entirely soft robot," which they call Octobot (it has eight arms, like an octopus).  It has no metal, no battery, no electronics of any sort, yet manages to move under its own power.  It uses a "microfluidic logic circuit" rather than a circuit board to control the movements of its arms and to power itself along, using gas reactions.

And, to make it even cooler, they 3D-printed it.

Octobot seems cute, almost cuddly, more like a child's bath toy rather than a glimpse into the future of robotics.  The researchers are careful to note that, right now, it is only a proof of concept.  It can't do much, and it runs out of power within a few minutes.  But they're already planning a next generation that can "crawl, swim, and interact with its environment," and hope their efforts inspire other researchers.  Some are already speculating about other uses, such as in marine environments -- or within the human body.

If Octobot doesn't -- yet -- quite sound like what Ray Kurzweil envisions, perhaps some work being done in Israel comes closer.  Researchers there used "DNA origami" to create nanobots, which they injected into cockroaches.  The nanobots contained drugs, which, amazingly, the nanobots released based on the brain activity of a volunteer (they had him do math).  He was hooked up to an EEG; his brain activity triggered an electromagnetic coil, which caused the nanobot to release the drugs.  When he stopped calculating, the nanobot stopped releasing the drug.

The researchers see great potential for people to trigger the release of drugs based on their own mental state, not just calculations but moods or feelings.  As they wrote,
"This technology enables the online switching of a bioactive molecule on and off in response to a subject's cognitive state, with potential implications to therapeutic control in disorders such as schizophrenia, depression, and attention deficits, which are among the most challenging conditions to diagnose and treat."  
Researchers in Canada see similar potential for using nanobots to attack cancer.  They loaded up a bacteria with cancer drugs, and used magnetic nanoparticles to steer the bacteria to tumors (in mice).  The nanobots detected the most oxygen-depleted zones -- which indicate the most rapidly growing tumor cells -- and released the drugs in them.

The researchers believe their approach will allow much more targeted chemotherapy, improving effectiveness while minimizing or even eliminating harmful side effects.  Moreover, they say,
"This innovative use of nanotransporters will have an impact not only on creating more advanced engineering concepts and original intervention methods, but it also throws the door wide open to the synthesis of new vehicles for therapeutic, imaging and diagnostic agents."
So far they've just done tests in mice; the Israeli researchers are hoping to test their approach with terminally ill cancer patients very soon.

Another set of researchers, in Switzerland, are working on yet another version of nanobots.  They are also trying to imitate bacteria to deliver drugs to targeted locations.  They layer nanoparticles in "biocompatible hydrogel," line up the nanoparticles via electromagnetic fields, solidify the hydrogel, and insert it into a fluid.  They can make the particles move using magnetic fields, and can change its shape using heat.  These allow for a wide range of movement and behaviors.

The Swiss researchers see the use of their nanobots not just in delivering drugs with great precision but also for clearing arteries.

Victoria Webster, a Ph.D. candidate in engineering at Case Western Reserve University, discussed some of their work in building what she called "biobots" -- robots powered by living cells. They're using sea slugs as a platform, both because it has evolved to survive in a wide range of environments and because we already know much about its neural network, potentially making it easier to program its neurons to do desired tasks.,  She cited targeted drug delivery, cleaning up clots, or strengthening weak blood vessels to prevent aneurysms.  

These are only a few examples of how nanotechnology is progressing rapidly.  There are plenty of others.  So far GlaxoSmithKine is the only major pharma company known to be working on nanobot treatments (which they call "bioelectronics"), but if the field pans out others will have to follow suit, or become buggy manufacturers in an automobile world.

Ray Kurzweil predicts that nanobots will be assisting our immune systems by the 2020's, and that by 2029 will annually add a year to our life expectancy.  As he describes it, "we're starting to reprogram the outdated software of life...we're programming them [genes] away from disease, away from aging."  By the 2030's the nanobots will be in our brain, giving us an additional neocortex that will make us much smarter, although he admits, "but the truth is, we don't know what it will look like."

