Putting Healthcare on a Platform

People in healthcare have been speculating for years about who or what will be the "Uber of healthcare."  Uber shocked the transportation industry with its peer-to-peer business model, slick technologies, and almost blithe disregard for numerous regulations that might have dampened its model.  Certainly, many thought, the creaky, inefficient healthcare system was vulnerable to disruption from a similar outsider, perhaps even Uber itself (UberHealth, after all).

So I found it amusing that it turns out that Uber has aspirations itself; it wants to Amazon. 

Credit: The Street

Uber is doing its road show in preparation for its IPO next month, which is expected to raise as much as $91b.  The New York Times quotes CEO Dara Khosrowshahi in an Recode interview last year as saying: "We want to kind of be the Amazon for transportation."  In another interview last summer, he elaborated on this goal:

Cars are to us what books were to Amazon.  Just like Amazon was able to build this extraordinary infrastructure on the back of books and go into additional categories, you are going to see the same from Uber.

Uber Eats is touted as an example of this kind of opportunity, and Uber hopes that Uber Freight will have similar success.  The Times also cited their efforts in scooters, autonomous vehicles, and payment infrastructure as other opportunities. 

Shawn Carolan of Menlo Ventures told the Times: "Because the ubiquitous need for transportation is so huge, they’re able to cross-sell different products to their existing customer base."  Another VC, Mitchel Green of Lead Edge Capital, was also effusive: "Uber, like Amazon, operates with an obsession on customer value over anything else."

Of course, cynics suspect the Amazon comparisons are an attempt at a financial sleight of hand.  Uber's growth is impressive, but shows signs of slowing, while its losses are mounting -- as much as $1b in the first quarter alone.  Amazon was famously unprofitable for many years, as it invested in growth and infrastructure (such as its cloud service AWS), and Uber would like investors to show similar patience.  

Leading tech companies -- not just Amazon but also Alphabet, Apple, and Facebook -- have established themselves as platforms for a range of products and services, which allows them to build success upon success and further entrenching themselves into customers' lives.  Business platforms create value through network effects, connecting two groups of users -- consumers and suppliers, consumers with other consumers, businesses with other businesses, etc.  

Credit: Applico

Uber is already a platform connecting riders and drivers, and it is a platform that can expand by doing more things for riders with more kinds of transportation options.  The thing I keep wondering about is: where are healthcare's platforms?

Healthcare, especially in the U.S., is known for how complicated (and expensive) it is.  People -- patients/consumers -- have a hard time finding the right treatments, the right health care professionals and organizations, and the right price.  Even communication is difficult in healthcare; faxes are preferred over emails and texts, waiting in line or in a phone tree can be maddening, and terminology is too often opaque, such as on bills or insurance "explanation of benefits." 

Healthcare needs platforms. 

Some are calling for "Medicare For All" -- whatever that means.  Others might prefer, say, Kaiser Permanente for All, or Mayo Clinic for All.  But those aren't platforms, and they wouldn't address many of healthcare's underlying problems. 

Credit: Symphony Corp.

Done right, electronic health records could be -- or could have been -- a platform.  Expand the kinds and sources of information collected, make them more useful to consumers in their daily lives, introduce more interfaces (e.g., telehealth), and they'd start to look like a viable platform.  Unfortunately, neither healthcare professionals nor patients are enamoured of the current EHRs, which have often been seen as being more about billing and more about intra-organization than about a broader perspective of our health. 

Apple is certainly thinking about life as a healthcare platform.  Its Apple Watch is already has an ECG app that can be used to detect Afib, and it is working with a growing number of health organizations that support sharing health records on the iPhone.  Earlier this year CEO Tim Cook said: "if you zoom out into the future, and you look back, and you ask the question, 'What was Apple's greatest contribution to mankind,' it will be about health."

