Wednesday, May 31, 2017

Building a Better Health Care System

Several Kaiser Permanente executives recently urged that we stop wasting patients' time.  They cited the ultimately tragic example of Jess Jacobs, who used her Six Sigma expertise to calculate that only 4.75% of her outpatient visits and 0.08% of her inpatient stays were spent actually treating her conditions.  They then outlined how they've re-engineered some of Kaiser's processes "to upend traditional paradigms and make saving our patients’ time a part of our standard quality measures."

That's a start, but, if we're going to re-engineer health care processes, let's really re-engineer them.  The future is patient-driven, on-demand, and just-in-time.

Hey: it's the 21st century.  We have computers and smartphones, we have unobtrusive sensors, and we're beginning to have meaningful artificial intelligence (AI).  The health care system shouldn't still be built around waiting or even on in-person contact.  It may still include those, but they should be the exception, not the norm.

Let's look at what it might look like:

  • You wake up in the morning and will already have more information about your health than your doctor does now, between, say, biosensors on your skin, ingestible sensors,  even smart toilets.  
  • All that data will go to your personal health assistant, such as Baidu's Melody or  It will know your norms, understand when something appears off, and listen to your (health) complaints.  It will give you a good idea what might be wrong and what you should do about it.  Perhaps most importantly, it will tell you when you need to consult which doctor.
  • The first stop will usually be to consult an AI "doctor."  It be available 24/7, and will have access to all your data and all the deep learning only AIs can accumulate.  
  • If you do see a human doctor, chances are it will be first via a screen (or VR/AR).  They will be the best available expert for your problem; not just locally, but in the world.  In-person visits will be reserved for the most urgent problems requiring hands-on care.
  • When you do have to visit an office or facility, it won't be like today, full of forms, waiting, and uncertainty.  It will be more like visiting an expensive spa, where you are treated like royalty.  They'll be ready for you, cater to your unique needs, and get you in and out efficiently.  
  • "Minimally invasive" will take on whole new meanings, from ingestible robot surgeons to reprogramming our immune cells to tweaking our microbiome.  
  • With so much of our care AI-driven or AI-supported, there will be much less reliance on hunches or outdated research, and more on data and evidence of efficacy, reducing the current "epidemic" of over-testing and use of unnecessary procedures. 

Sound optimistic?  Ray Dorsey and Eric Topel write about the future of office visits, and while they don't go as far as the above, they do assert: "Tomorrow’s office visit will increasingly take place everywhere but the office."
They include on-demand home visits and hospital-at-home models in their prediction, pointing out:
While most patients like their doctor, almost no one likes going to the doctor. By contrast, tomorrow’s office visit will offer patients unprecedented access to confidential, expert care that is delivered conveniently in the comfort of their homes.
The big question is less where or how visits happen, but who is making them.  I.e., whether AI can truly supplant the role of human practitioners for much of our care.

Newsweek recently proclaimed that AI will "cure" our health care system, and claimed, "we’re close to being able to build AI software that can at least supplant that first visit to a doctor when you’re sick—which, of course, is when you least want to travel to a doctor’s office."

Their optimistic prediction:
Add it up, and in these next few years we’re going to see a parade of tech applications that reduce demand on the health care system while giving all of us more access to care. Doctors should be freed up to do a better job for patients who truly need their attention. 
CNBC's Christina Farr, interviewed several doctors about AI's future.  She found that physicians were skeptical of sweeping changes -- but many agreed they hoped AI could free them of more mundane tasks, which would help them spend more time with patients.

Rasu Shrestha, chief innovation officer for UPMC, told Ms. Farr: "Health and health care is too human a notion for AI alone to cure it."  That is certainly true, and Newsweek's headline went further than the actual article did.  There will be human doctors, but they are likely to be doing different things and doing those things differently.  And they will almost certainly be supported by AI.

We have to remember that, by definition, most doctors are average.  Maybe 10-15% are great, maybe 10-15% are poor, and the rest are in the middle.  The law of averages is not good that the doctor you end up with is one of the great ones.  Even if you manage to identify one, getting to see him/her is often a challenge.

On the other hand, all it takes is for someone to develop one AI that is better than the average human doctor.   Unlike human doctors, such an AI is not limited by geography or patient load. It doesn't sleep or take days off.  It could, in theory, see all the patients who want to consult it.  It may or may not be better than great doctors, but it certainly would be more available than them, and would be better than the average doctor you might otherwise end up with.

And that's why AIs will ultimately prevail for most of our needs.

We used to expect other humans to operate elevators and dial phone calls for us.  We used to have personal relationships with our grocers and butchers.  Technology and convenience eroded or eliminated these and other kinds of interactions, and that will happen in health care as well.

We often talk about the importance of patient-physician relationship, but when you rush to the ER or suddenly get surgery, competence outweighs familiarity.  If AIs can help get us better, we'll use them, and that opens up many opportunities for change.

Many protest that "health care is different," and won't follow the patterns of other industries.  They're often happy to try to just make the current system less bad.  That's too low a bar.

Let's re-engineer our health care system to take full advantage of the available and the coming technology, and to truly respect our needs, preferences -- and time.

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