If Dr. Kurzweil and the myriad of researchers working in the field or not, within a generation the practice of medicine will start to be unrecognizably different.  Our current surgeries, prescription drugs, chemotherapies, radiation therapies, and other interventions will start to seem crude and, in some cases, as misguided as, say, bloodletting.

That's all great news, assuming everyone has access to and can equally afford the enhancements, but could also potentially vastly exacerbate differences between socioeconomic classes, as John Koetsier fears.   The technology is going to make huge changes not just in medicine and health care but in society more broadly.  Hopefully it will help us not just be smarter but also wiser about how we use our new capabilities.

Octobot doesn't seem quite so cuddly now, does it?

Sunday, August 21, 2016

Pardon Me, Your Interface Is Showing

In a great post, "Doctor as Designer" Joyce Lee laments the "sad state of product and design in healthcare," and asks "when will device and drug companies create user-centered innovations that actually improve the lives of patients instead of their bottom line?"

I heartily agree with Dr. Lee's point, and think the question can be extended to the rest of the health care system.

Dr. Lee uses two examples to compare health care to consumer goods.  Heinz took a product design -- the glass ketchup bottle -- that had been around for over a hundred years, and greatly improved the user experience by changing to a squeezable "upside down" bottle.  This not only kept the ketchup from concentrating at the bottom but also avoided the need to hold the bottle at a special angle or to tap at a particular spot just to get the ketchup out.

She contrasts this with the Epi-pen.  It is not only hard to use correctly, but its manufacturer has used the recalls of competitors' medications to jack up its price by several hundred percent (from $100 to over $600).  Dr, Lee notes that some consumers are simply buying their own epinephrine and needles to create their DIY version, for about $5, "which means that we are paying $600 for a hunk of badly designed plastic!"    

Bad design for more money; it sure sounds like health care, doesn't it?

When I think about health care's lack of user-centered design, though, I think less about Epi-pens or medical devices and about more common patient interactions, like in doctor's offices or hospitals.

Kaiser Health News recently published two articles on the experience of elderly patients in the hospital.  The first noted that, ironically, elderly patients often are admitted sick but leave disabled.  It is important -- but uncommon -- for hospitals to focus on how to get the patient back home living as independently as possible.  Bed rest, catheters, IVs, interrupted sleep, and unappetizing food all can work against that goal.

The second KHN article stressed the need to keep hospitalized elderly patients moving.  A 2009 study found that such patients spend 83% of their stay in bed, being out of bed a median of only 43 minutes per day.  One nurse warns patients, "the bed is not your friend."

Hospitals are just protecting themselves from lawsuits.  A geriatrician explained that families won't sue if their parent gets weaker while in the hospital, but may sue if he/she falls, so preventing falls trumps preparing patients to go home independently.

As another geriatrician noted: "The older you are, the worse the hospital is for you."  Still another physician likened current approaches to a "smart bomb."  "We blow away the disease," he said, "but we leave a lot of collateral damage."

If that isn't a good description of our "health care" system, I don't know what is.

Design matters.  KHN cites examples of hospitals that have created special units that pay more attention to helping patients be more mobile -- through changes in room design, assuring that walkers are widely available, and focused care processes.  It can be done.

Certainly hospitals are much different than a generation ago, with semi-private rooms on their way out (who ever thought that was a good idea in the first place?) and amenities like WiFi more common.  Hospitals are said to be borrowing from the hotel industry to improve patient experience, but this may aimed more at marketing and revenue-enhancement opportunities than to improving patient care.

Still, I suspect that the next time a patient confuses a hospital for a hotel will be the first.

The health care system is recognizing that it needs to engage people differently.  Such engagement is seen as essential to getting them more involved in their health, especially in managing chronic conditions.  It is potentially big business, with the patient engagement market expected to grow from $7.4b in 2015 to $39b by 2024, according to Grand View Research.  

MobiHealthNews sees a big role for consumer health tech companies in this, particularly on the B2B side.  They cite numerous examples of alliances, acquisitions, and partnerships along those lines.  When it comes to improving patient experience, it asks, "What better place to turn than devices and apps that have already proven themselves engaging and delightful in the direct-to-consumer world?"