Similarly, Amazon seems to have plenty of healthcare ambitions, including its acquisition of PillPack and Haven, its joint venture with JP Morgan Chase and Berkshire Hathaway, to name two of many.  Alphabet has an array of healthcare-related efforts and investments, and Facebook is exploring the space.  

There are going to be platforms in healthcare.  The question is whether they will come from outside healthcare, or from within.  

In additions to EHRs, telehealth companies could be a logical basis for a platform, connecting patients and healthcare professionals in a variety of ways and a number of business models.  There are services like ZocDoc (patients and doctors) or PatientsLikeMe (patients and patients) that have platform potential.  But, so far, they are all mostly staying in their lanes.  

What remains to be seen is:

• who has the technology to really simplify healthcare?
• who offers the experience that wows users?
• who can quickly generate the kind of network effects that serve to accelerate growth?

Right now, it's not clear that any organization -- in or out of healthcare -- can yet demonstrate clear superiority in those dimensions.  

Healthcare wants to be more like Uber.  Uber wants to be more like Amazon.  Amazon wants to be part of healthcare.  Someone, somewhere, sometime will somehow break that circle and healthcare will have the platform(s) it needs.  

We're waiting.  

Robots Need DNA too

DNA, it seems, never ceases to amaze.  It's not enough that it powers all known forms of life on our planet, in all types of organisms, under a dizzying array of conditions.  It's not enough that we're slowly but steadily cracking the code to find out what it is doing, and even starting to purposely modify it.  Heck, it's not even enough that we're figuring out how to store other information in it, and even to use it for computing.

Now scientists are using it to create new kinds of "lifelike" mechanisms.   Pandora, we may have found your box.

DASH-created "lifelike" material.  Credit: John Munson/Cornell University

Researchers from Cornell recently reported on their advances.  They used something called DASH -- DNA-based Assembly and Synthesis of Hierarchical -- to create "a DNA material with capabilities of metabolism, in addition to self-assembly and organization – three key traits of life."

Professor Dan Luo, one of the researchers, said:

We are introducing a brand-new, lifelike material concept powered by its very own artificial metabolism. We are not making something that’s alive, but we are creating materials that are much more lifelike than have ever been seen before.

 In the following video, Professor Luo explained that "what we are trying to do is make materials live."

That sends chills up my spine, and not necessarily in a good way. 

Lead author Shogo Hamada elaborated:

The designs are still primitive, but they showed a new route to create dynamic machines from biomolecules. We are at a first step of building lifelike robots by artificial metabolism.  Even from a simple design, we were able to create sophisticated behaviors like racing. Artificial metabolism could open a new frontier in robotics.

The reference to racing in his quote refers to the fact their their mechanisms were capable to motion -- likened to how slime mold moves -- and they literally had their "lifelike materials" racing each other.  If I'm reading the research paper correctly, the mechanisms were even capable of hindering their competitor: "the faster moving body could affect and alter the state of another track to Decay, thus slowing down the locomotion of the body at the other track by triggering the degeneration."

Well, that's lifelike, all right.

Credit: Hamada, et. alia, Science Robotics

It wasn't all days at the race track; oh-by-the-way, they also demonstrated its potential for pathogen detection, which sounds like it could prove pretty useful.

These mechanisms eat, grow, move, replicate, evolve,and die.  Dr. Luo says: "More excitingly, the use of DNA gives the whole system a self-evolutionary possibility.  That is huge."  Dr. Hamada adds: "Ultimately, the system may lead to lifelike self-reproducing machines."

Those chills are back.

The paper concluded with several potential uses for their work:

• "It is not difficult to envision that the material could be integrated as a locomotive element in biomolecular machines and robots (29, 41–50). 
• The DASH patterns could be easily recognized by naked eyes or smartphones, which may lead to better detection technologies that are more feasible in point-of-care settings. 
• DASH may also be used as a template for other materials, for example, to create dynamic waves of protein expression or nanoparticle assemblies. 
• In addition, we envision that further expansion of artificial metabolism may be used for self-sustaining structural components (51) and self-adapting substrates for chemical production pathways."

