Tuesday, May 23, 2017

Rise of the Drones

For those of us of a certain age, we expected to be living in a Jetsons-type world, complete with flying cars.  That hasn't happened, but it is starting to appear as though the skies may, indeed, soon be full of flying vehicles.  It's just that they may not have people in them.

Welcome to the brave new world of drones.
Many people may have viewed drones as a toy akin to radio-controlled airplanes (indeed, that's how they've been regulated).  We're beyond that now.  Last summer PwC asked "Are commercial drones ready for take-off?"  They thought so, estimating the total available market for drone-enabled services at $127b

Many companies have already been testing use of drones for various kinds of delivery.  Domino's, for example, has tested drones to deliver pizza, and Chiptole delivered burritos (in partnership with Alphabet).   

The company everyone is waiting for, though, has been Amazon.  They've already piloted Prime Air Service in England.  It offers a large but limited set of items, stored in a specially designed fulfillment center, while promising delivery within thirty minutes, as if you were ordering a pizza. 

Here's their video:


I don't know how crazy I'd be about having my new Fire TV delivered to the middle of a wet field, as happened to the customer in the video, but one takes their point.  If you already thought Amazon was fast, be prepared to think again.

Bloomberg reports that Amazon has now opened up a drone research center in France, aimed at developing their own flight control system.  It is one thing to program drones to avoid stationary landmarks like buildings or hills, and it's certainly easy to imagine using transponders to avoid other drones, but Amazon is thinking about "non-collaborative flying objects."

A.K.A., birds.                                                                

As Paul Meisner, Amazon's vice president for global innovation and communications, told Bloomberg, "Geese will never be collaborative so we have to sense and avoid those obstacles."  He admitted that there are many regulatory hurdles ahead, which may take years to fully resolve, but vowed, "We’re not going to launch this until we can demonstrate its safety."

This is not going to all be about getting your books, or your socks, or even your new HD television faster.  It is going to impact many industries -- including health care.

And that impact has already started to happen.

Zipline International, for example, is already delivering medical supplies by drone in Rwanda.  They deliver directly to isolated clinics despite any intervening "challenging terrain and gaps in infrastructure."  They plan to limit themselves to medical supplies, but not only in developing countries; they see rural areas in the U.S. as potential opportunities as well.  Last fall they raised $25 million in Series B funding.  

Drones are also being considered for medical supply delivery in Guyana, Haiti, and the Philippines.  

And drone delivery is already being tested in more urban areas.  The Verge reported that Swiss Post, its national postal service, is working with two hospitals in Lugano to ferry lab samples between them, which Swiss Post claims is the first commercial deployment of drones in an urban area.  Its press release claimed that "the regular use of drones between the two hospitals will become an everyday occurrence." 

Similarly, Johns Hopkins has been testing drone transport of blood supplies, concluding that it is "an effective, safe, and timely way to get blood products to remote accident or natural catastrophe sites, or other time-sensitive destinations."

Airbus is developing the A-180 drone specifically to deliver medical supplies, especially for emergencies.  Its cargo capsule is "capable of transporting everything from medicine and antivenin to supplemental blood and even organs."  A company called Otherlab is going a different direction.  Wired reports that their drone will deliver its package -- then decompose, making it ideal for deliveries to humanitarian crises (or to battle sites, since Darpa helped fund them).  

Lest we focus too narrowly on the concept of drones delivering medical supplies, argodesign has proposed a flying ambulance, which could be operated as a drone or by a pilot.  If you've ever seen ambulances stuck in traffic and felt sorry for the patients relying on them, such ambulances could be the solution -- arriving faster and to locations regular ambulances could not reach.  

Their concept:



But for real impact, let's go back to Amazon.  CNBC's Christina Farr broke the news last week that Amazon was considering getting into the pharmacy business.  They reportedly have been considering the move for several years, but now are starting to hire experts in the field, including a business lead..  They already sell various medical supplies and equipment.

Amazon knows prescription drugs is a complicated market, but one that experts and consumers agree needs significant change, due to high prices that are further obscured by various middlemen, hidden rebates, manufacturer coupons, and health plan discounts.  Stephen Buck, cofounder of GoodRx, told Ms. Farr, "I think Amazon would introduce a lot of transparency to what drugs really cost," estimating that it could be a $25b to $50b market opportunity for Amazon.

Even for Amazon, that's a lot of money.

Put rapid delivery -- especially with drones -- together with lower and more transparent prices, and it is no wonder that the stocks of CVS and Walgreens took a hit when the news broke about Amazon's new interest.

Dan Diamond writes in Forbes that Amazon's entry could be a game-changer.  He says: "for all of the major new players eying the health care market — with Apple pushing to collect health data through the Apple Watch, or Walmart beginning to deliver care at its stores — Amazon's innovative plan is arguably best-positioned to fill an existing gap."

Can anyone imagine Amazon would have much patience with PBMs like Express Scripts or Optum?

Kevin Schulman, a Duke professor of medicine, is intrigued by other possibilities Amazon could take advantage of, telling the Washington Post: “If Amazon would know that you have diabetes or hypertension they could do a lot with that data.  In principle, they could set up a marketplace where they behave differently, with different rules and different privacy practices.”

Health care has been all-too-much a story of waiting.  That's quickly changing, with telemedicine, WebMD, retail clinics, and -- soon -- 3D printing and health care robots.  We can add health care drones to the list, allowing 30-minutes-or-less kinds of promises that we haven't even begun to tease out yet.

Bring on the drones!