The problem may be that we're still not quite sure who the "customer" is.  According to Xerox, nearly 50% of consumers say they take "complete responsibility" for their heath, but only 6% of health professionals think that is true.  Nearly 40% of providers and payors think consumers don't even know how to take charge of their health.

It's hard to design for a health care system when we don't even agree who is "in charge" of our health.

If you think too much about the interface, it's bad design, creating friction.  The health care system is full of this kind of friction.  Think of selecting a health plan, understanding health coverage, finding a provider, getting an appointment, waiting to receive care, or understanding a diagnosis and treatment options.  And don't get me started on EHRs.

Martin Legowiecki, writing in TechCrunch, thinks UI should be "invisible" and that AI is the way to get to that.  The world, in his view, should be as easy as walking into your favorite bar and having the bartender have your favorite drink ready as soon as you sit down.  As he says, "that's a lot of interaction, without any 'interaction.'"

Or, as he puts it more pithily, "the ultimate UI is no UI."

In an Internet of Things world, we could use normal language to talk to our environment, with the omnipresent AI able to understand and apply conceptual awareness to accommodate our needs.  Picture a hospital bed that not only warns you when you've been immobile too long but also "helps" you get up, or a doctor's office that pulls together all the necessary information on you before you even arrive.

Design starts with making something functional, and good design tries to make easier to use, or at least more attractive.  Really good design doesn't make us think about how clever the designers are but, rather, allows us to forget that they did anything at all.

Health care could use some really good design.

Monday, August 15, 2016

Out With the Old...Wait, Not in Health Care

The last company still manufacturing VCRs announced it has ceased their production.  VCRs had a good run, most households had one, but their time has passed.  Meanwhile, the stethoscope is celebrating its 200th birthday, and is still virtually the universal symbol for health care professionals.  

There has got to be a moral in there somewhere.

VCRs revolutionized our TV viewing experience.   We could record television shows to not only watch programs at our own convenience, but we could also fast forward through commercials!  We could watch the movies we wanted, when we wanted to, in the comfort of our own homes.  Video rental outlets popped up everywhere, from boutique neighborhood stores to wildly successful chains like Blockbuster.    

Alas, technology moves along.  DVRs came along in the 1990's, especially TiVo.  Suddenly those VCRs seemed old-fashioned.  As broadband has become more common, streaming services are now threatening to render DVRs obsolete as well.  Blockbuster is gone, while Netflix has been nimble enough to remake itself primarily as a streaming service.  

VCRs are a classic example of how technology (usually) moves on.  Except in health care.

Like stethoscopes.  Digital advocate Dr. Eric Topol recently tweeted: "The stethoscope's 200th birthday should be its funeral."  Jagat Narula, a dean at the Icahn School of Medicine at Mt. Sinai, flatly says, "The stethoscope is dead.  The time for the stethoscope is gone."  

That's all well and good, but -- to paraphrase Mark Twain -- reports of its death are greatly exaggerated.

The well-known story is that the stethoscope was invented by René Laënnec to avoid having to listen to a female patient's chest by putting his ear to her chest, as he thought that technique improper.  Laënnec's crude tube was gradually improved upon over the years.  Stethoscopes became a de facto symbol of being a physician, along with white coats (which have their own baggage).   Google "physician" and almost all the resulting images show physicians with stethoscopes.  

It's not like stethoscopes do all that good a job, or, perhaps, that physicians use them all that well.  A 2014 study found that participants only detected all tested sounds 69% of the time.  As the authors diplomatically concluded, "a clear opportunity for improving basic auscultations skills in our health care professionals continues to exist."   

Similarly, a 1997 study found that: "Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events," while a 2006 study found that stethoscope skills did not improve after the third year of medical school and "...may decline after years in practice."  Whoops.

Oh, and stethoscopes also help carry germs.

And it's not like there aren't alternatives.  As one might expect in the 21st century, there are electronic/digital stethoscopes.  These allow for amplification of body sounds, and even for the transmission and recording of those sounds.   Their output can be converted into graphic representation and compared, either historically for the same patient or to established parameters.  