It's just beginning.

There has been a lot of attention on engineering advances that will allow for nanobots, including uses with our bodies and so-called "soft robots," but we should be given equal attention to what is called synthetic biology.

Credit: The Scientist

Synthetic biology isn't necessarily or even predominately about creating new kinds of biology, as the researchers at Cornell are doing, but reprogramming existing forms of life. They're being programmed to eat CO2 (thus helping with global warming), help with recycling, get rid of toxic wastes, even make medicines. 

A Columbia researcher believes that new techniques for programming bacteria, for example, "will help us personalize medical treatments by creating a patient’s cancer in a dish, and rapidly identify the best therapy for the specific individual."

In the not-too-distant future, we're going to be programming lifeforms and "lifelike materials" t do our bidding at the molecular or cellular level.  People have speculated on swarms of nanobots patrolling our bodies to ensure our health, but that may be a too mechanistic view of the future.  Those nanobots may be less engineering marvels than biological ones, and their programming may recreate the evolution versus intelligent design debate.  

Humans once thought our species was unique, until evolution taught us that we are related to all the others.  We then thought that surely our genome was certainly bigger and more "complex" than those of other species, until we discovered that neither is really true.  More recently, we've realized that "we" aren't even uniquely human; in addition to our DNA containing DNA from extinct types of humans, most of the genes in and on our bodies come from our microbiota.  

We've been debating and worrying about when A.I. might become truly intelligent, even self-aware, but the Cornell research is giving us something equally profound to debate: how to draw the line between "life" and "things"?

Medicine, healthcare, and health are going to have to develop more 21st century versions.  What we've been doing will look like brute force, human-centric approaches.  Synthetic biology and molecular engineering open up new and exciting possibilities, and some of those possibilities will upend the status quo in healthcare in ways we can barely even imagine now.  

It's not going to be enough to think of new approaches.  We're going to have to find new ways to even think about those new approaches.  
  
In the meantime, let's go watch some DASH dashes!

Healthcare's Black Holes

If you are anything like me, you were transfixed by last week's first-ever photographs of an actual black hole.  If you somehow missed the coverage, I urge you to take time to read about it, such as here or here.  And if this accomplishment holds no interest for you, then you're probably not going to be interested in this article either, although it is about healthcare's metaphorical black holes rather than honest-to-goodness black holes.

Credit: Event Horizon Telescope Collaboration, via National Science Foundation

Black holes were an unintended consequence of Einstein's General Theory of Relativity.  He published it in 1916, and soon after that one sharp reader -- Karl Schwarzschild -- found that its equations called for areas of space in which gravity was so strong that not even light could escape.  Most experts (including Einstein) scoffed, treated them as mere mathematical curiosities.  It wasn't until the 1960's that people started taking them seriously (or that they acquired that catchy name).

They've been featured in numerous science fiction movies/television shows, along with some very plausible simulated images.  The breakthrough last week was an actual image (shown above).  It took collaboration between over 200 scientists working at eight radio observatories on six mountains on four continents, along with two years of data analysis.

Here's a video featuring Katie Bouman, who has become the face of the effort:

The black hole is 55 million light years away; in case you don't know, a light year is, well, very, very far away.  Some have complained that the picture is blurry, but it has been analogized to reading a text in New York from Paris, or counting the dimples on a golf ball in Los Angeles from New York.  As one of the lead scientists told The New York Times,  "It’s astonishing to think humans can turn the Earth into a telescope and see a black hole."

Astonishing indeed.  Meanwhile, one of my Twitter buddies Megan Janus (@Megan_Janus) praised this monumental effort in collaboration and challenged: "Imagine what we could do for healthcare with true interoperability!"