Tuesday, May 16, 2017

Picture That

Mala Anand, SAP's President and EVP- Analytics, recently wrote, "data is the fuel for the digital economy."  We generate more data than ever before, are finding new ways to derive value out of that data, and organizations in most industries are realizing that effectively applying that value is critical for success.  Health care included.  

Our problem, though, may not be in either generating or analyzing all that data, but in visualizing it.

Dataconomy used the example of the weather, for which we have huge datasets and highly sophisticated prediction models, all of which have to get boiled down into the slick graphics we've come to expect from our local weatherperson.

It is not enough to have the right data or the right data scientists; "you also need someone who has domain knowledge of your business and the ability to effectively communicate information back to end users."

Co.Design reported on new research from Autodesk that help illustrate (pun intended) how visualizing data is "a crucial part of analysis that can reveal surprising things about your data." The research takes 12 seemingly similar datasets that end up having very different graphical representations, providing insights that might otherwise have been missed.
Source: Audodesk
A recent Health Catalyst article, by Huesch and Mosher made the case for more data scientists in health care, noting that, among other things:

  • 30% of the world's stored data comes from the health care industry;
  • Of the approximately 6,000 data scientists in the U.S., only 180 work in health care;
  • health care could use 10 to 20 times more data scientists.
If you're having trouble with the math (perhaps you need a picture!), a sector that is 20% of our economy and has 30% of the data only employs 3% of its data scientists.  That sure seems like a problem.  

The authors outline of the barriers that have led to this shortfall, outline the buy-versus-build dilemma health care organizations face when it comes to beefing up their expertise, but believe that
Putting these pieces together will help the overall health care sector to achieve the same much-needed improvements in cost, outcomes, access, and experience that the data revolution has achieved in so many other industries.
It may not be easy.  Health care faces fierce competition for data scientists.  IBM recently profiled how fast the field is growing, with annual job openings increasing by 364,000 by 2020 -- 2,720,00 in total.  
Source: IBM
Unfortunately, the talent pool is nowhere near what it needs to be.  PwC, working with the Business-Higher Education Forum, urged that we address the skill gaps for data science and analytics: 69% of employers want workers with such skills, but only 23% of educators say their graduates have them.  They repeatedly cited data visualization as one of the core competencies needed.  

Having a bunch of quants produce reams of spreadsheets with statistically meaningful analyses of zillions of numbers is all well and good, but may not do much to improve anything we do, unless the decision-makers can understand them.  Health care already has plenty of statistics, many of which clinicians do not make full use of and which most consumers do not understand.  

Let's face it; most of us are not good with numbers.  Most of us don't think in numbers.  Most of us think in pictures.

Data visualization is a new form of visual communication, helping to provide insights into large datasets.  If you've seen an infographic, you've seen one form of data visualization.  The University of British Columbia provided this overview on the field:


A key statement: "it provides insight into complex datasets by communicating their key aspects in more intuitive and meaningful ways."

To date, most data visualization has been in 2D, seen on a screen or piece of paper, but we're already seeing efforts to portray data in virtual reality, such as by "creative science studio" Kineviz.  Holograms may be next.

Health care, despite its paucity of data scientists, is trying to embrace the data visualization.  For example, the American Academy of Family Physicians just issued their Vision for a Principled Redesign of Health Information Technology, describing their vision for how HIT can support improved care.  Data visualization was one of the first priorities listed, as they predict it will "...make it easy for the clinician to see patterns and make insight..."

Abhinav Shashank, cofounder of Innovaccer, sees data visualization as key to the future of health care:
Once physicians move away from long, incomprehensible data flows, and find an alternative that helps them instinctively read, isolate, and act upon the insights, only then can we be one step closer to a data-driven, value-based care. 
The University of Michigan Center for Health Communications Research, through funding by the Robert Wood Foundation, founded Visualizing Health,  A video explains their purpose:

Their interest is not just academic; they want to help people do their own data visualization.  They provide a toolkit for consumers and organizations to better display data, including The Wizard and a gallery of visual approaches to data.

Health care is desperately trying to reshape itself from a hands-on, more-art-than-science, physician-centered enterprise to a data-driven, value-based, patient-centered science.  We're not there yet.  Big data is expected to play a crucial role in this transformation, but, as Sutter Health's CHIO Sameer Badlani recently said, "Big data has moved on from infancy.  It's in the terrible twos right now.  We're still trying to figure out what to do with it."

A large part of that has to be how to explain all that data to its various users -- practitioners, executives, and consumers.  Data visualization will be key.  Health care may or may not need more doctors, but it certainly needs more innovative business models, better technology designers, and more data and computer scientists.

And data visualization experts.

Google has invited designers and artists from around the world to tell better stories about Google data through data visualization.  What health care organization is ready to do the same with their data?

Wednesday, May 10, 2017

Ask More, Listen Better

A new study in JAMA suggests that nearly one-in-three drugs approved by the FDA between 2001 and 2010 had post-market safety issues, which caused safety communications to physicians and consumers, "black-box" warnings on labels, and drug withdrawals.

It is not clear how many patients may have died or otherwise harmed by these issues.

Some complain the FDA takes too long to approve new drugs, but Kaiser Health News pointed out that the same Yale researchers had previously found that the FDA actually approves faster than European counterparts, and the study found that clinical trials typically involve less than 1,000 patients, and usually for less than six months.

Lead author Joseph Ross, M.D., noted: "No drug is completely safe, and during premarket evaluation, we are not going to pick up all the safety signals," and urged "that we have a strong system in place to continually evaluate drugs and to communicate new safety concerns quickly and effectively."

Dr. Eric Topol, who was not involved in the research, told the Washington Post that he was troubled but not surprised by the findings, and similarly suggested: "Why not have a standard where we put every new drug under watch, and see if we could catch a problem before the drug is widely advertised?"