There are also handheld ultrasounds that provide another strong alternative.  Ultrasound has been a diagnostic tool for decades, but handheld units only became available in the late 1990's.  The question of whether they would make stethoscopes obsolete was soon being asked, and there is plenty of research supporting the assertion that they are as good or better than stethoscopes.   

And now, of course, there are smartphone apps for stethoscopes.  Apple was claiming 3 million doctors had downloaded its $0.99 stethoscope app as long ago as 2010, with Android versions also available.  HealthBud, a new device that uses smartphones, has research to back up its claim that it is at least as good as stethoscopes, and is seeking FDA approval.  Its developer claims, "This device is much less expensive to produce and offers a safer alternative to both traditional and disposable models without sacrificing sound quality." 

And yet stethoscopes hang in there.  

We might like to think that physicians continue to use traditional stethoscopes because they are simply being thrifty, since electronic stethoscopes and handheld ultrasounds are much more expensive, but that seems a reach.  They've certainly not been reluctant to adapt other types of newer, more expensive technology -- at least, not as long as they can charge more for it.  

It is a conundrum that has bedeviled economists: why in health care does new technology almost always increase costs, unlike most other industries?  E.g., DVRs were much better than VCRs, but quickly became comparably priced.  Professor Kentaro Toyama cites what he calls technology's Law of Amplification: "Technology’s primary effect is to amplify, not necessarily to improve upon, underlying human inclinations."

And in health care, those underlying inclinations don't drive towards greater value.

When it comes to stethoscopes, it's not about the money.  Many physicians believe that the stethoscope helps foster the patient-physician relationship.  In a recent article in The Atlantic, Andrew Bomback admitted that, "Indeed, for many doctors (myself included), the stethoscope exam has become more ceremony than utility."  He cites the case of a colleague who borrowed a stethoscope -- even though it was only a low-end model -- before examining a patient, explaining, "Patients expect you to have one of these things."

Physician/engineer Elazer Edelman argues that a stethoscope exam can help to create a bond between patients and physicians.  He worries that technology may be fraying the "tether" between doctors and patients. Still, if the relationship depends on which device a physician uses to listen to our chest, that relationship is in bigger trouble than we think.

The stethoscope illustrates that health care can be anything but rational.  Their use -- like those white coats -- persists because both patients and physicians expect them to be used.  It is a form of status worship.  Honestly, it's not dissimilar to talismans that more primitive cultures expect from their medicine men, their shamans, their witch doctors.  

Given what we know about the power of placebos, we may not be as different from those primitive societies as we like to think.  

So, R.I.P. VCRs, and thanks for the memories.  As for stethoscopes, and for health care more generally, though, maybe the moral is that we should focus less on status symbols and more on what is best for patients.  

Sunday, August 7, 2016

Reading This May Be Hazardous to Your Health

You better sit down for this.  No, on second thought, you better not.  Unless you are reading this while walking on a treadmill, the time it takes you to read this may shorten your life, at least a little.

It's not the contents of the post, which hopefully will be somewhat provocative but not actually dangerous.  No, it's the sitting part that poses the risk.

Several new studies help illustrate the risk of being inactive.  One study in The Lancet found that at least an hour of moderate intensity exercise is needed to offset sitting eight hours a day -- e.g., about the amount of the time that many office workers spend at their desk (and that others spend in front of the TV or gaming console).

Sitting without the offsetting exercise increased mortality risk by close to 60%.  Indeed, the risk of this inactivity is on par with smoking.  The lead author acknowledged that many people may have a hard time finding an hour a day to exercise, but pointed out that: "if this is unmanageable, then at least doing some exercise each day can help reduce the risk."

A second study, also in The Lancet, tried to quantify the cost of physical inactivity.  It "conservatively estimated" its worldwide economic impact at $53.8b, plus $13.7b in productivity losses.  In addition, it accounted for 13.4 million disability-adjusted life years, which take into account the true personal cost -- years lost due to premature deaths and to disability while alive.

If anything, these numbers seems low given the order of magnitude that such inactivity appears to have on mortality and morbidity.