That got me thinking about "black holes" in healthcare.  Here's a short list:

Data silos: Until fairly recently, most of our healthcare data was locked away in paper records, only laboriously compiled into more aggregate collections that could be analyzed.  Now we have no shortage of digital health data and bravely talk about the power of Big Data, but true interoperability remains a goal.

If you happen to receive care within a health system, or sometimes between health systems that use the same EHR platform, the odds of your data following you are much higher now than ever, but otherwise, probably not.  It is widely agreed this is a problem, many are working on it, we know ways we could address it, but if your life depended on it -- and it might -- don't count on it anytime soon.

Data goes in, but, all-too-often, it doesn't come out.

Credit: Flying Blind

Data: There are some kinds of health data -- like weight or blood pressure -- that have been tracked since the advent of modern medicine.  We've been adding to the list as we've developed new things to measure and new ways to measure them.  Now we're in the early stages of a torrent of new data, especially from smart devices, including fitness trackers and medical implants.

This seems like a good thing, but not necessarily.  We don't really know which data is important, when, for whom.  We don't know who should be looking at all this data, how or when.  In many cases, even if the data helps us recognize there is an issue, we don't necessarily know what to do about it.  Even worse, not only do you not control yours, you don't even know what is being done with it.

The data might as well be in a black hole.

Decisions: As we creep closer to using A.I. for diagnosis/treatment decisions, many worry that the A.I. might use "black box" logic that will preclude us from understanding why it makes those decisions.  But, as others point out, we already have that problem; it's just that the black box reasoning takes place within physicians' heads.

Medical decisions vary due to  dizzying array of circumstances -- such as where physicians went to medical school, where they did their residency, whom they practice with, how and by whom they are paid, what research they happen to have read/remember, how many similar cases they've seen or done.  They might offer an explanation for their decision, but it's anyone's guess whether that explanation is the truth or a rationalization of other influences, which they may or may not be aware of.

The decision process may be like a black box than a black hole, but, either way, we don't know what happens inside.

Medical care: The scary thing about black holes is that their gravity inexorably drags in everything within its reach.  Unless you are very far away or have sufficient escape velocity, you will get pulled in, and, once you are sucked in, you are never getting out.

We call it our "healthcare" system, but usually what we mean is medical care.  It treats illnesses, it puts us under the care of medical professionals, it turns us into patients.  A doctor's visit begats prescriptions, and perhaps some testing.  Testing leads to procedures.  Procedures lead to hospital stays.  Hospital stays lead to....you get the idea.

What we might once have thought of as "health" -- or never thought about at all -- becomes "health care," a.k.a. medical care.  And once you transform from a person, whose health belongs to you, to a patient, your health is never quite your own again.   You've been sucked into the medical care black hole.

And, chances are, you're never getting out.

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There's not much we can do about real black holes.  They may (or may not) preserve information, they may (or may not) create wormholes, and they may (or may not) eventually evaporate.  But the above examples of healthcare's black holes are ones that we've created, and they're ones we can do something about.  We can escape them, we can get the information in them out, and we can reverse their effects.

If some humans can figure out how to take a picture of a real black hole, certainly other humans can fix healthcare's black holes.

Get Used to Fun(gal) Company

Like many people, I have become more aware in recent years of the microbiome and its impact on our health, but I'd been unaware of the mycobiome, its fungal subset.  That changed when I read an in-depth story in The New York Times on a drug resistant fungus named Candida auris.

It reported on a man who recently died in a U.S. hospital from it, and here's the scariest part of the story:

"Everything was positive — the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive."

The story went on to explain: "Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa."   Dr. Tom Chiller, who heads C.D.C.'s fungal branch (who knew!) said: "It is a creature from the black lagoon.  It bubbled up and now it is everywhere."

Spread of Candida auris.  Credit: The New York Times. Image from Kazuo Satoh et al., Microbiology and Immunology

Some would argue that, as bad as it sounds, your chances of contracting Candida auris is actually very small, but my feeling is: ignore the mycobiome at your own risk.