Why not indeed?

In fact, why just new drugs, and why only drugs?

Take medical devices.  The FDA has a formal process for medical device reporting, which they say results in "several hundred thousand medical device reports of suspected device-associated deaths, serious injuries and malfunctions."

That sounds ominous.

Still, though, these reports require that the manufacturer report instances when their device "may have caused or contributed to a death or serious injury," which requires that someone -- a facility, a doctor, patient, etc -- tell them.  Of course, deciding what "caused or contributed" to a death or serious injury is probably as unclear as what entails a "serious injury."

Last year the FDA cited 12 hospitals for failing to report such issues, while also warning that "we believe that these hospitals are not unique in that there is limited to no reporting to FDA or to the manufacturers at some hospitals."  Reporting by the actual patients and their families is voluntary, and most of us probably would not think of doing so in most circumstances.

Even worse, as Elizabeth Rosenthal profiled in An American Sickness, manufacturers can sometimes avoid FDA approval entirely, as happened with, for example, hip implants and surgical mesh.   Such problems may never be reported, or only after damaging enough patients that someone finally realizes there is a problem.

One has to believe more doesn't get reported than does.

This lack of ongoing oversight is a pervasive problem in our health care system.  Ever read those warning labels on drugs, which detail all the potential side effects?  Do they make you feel better, or worse?  Do they help you understand how likely you are to have them?

Chances are, none of the clinical trials had patients with your specific set of health issues or with your exact combination of other medications, so it's anyone's guess how you might respond to a drug, new or old.

More to the point, if you do suffer any side effects, what are you supposed to do?  You may just accept them.  Or perhaps tell your doctor, who maybe switches drugs, or maybe not.  In any event, probably no one is tracking or reporting the incidence of most such side effects.

This is not just a problem with drugs and devices.  Maybe you had a surgery.  If you ask your doctor before the surgery how back to "normal" you can expect to get, when, chances are he/she can't tell you -- and if he/she does, you'd be well-advised to question the source of those numbers.  There may be statistics on, say, how many patients get re-hospitalized and/or get an infection, but as to when you'll be walking without a limp, it's pretty subjective.

We track loads of "quality" metrics and conduct numerous patient satisfaction surveys, but not many people believe we're actually measuring quality, much less how a specific patient is doing today.  Nor do we have any firm idea what that patient should expect to feel like tomorrow.

Our mechanisms for tracking how patients are doing after we do something to them are minimal at best.  Physicians tend to rely on patients calling with any problems and on follow-up visits, but both leave lots of cracks to fall through -- and even they do not usually end up being recorded in any useful way.

This kind of "squeaky wheel" reporting is antiquated.  It comes from an age when it was hard to effectively track how people were dealing with their heath issues, and impossible to make sense of the mass of data that would be generated even if it was collected.

None of that is true now.

We have wearables.  We have online surveys.  We have medical device registries.  We have automated calls and texts.  We have patient review sites like Yelp (which may do better than formal surveys in tracking patient issues).  We'll soon have Internet of Things options that we can barely even imagine, from devices we won't even realize are there which are "listening" to us 24/7.

We should be able to track almost anything we wanted to about how a person is feeling, in real-time or near real-time.

No human could track all the data that will be generated, much less already-to-busy physicians.  That's OK; we have AIs that are becoming more and more able to sift through all this data and drawing meaning from it.  AIs could quantify the likelihood that you would get a side effect from a new drug, determine that you are suffering from a side effect from that drug, tell you when you should be able to walk how far after your knee implant.   They'll be able to alert your physician when something appears off.

Our current approach -- relying on someone to complain about problems -- is a way to uncover problems, but it is not nearly as effective as actively collecting and analyzing the data that would reveal the problems.  The good news is that we now can.  The bad new is that we are not.

We need to ask more, and listen better.

Tuesday, May 2, 2017

How About Some Meatballs?

You've probably heard of IKEA, the international retail giant that is known for its modernist design aesthetic and its clever some-assembly-required furniture.  You may have wandered around one of it cavernous stores or received their catalogs.  You may even have guessed that IKEA is the world's largest furniture retailer, with some 400 stores in almost 50 countries and annual sales of over $36b.

What you may not realize that IKEA's restaurant business has annual revenues of $1.8b.


Fast Company reported that IKEA has started taking its food division -- which includes cafe/restaurants and Food Markets -- more seriously.  Michael La Cour, the division's managing, told them:  
This might sound odd, but it’s almost something we didn’t notice.  But when I started putting the numbers into context of other food companies, suddenly I could see, well, it really is not that small.
At the time, in 2013, those revenues were $1.5b, but by 2016 were up to $1.8b.  OK, that's not McDonald's territory, but well-known chains like Five Guys, Steak-and-Shake, or P.F. Changs would salivate at those numbers, or at the 8% annual growth.  IKEA serves some 650 million diners a year, and are known for their family-friendly prices.

And, of course, for their meatballs.

Business Insider calls them "one of the most underrated restaurant chains in America."  LA food critic Merrill Shindler noted that the Burbank IKEA's restaurant holds 800 diners at a time, "But show up on a Saturday at lunchtime and perhaps twice and even three times that many are lined up, cheerful and flushed with the joy of consumption, and hungry for Swedish meatballs."

Oh, two other facts that should be of interest.  IKEA estimates that 30% of their restaurant customers are coming there just to eat, not to shop,  The cafes may have started as a way to help keep people shopping longer, but they've become a dining destination for some customers.


Which leads to the second interesting point: they've tested standalone pop-up restaurants in several cities, including London, Paris, Oslo and Toronto.