The authors noted their various assumptions that make these results conservative, but conclude nonetheless that: "Physical inactivity is a global pandemic that causes not only morbidity and mortality, but also a major economic burden worldwide."  One suspects "pandemic" was chosen lightly.

The third study, from researchers at the University of Gothenberg (Sweden), echoed the Lancet results in that they found that having a low aerobic capacity (which is highly correlated with physical activity) had almost as much effect on health as smoking.  They followed a cohort of men born for some fifty years, giving them an extremely powerful set of data.

The men with the lowest aerobic capacity had a 42% greater chance of dying than the most fit segment, and a 21% greater mortality than those of average capacity.  Aerobic capacity was more important than high blood pressure or high cholesterol.  Again, only smoking had a greater impact on mortality.

As the lead researcher said, "We have come a long way in reducing smoking. The next major challenge is to keep us physically active and also to reduce physical inactivity, such as prolonged sitting."

None of this should be news.  Numerous studies have validated the positive impact exercise has on our health and well-being.  These impacts include not just the expected impacts on cardiovascular health but also reducing the risk of cancerhot flashes, depression diabetic retinopathy, and dementia, to name a few.

If exercise was a pill, some drug company would tout it as a miracle cure and make a fortune.

In fact, researchers are working on such a pill, which just illustrates that we'd rather take short-cuts to health.  New research confirms that our love/hate relationship with prescription drugs continues, with almost 60% of adults now taking at least one prescription annually and 15% taking at least 5 -- double the percentage just 12 years ago.

Meanwhile, the CDC reports that we weigh 15 pounds more than we did 20 years ago (alas, not because we're any taller).  About half of us get a gentleman's C on our aerobic exercise, but only 21% meet the federal physical activity recommendations,  Truth be told, about three-quarters of us don't exercise regularly.

Perhaps we need our doctors to prescribe exercise, like they would a prescription.  A study in the Canadian Medical Journal Association (CMAJ) proposed exactly that, specifically for several chronic conditions, including osteoarthritis, low back pain, Type 2 diabetes, COPD, and coronary heart disease.  The lead author noted: "Many doctors and their patients aren't aware that exercise is a treatment for these chronic conditions and can provide as much benefit as drugs or surgery, and typically with fewer harms."

One would expect that the impact would be even more powerful on those who have not yet acquired a chronic condition.

There is even an Exercise in Medicine initiative, managed by the American College of Sports Medicine, that encourages doctors to include physical activity in their treatment plans (and to use credentialed EIM programs and exercise professionals).

Leave it to our health care system to medicalize even exercise.

The analogy of physical inactivity to smoking may be illustrative.  Smoking prevalence peaked in the 1940's, with close to half the adult population smoking.  It took Surgeon General reports, "voluntary" bans on television ads, warnings on labels, and successful lawsuits to drop the rate to around 20% today.  However, we're still seeing the tail end of those earlier smoking rates, through the incidence of lung cancer, emphysema, and other disorders in those earlier generations.

We may need a similar campaign for more exercise (hmm, maybe a moonshot).

Look, we shouldn't need our doctors to tell us we need more exercise.  We know it.  We shouldn't need our employers to incent us to get it, through wellness programs.  We know it (and those programs have not proved particularly effective anyway).  We shouldn't need to go to an EIM "exercise professional" to get an EIM program.  We know how to exercise.  

This is not a failure of our health care system (or, as I prefer to call it, our medical care system).  This is our failure.  Certainly health care professionals should be encouraging us, and advising any of us with specific health issues how to exercise safely.  Certainly our friends and family need to be supporting us, and we them.  But it starts with us, for ourselves.

After all, we pay for it when we don't exercise.  We pay in higher costs for deductibles and coinsurance.  We pay in higher health insurance premiums.  We pay in higher taxes for social insurance programs.  Most of all, we pay in how we feel.  

Technology can help.  We have so many options about how we can track our activity, measure exactly how far we go, even socialize our efforts.  Games like Pokomon Go or Geocaching has shown we can even make it fun.

Now stop reading and go take a walk.