Curbed reports that,IKEA demurred on expansion plans for its food division, saying no decisions on standalone restaurants have yet been made, but one would have to guess that it is much less expensive to open up an IKEA restaurant than a new IKEA store, with pop-up restaurants especially cheap to test.  

And then I think about hospital food.

That's not entirely fair, of course.  Many hospitals have made efforts to upgrade at least the appearance of their cafeteria, to make the food selections healthier and more appealing, and to give patients more control about what their choices are.  Still, though, as Dr. Joel Kahn wrote in the Huffington Post last year, "There is wide agreement that the quality and choices of food at most hospitals is abysmal."

The Physicians Committee for Responsible Medicine scored the food menus of multiple hospitals, finding significant variation in how healthy their offerings were.  In the previous year's report, they detailed how many hospitals contract with fast food firms under terms that they say helps promote unhealthful foods.

It is not a pretty picture.

Two things I'm pretty sure of: unlike IKEA's cafes, no one is choosing to dine in a hospital cafeteria, and no hospitals are thinking about opening their own free-standing restaurants, pop-up or not.

To be fair, institutional food is hard.  Not many people like school lunches or find stadium food a good value, and let's not even talk about prison food.  In hospitals there is the additional problem of trying to balance the needs of sick patients versus the tastes of their presumably healthier visitors.  The end result is often food that no one likes and that no one would stay longer for, much less come for.

You have to wonder how IKEA would address the problem.  Or, as they might see it, the opportunity.

Many retailers offer some food options.  Still, though, no one is praising Walmart or Costco food, and most of the cafes that large department stores used to offer have gone by the wayside.  IKEA knew it had hungry customers and wanted to help them with that, managing to do so with good quality and affordable prices.

It wasn't their business but they made it their business, and did it well enough for it to become a business on its own.

There are two distinct lessons that health care organizations should learn from this:

  1. If you're going to do something, do it well.  Hospitals have to serve food, and their "customers" don't have much choice about eating it, but that's no reason to do it badly.  If a furniture retailer can make a dining experience delightful, why can't a hospital?  
  2. Be open to opportunities: IKEA wasn't really in the food business, much less the restaurant business.  But once they realized its potential, they weren't afraid to embrace it.  No "but we're in the furniture business!" objections.  They were good at something, customers were seeking them out, so they didn't let their past dictate their future.
This is not a suggestion for hospitals to get in the restaurant business (although it is a plea for them to at least do their food services better!).  It is, rather, a suggestion that health care organizations -- not just hospitals -- do a better job of identifying and taking fuller advantage of their assets and opportunities.  

Hospitals have been on an consolidation/acquisition spree, both horizontally and vertically.  Much of that, though, seems to have been more about locking up their existing markets than opening up new ones.  Certainly we have hospital systems like UPMC or the Cleveland Clinic expanding internationally, many health systems opting to get in the health insurance business, lots of hospital-run health clubs, and much investment in new technologies.  

Still, though, how many are doing something that really makes you think "well, that's interesting!"?  Like IKEA's expanding into the restaurant business.  

If meatballs prove to be IKEA's breakthrough asset into a new business, which of their assets are health care organizations overlooking?

Tuesday, April 25, 2017

Clicks-and-Mortar: Health Care's Future

The woes of the retail industry are well known, and are usually blamed on the impact of the Internet.  Credit Suisse projects that 8,600 brick-and-mortar stores will close in 2017, which would beat the record set in 2008, at the height of the last recession.  There are "zombie malls," full of empty stores but not yet shuttered.

And then there's health care, where the retail business is booming.

In a recent Wall Street Journal article, Christopher Mims set forth Three Hard Lessons the Internet is Teaching Traditional Stores.  The lessons are:
  1. Data is King
  2. Personalization + Automation = Profits
  3. Legacy Tech Won't Cut It
It's easy to see how all those also apply to health care.

But health care is different, right?  Patients want to see their physician.  That physical touch, that personal interaction, is a key part of the process.  It's not something that can be replicated over a computer screen.  

Yeah, well, the retail industry has been through all that.  Retail once primarily meant local mom-and-pop stores.  They knew their customers and made choices on their behalf.  Customers had little say in the choice of products, nor much ability to compare prices.  But it was all very personal.

The 19th century saw innovations like mail order catalogs (e.g., Montgomery Ward, Sears Roebuck) and department stores (e.g., Macy's, Wanamakers, Marshall Field's), while the 20th century added shopping malls.  Each helped distance consumers from their local merchants.  

Still, though, when Amazon came along, booksellers were adamant: no one wants to buy books sight unseen!  When that truism was proven false, other sectors of retail had their turn in the Internet spotlight, and the last twenty years of results haven't been pretty for them.  

It turns out that the personal touch isn't quite as important as retailers liked to think.

As for health care, it seems to be surviving the Internet onslaught pretty well.  WebMD alone has more monthly visits than to all the doctors in the U.S., but any declines in doctor visits are more likely due to economic factors than to internet searches.  Telemedicine has been touted as one of the next great health care innovations, but research suggests that, while it may substitute some in-person visits, it more than offsets that with new visits.  

Health care is following some historical retail trends.  Independent physician practices are quickly getting purchased by health systems,  which are becoming the department stores of health care -- down to their sprawling suburban campuses and their vertical integration of services.  Even independent practices increasingly rely on impersonal billing and practice management companies.  Everyone has computers, especially for the money, but few have really changed their processes to take full advantage of them.

It's very 1960s in the health care retail world.

As for that "personal touch," well, a Harvard study found that the average doctor visit takes 121 minutes of patients' time, only 15-20 minutes of which is actually spent with the doctor.  That's after being able to actually get an appointment, which can take weeks.  


That's not the kind of personal experience that consumers really want.

So why hasn't health care been more disrupted by the Internet?  Well, for one thing, when you buy a book online, your state doesn't require that you buy it from a bookstore that is licensed by its not-so-friendly licensing board, as is true with seeing doctors over the internet.  The state medical licensing boards are ostensibly there for our protection, but time and time again have acted as though protecting physicians' livelihoods is their main concern.

Strike one for disruption.

For another thing, we (usually) trust our doctors.  Then again, we used to trust recommendations from bookstore staff too.  That is, when they had time for us, if they seemed knowledgeable, and if they were making recommendations that fit us rather than just their own preferences.  AI-based recommendations from Amazon may not be as good as those from a really good bookstore employee, but are probably a lot better than those from the mediocre workers you were more likely to encounter.

Think the same thing won't happen when AI gets better at diagnoses?

Let's go back to Mr. Mims three lessons and see how they apply to health care:

  • Data is King: Health care collects a lot of data, and will get even more with all the new sensors.  Not all of that data is meaningful, much less actionable.  Health care providers sometimes share your data, but not always with your consent and rarely to your direct benefit.  All of that will change.  For example, Google's Verily has started Project Baseline to do in-depth tracking of 10,000 volunteers.  Their motto: "We mapped the world.  Now let's map human health."  The big tech companies know their customers very well and tailor interactions accordingly; health care must as well.
  • Personalization + Automation = Profits: Mr. Mims cited Amazon Go as an example of how these two features could boost margins, and Information Age similarly described retail experiences based on more automation and better knowledge of customers.  Meanwhile, we're stuck in waiting rooms, filling out forms we've already filled out elsewhere. That is not a personal experience that can survive in the 21st century.  It has to be smoother, faster, and friction-less.  
  • Legacy Tech Won't Cut It: EHRs that no one likes.  Claims systems that take weeks to process a claim.  Billing processes that produce bills no one can understand.  Records that are siloed when we want them shared, yet all too open to being hacked.  The list could go on almost indefinitely.  All too often, health care's tech is not ready for prime time.  
The question is, are health care's leaders learning these lessons?

The future of retail appears to be in "clicks-and-mortar" (or "bricks-and-clicks").  Amazon is opening up physical stores, while Wal-Mart is beefing up its online credentials.  They and other retailers know that consumers want things fast, sometimes in person and sometimes not, like options, and always are paying attention to the cost.  It takes both online and in-person presence.

Health care can act like B Dalton or Borders, assuming until it is too late that their consumers will visit them in person, because they always had.  Or it can act now to jump to the data-driven "clicks-and-mortar" approach that other retail businesses are moving to.  

Health care organizations which get that right will be the one to survive.  The rest are zombies, dead but not aware of it.

Tuesday, April 18, 2017

Think Bigger. Fail Often.

Alan Kay recently outlined some of the principles that he thought made Xerox's PARC so successful (if you don't know who Alan Kay is or why PARC was so special, you should try to find out).  One was: "'It's baseball,' not 'golf'...Not getting a hit is not failure but the overhead for getting hits."

That doesn't quite square with my impression of golf, but I take the point.  It's about the price of success.

As psychologist Dean Simonton pointed out in Origins of Genius: "The more successes there are, the more failures there are as well."  "Quality," he wrote, "is a probabilistic function of quantity."    

We talk a lot about innovation these days, especially "disruptive innovation."  Why not?  It sounds cool, it allows people to think they're on the cutting edge, and it often excites investors.  But perhaps we've lost sight of what it is supposed to actually be.  

Vuki Vujasinovic recently wrote in Forbes that: "Almost every use of the phrase ‘disruptive innovation’ as we see it today is wrong."  He cited several such examples, including Porsche and even Uber, and reminded us that the phrase doesn't just mean "change" or a new entrant in a market.  

Mr. Vujasinovic urged would-be innovators to be more precise with their claims, reserving "disruption" for true disruption.  Instead, he suggested: "Say you are doing something different, say you are changing the way something is done, but don’t say you’re disrupting something just because it’s a nice word you want people to repeat."

To go back to the baseball analogy, in health care these days we don't have a lot of home run hitters.  We have a lot of companies who are single hitters -- or maybe are just trying to bunt.  There are too few people swinging for the fences.

And even fewer trying to invent a brand-new game, one better suited for the 21st century.

Some examples may help illustrate why.

Wired published an excerpt of Rutger Bregman's new book Utopia for Realists, in which he gives several examples (such as the 2008 financial crisis) where "cognitive dissonance" kept well-educated, intelligent people from seeing what should have been obvious problems.  We're so set in our ways that we keep going down the same track even as it should become increasingly obvious that it is a dead-end.  As a result:
When reality clashes with our deepest convictions, we’d rather recalibrate reality than amend our worldview. Not only that, we become even more rigid in our beliefs than before.
I.e., no one likes our health care system, it's demonstrably not doing a very good job and doing so at a very high cost, but, hey, let's just tinker at the edges.

Professor Bregman does believe that new ideas can change the world, but it may take some sudden shocks and persistent objectors to get people to change their mindsets.  Our trouble, he warns, is that "we inhabit a world of managers and technocrats," who focus on the problems and solutions at hand.

In other words, singles hitters.  Never fear, though, he reminds us: "Ideas, however outrageous, have changed the world, and they will again."

John Nosta similarly warns in Psychology Today that innovation is too often throttled by "the mushy middle," usually in the name of collaboration.  Innovation is not about collaboration and certainly not about consensus, because: "Innovation is not an intellectual average."

He asserts that we need those "high performers" and their sometimes outrageous ideas, instead of "having their fragile voice crushed by generic consensus."

Lastly, in Fast Company, a trio of researchers noted the subtle power of default choices.  How choices are presented -- like opt-in versus opt-out -- has a strong impact on decisions.  Organ donation is a classic example, where the percentage of people agreeing to being an organ donor is significantly higher (like 80% higher) when it is presented as the default choice.

Disclosure about the options doesn't help as much as we'd like to think, because, "Research shows that making an option the default leads people to focus on reasons to accept the default and reject the alternative first and foremost."

We may not always realize the default options we're being given, especially when confronting a highly complex, inter-dependent system like health care.  We think we're changing something, but usually we're only doing so within the default options the existing system gives us.

John Nosta also writes about how Apple and Google's recent forays into health care should be a wake-up call for the life science industry, "which oftentimes has relied on the snooze function of line extensions and extended-release drugs as the source of income and innovation."  Those two companies' "expectedly unexpected" innovation in this area is welcome, but even they may be too entrenched into the existing approaches to have truly disruptive impact.

So, all you would-be health care innovators: are you prepared to fail, lots of times, before you succeed?  Are your ideas truly disruptive, or simply twists on what we've been doing?  Is yours a bold vision of what could be, or is it of just slightly further down the road that we're already on?

For example, when I read about an interesting start-up Better, which seeks to help consumers with their health insurance claims -- fighting with insurers and providers to ensure consumers only pay what they should -- I have two conflicting thoughts:

  1. Consumers certainly need help like this;
  2. I wish they'd focused instead on making the underlying problem(s) go away.
I love telehealth.  I love digital health.  I love direct primary care.  I love having AI help doctors.  They -- and numerous other examples -- are all important developments that, arguably, will help make our health care system better.

But they are not disruptive innovations.  They are not swinging for the fences.

Our health care system is so inefficient and so wasteful that it's almost too easy for innovators to pick a problem and make it at least less bad.  It certainly needs that.  If that's all they are looking for (and to get their piece of the $3 trillion pie), well, you can't hardly blame them.  

Me, though, I'm rooting for the innovators who are swinging big and are willing to miss a lot.  They're the ones who will eventually get us to the health care system of the future.

Tuesday, April 11, 2017

Losing the Doctor Lottery

Donna Jackson Nakazawa's insightful Health Affairs article "How to Win the Doctor Lottery" is, in turn, sad, frightening, wise, and hopeful.  She recounts some of her personal travails in finding the right doctors, the ones who will truly listen and become "a partner on my path to healing," and offers several suggestions about what has to happen for us to have more chance to "win."  

The real question, though, is not how to win the doctor lottery we find ourselves in, but why we're playing it at all.

Getting the right doctor is hard.  Consider the following:
  • It's easy enough to find out where a physician went to medical school and did their residency.  It's not as easy to know what the best medical schools or best teaching hospitals are, other than by reputations (that may or may not be deserved).  Maybe your doctor went to Harvard and did their residency at Johns Hopkins, but, otherwise, you may not be so sure about how good their training was.
  • Even if you did know how good their place of training was, you still wouldn't know how your doctor did there.  They might have been last in their class.  Even if you did find this out, you don't know if it is better to have done worse at a "better" school or well at a lesser school.  
  • In fact, it's not really clear that where one went to medical school or did their residency, or how well one did in those, has any measurable impact on actual competence as a physician.
  • Being board certified as become an accepted measure of basic competence in a specialty, but there is fierce debate between physicians and the specialty boards as to whether the process -- particularly the ongoing maintenance of certification (MOC) -- does anything of the sort.  
  • It would be good to know if a physician has had drug or alcohol impairment issues, has been charged with sexual improprieties with patients, or has a large number of malpractice suits, but don't expect to be able to find any of those out.  The medical licensing boards who should know aren't likely to tell you.   
  • There are many measures for "quality" when it comes to physicians, but none that are considered definitive, many of which are not meaningful to consumers, and all-too-few of which focus on what we should care most about: patient outcomes.   
  • Even for data that should be readily quantifiable -- e.g., how many of these procedures did Dr. X do?  How many patients die under Dr. X's care?  How many patients with my diagnosis does Dr. X treat? --  are rarely actually discoverable.  
  • There are some physician satisfaction scores and patient ratings, but most of those are looked upon dubiously, due to low reporting volume and likelihood of being skewed by non-clinical factors (like wait time or how quick prescriptions were given).
  • When your physician recommends a treatment or a drug, you don't know if the physician is doing so because the latest research solidly demonstrates their efficacy.  The physician may be being paid on the side by a drug/pharma company, may be influenced by the most recent drug rep visit, hasn't kept current on the research or simply doesn't accept it because it wasn't the way he/she was trained.  
  • As skilled as you may be at researching doctors, you may still find yourself in an emergency or other rapidly developing situation, in which you end up being treated by doctors you haven't had time to research and have never heard of. 
It's a wonder any of us ever find the "right" doctor.

Calling choosing the right physician a "lottery" may be being unfair to lotteries.  At least lotteries disclose the odds of winning, low though they might be, and it is usually clear very quickly whether there is a winner and who it is.  

In health care, you may never really know if you've won or lost, or may only find out much too late to do anything about it.  You may have gone through unnecessary pain and suffering, you may have lost years of better health, or you actually die.  

And, of course, you'll get billed for everything all along the way.

The even sadder thing is that it's like this throughout health care.  It may be marginally better for hospitals, in least in terms of more available data, but the usefulness of even that is not entirely clear.  For other types of health care professionals or institutions, information is even less available than for physicians.

Similarly, data on efficacy of treatments, procedures, or drugs is highly variable, often not disclosed to or discussed with patients, and usually not easily understood by them.     


In the end, most of us select a doctor based on the recommendations of friends and family, or another doctor, all of which are likely to be subjective as well.  And if it is true that most of us have confidence in our current doctor, that may be because we've switched from doctors in whom we lacked it (a phenomenon that seems little tracked).

It's still a lottery.

Most people who play the lottery know their odds of winning are low, and aren't betting their financial future or their lives on it.  For most of us, most of the time, picking the right physician is not a life-or-death decision either.  But when it is, we'd all like the decision to be more than random luck.

It is like the scene in WarGames, where the computer concludes the only way to win is not to play:


We don't have a data-driven health care system.  We don't have a performance/outcomes-driven system.  We tolerate it because we usually don't realize it, because most of the time it doesn't impact most of us.  But those are poor excuses.  We can, and should, demand better.

Playing the lottery is not a sound financial strategy, and it shouldn't be our strategy for getting heath care either.  

Wednesday, April 5, 2017

That Does Not Compute

OK, you use your smartphone all the time: you use the latest and greatest apps, you can text or tweet with the best of them, you have the knack for selfies, and so on.  You probably also have a computer, tablet, and a gaming system, each of which you are also very proficient with.  No question: you are a whiz with electronic devices.

But, if you're like most of us, you don't really know how or why they work.

Maybe that's OK.  Most of us don't know how our cars work either, couldn't explain how heavier-than-air flight is possible, have no idea what the periodic table means to our daily lives, and would be in trouble if our lives depending on us making, say, bricks or glass.

Still, though, as Captain Kirk once said (in a very different context), you have to know why things work.
We're not all going to become computer programmers.  Everyone doesn't need to major in computer science.  But we could all use to have a better understanding of how and why computers -- or, at least, computer programs -- work.

Welcome to computational thinking.

The concept was introduced by Jeannette Wing in a seminal paper in 2006.  She suggested that it was a fundamental skill that should be considered akin to reading, writing, and arithmetic -- learning how to solve problems by "reformulating a seemingly difficult problem into one we know how to solve, perhaps by reduction, embedding, transformation, or simulation."

She further clarified that it has the following characteristics:
  • Conceptualizing, not programming
  • Fundamental, not rote skill
  • A way that humans, not computers, think
  • Complements and combines mathematical and engineering thinking
  • Ideas, not artifacts
  • For everyone, everywhere.
Dr. Wing believes we've come a long way since her manifesto, and she may be right.  For example, Microsoft sponsors Carnegie Mellon's Center for Computational Thinking, and Google offers Exploring Computational Thinking, "a curated collection of lesson plans, videos, and other resources on computational thinking (CT)."  It includes an online course for educators.

A new initiative, Ignite My Future, wants to train 20,000 teachers to help make computational thinking a fundamental skill, hoping to engage a million students over the next five years.  One of the last initiatives President Obama announced was the Computer Science for All Initiative, providing $4b to improve K-12 computer science education (how it survives the new Administration remains to be seen).

A recent New York Times article, notes that, while the number of computer science majors has doubled since 2011, there is growing appeal to learn more about computer science by non-CS majors: "Between 2005 and 2015, enrollment of non-majors in introductory, mid- and upper-level computer science courses grew by 177 percent, 251 percent and 143 percent, respectively."

There is now an Advanced Placement course Computer Science Principles that "introduces students to the foundational concepts of computer science and challenges them to explore how computing and technology can impact the world."


The Times also profiled a number of ways that "non-techies" can learn elements of computational thinking, because "Code, it seems, is the lingua franca of the modern economy." The options include CS+X initiatives in college, a number of intensive "boot camps," and an increasing number of online courses, such as through Coursera, edX, and Udacity.   

Sebastian Thrun, co-founder and chairman of Udacity, argues that this kind of thinking is important for everyone because: "It’s a people skill, getting your brain inside the computer, to think like it does and understand that it’s just a little device that can only do what it’s told."

Still, computational thinking is not a panacea; as Shriram Krishnamurthi, a computer science professor at Brown, warned The Times, in our current culture, "we are just overly intoxicated with computer science.”

One of my favorite approaches to demystifying programming, Raspberry Pi, has sold some 12.5 million of its ultra-cheap, ultra-simple computers, making the 3rd best selling "general purpose computer" ever.  

Do a search for Raspberry Pi and you'll find thousands of examples of things people are doing with them, from simple tasks that children can do to sophisticated hacks.  Heck, someone has made a LEGO Macintosh Classic using a Raspberry Pi.

There's a new industry in toys for children that help teach coding, as The New York Times also reported. including Cubetto (which, at $225, is a lot more expansive than Raspberry Pis).  

All of which is to say, there's getting to be fewer and fewer reasons why people don't learn computational thinking.

And health care sure could use some more of it.

Health care likes to think of itself as a science, and it has many trappings of science, but even in the 21st century it remains much more of an art.  After all, this is the industry in which it was just reported that 20% of patients with serious conditions have been misdiagnosed -- in fact, most people are likely to experience at least one diagnostic error in their lifetime -- and in which we have an "epidemic" of unnecessary care.

It is an industry in which the technology often frustrates both the providers and the patients (e.g., EHRs and mammograms, respectively), where design is confusing at best and harmful to patients at worst.   It is an industry in which the coding has gone beyond arcane to incomprehensible,  

And it is an industry where there is surprisingly little data on efficacy, even less agreement about how to measure quality or value, and little training to help clinicians interpret or explain the data that does exist.  It is an industry that is bracing for its era of Big Data, and may not be at all ready.

So, yes, some computational thinking in health care certainly seems like it would be in order.

Thursday, March 30, 2017

I'll Pay For You, But Not Them

Elizabeth Rosenthal's searing article about medical billing, adapted from her forthcoming book An American Illness, is well worth a read.  Its topic of sophisticated medical billing/upcoding -- done by organizations ostensibly acting in the best interests of patients and often under the guise of a non-profit status -- is also worthy of a discussion itself.  This is not that discussion.

What jumped out to me (and to many others, on Twitter and elsewhere) was the following indictment:
In other countries, when patients recover from a terrifying brain bleed — or, for that matter, when they battle cancer, or heal from a serious accident, or face down any other life-threatening health condition — they are allowed to spend their days focusing on getting better. Only in America do medical treatment and recovery coexist with a peculiar national dread: the struggle to figure out from the mounting pile of bills what portion of the fantastical charges you actually must pay. It is the sickness that eventually afflicts most every American.

Which leads me to crowdfunding.

Crowdfunding is hot.  Sites such as GoFundMe, Kickstarter, Indiegogo, or YouCaring are provide platforms for people requesting money to pitch their case, and for potential donors to see them and, if so inclined, to contribute.  The market was estimated at $34b in 2015 (about half of which was in North America), and is projected to grow at an annual compounded rate of 27% from 2016-2020.  It's big business.

Although the Affordable Care Act has sharply reduced the number of uninsured, the facts are that almost 30 million remain uninsured, health insurance deductibles continue to rise rapidly, and almost 70% of Americans have less than $1,000 in the bank to cover "emergency bills -- such as medical bills.

It's no wonder that crowdfunding has become popular.

The Pew Research Center found that, in 2016, 22% of Americans had contributed to a crowdfunding project, while another 41% had at least heard of crowdfunding.  About two-thirds of the contributions had gone to help someone in need; mostly commonly, a friend, friend-of-a-friend, or family member.  Only 3% had created such a campaign for themselves.

Assistance with medical expenses is a leading type of campaign.  Some 70% of GoFundMe's campaigns are in the medical category, CEO Rob Solomon told Esquire.

This seems like a good thing, right?  Matching up people who need help paying their medical bills with people who can help them?  It certainly can be, but it also has its share of problems.

For one thing, it often doesn't succeed.  A University of Washington study examined 200 GoFundMe health expense campaigns, and found that 90% did not reach their goals.  On average, they only raised 40% of their target; 10% netted less than $100.

The authors didn't pull their punches, warning that crowdfunding could "deepen social and health inequities in the U.S. by promoting forms of individualized charity that rely on unequally- distributed literacies to demonstrate deservingness and worth."

A recent Viewpoint in JAMA, by Young and Scheinberg, echoed these concerns.  They acknowledged that such campaigns can be effective, and can make the process of matching donors with need more efficient.  They raised several concerns, such as the role of physicians in such campaigns, especially if the information the campaign presents is inaccurate or misleading.

However, one of their most powerful concerns is the following:
it is important to recognize potential for unfairly advantaging those with the means to engage with online tools and tap into large social networks, which may lead to an underrepresentation of cases with the greatest need in which patients lack the tools to coordinate effective crowdfunding campaigns.
In other words, funds may not go to the most needy, but rather to the most media-savvy.

Esquire devoted an article on this problem, aptly headlined Go Viral or Die Trying.  It leads with the story of Kati McFranland, who confronted Senator Tom Cotton at a town hall event about coverage for pre-existing conditions.  She was articulate, attractive, had a real need -- and got national media exposure.

As media coverage boomed, so did her YouCaring campaign, going from $1500 to close to $50,000.

The article also cited a family who hired a professional photographer to create a video for their daughter's campaign; it helped them eventually raise $4 million.  GoFundMe's Solomon said: "A picture is worth 1,000 words, a video is worth maybe a million, It's really a storytelling platform, the more interesting and compelling the story the better these will do."

So, crowdfunding success may be based less on need than on how attractive you (or your children) are, how much you look like the people with money, how professionally done your campaign is, and how large your social media footprint is.

If any of that sounds fair, then our current health care system must also sound like the epitome of fairness.

Maybe that's just life in the 21st century.  Maybe that just the consequence of social media; it's hard to engage, and some causes and some people are simply more appealing -- most deserving or not.  Maybe decrying the potential unfairness is about as pointless as decrying our wealth inequalities.

But maybe not.

Look, even in the United States, we don't do organ transplants by who pitches the most appealing story, or even who has the most money.  We established UNOS to take (most of) those kinds of subjective factors out of who gets a life-saving transplant.  UNOS matches available organs with potential recipients based on a variety of objective factors; social media footprint is not one of them.

We need a UNOS for assistance with medical expenses

It wouldn't be easy, but UNOS wasn't UNOS overnight.  It took decades to become what we know as UNOS today.

At the least, a crowdfunding UNOS could take into account severity (and expected duration) of the medical condition, size of the medical bills, and ability to pay.

Oh, and back to Ms. Rosenthal's findings: no one should have unpaid bills based on charges.  Provider charges are absurd at best and outrageous at worst.  Health care providers need to be muscled into limiting their charges to their most common insurance payment rates for people without insurance, and for people with low incomes.

Crowdfunding is cool.  For entrepreneurs, artists, or social causes, it is a great way to get access to capital.  There's an intriguing role for crowdfunding loans -- not donations -- to people who need cash flow assistance with their health care expenses.

But it's not how we should be funding health care expenses for people who can't afford them.