If you're squeamish, the situation is worse.  A separate Times story points out that "you're covered in fungi," with fungi present both on the inside and the outside.  There's fungi at the bottom of the ocean, there's fungi at the top of mountains, and there's fungi in Antarctica.  One biologist says they are "on every grain of sand, in every gram of soil from the Arctic to the tropics." 

If all that makes you consider fleeing the Earth to escape it, a new study  has found that even the International Space Station is full of both bacteria and fungi.  The bacteria populations tend to ebb and flow, while the fungal communities are more stable over time.  

Stubborn little life forms, aren't they?  

Batrachochytrium dendrobatidis.  Credit: CSIRO

As Candida auris illustrates, fungi can be killers.  Science reports that a fungus named Batrachochytrium dendrobatidis (Bd) "has wiped out more species than any other disease," causing 91 species to go extinct and another 491 species to decline, especially among frogs.   That's why fungi like Candida auris that are resistant to current antifungals are scary.  We've started to recognize the problem of drug resistant bacteria, but, as a recent research paper declared: "Worldwide emergence of resistance to antifungal drugs challenges human health and food security."

Well, then, the solution is clear, right?  Find more of those antifungals and kill them all, right?  Not so fast.  As we've started to learn about the microbiome, the "right" mycobiome is essential to our health.  Fungi have been connected with, among others, Crohn's disease, ulcerative colitis, hepatitis B, asthma, prostate cancer, obesity, and graft versus host disease (GVHD).  We don't know when the problem is too much of them, too little, or too many of the "wrong" kind.  

And, yet, we're only starting to pay attention.  A 2016 report found that "only 269 of more than 6,000 Web of Science search results for the term “microbiome” even mention “fungus,” and the scientific search engine returns only 55 papers pertaining to the “mycobiome.”'   Studies about the microbiome generally are still a small minority of all medical research papers, and studies about the mycobiome are a tiny minority of that minority.

The author urged:

The scientific community must adopt an all-inclusive characterization of the human microbiome going forward; studies that focus solely on bacteria are myopic and doomed to failure, and they squander precious research funds.

We are literally swimming in our mycobiome, and having it swim within us, but we are just barely beginning to understand its importance.   "Myopic and doomed to failure" is an apt description of our current focuses.

Credit: Ghannoum and Tang, The Scientist

One expert, Dr. J. Curtis Nickel of Queen's College (Canada), told the Times:

I personally suspect that it’s an interaction of all the different bacteria, fungi and viruses.  An unhealthy population of these organisms exacerbates disease and perhaps even — this is the next step — causes it. But boy, we’re not there yet."

Boy, we are not. 

We tend to view healthcare as a fight.  We declare war on diseases.  We battle our maladies.  We have antibiotics, antivirals, and antifungals.  We beat illnesses.  Dying is a loss.  It all makes for a very colorful metaphor, and positions our clinicians and healthcare organizations as noble warriors, but it is a flawed metaphor.

Our health is not "our."  We think of ourselves as this collection of cells that share the same DNA, but it's not that simple.  Few of us live in a bubble; "we" includes the many other organisms that accumulate, starting at birth and continuing throughout our lives.  We can't avoid them, nor have we evolved to ignore them.  Our health lies in our co-existence with them -- whatever that means.

The problem is that, for the most part, we don't know what that means.

Brute force approaches like antibiotics have, no doubt, saved countless lives, but at an untold cost.  We're only starting to understand how these "anti" efforts have altered our microbiome and mycobiome, for how long, and to what effect.  We have yet to have our penicillin moment with the microbiome and mycobiome.

In many ways, 20th century medicine can be viewed as the era of antibiotics.  For all the good they've done, I think someday we'll look back at some of our current "anti" efforts as fighting a losing battle against things that should be our best allies.

My belief is that 21st century medicine will become viewed as the era of coexistence with our microbiota, when we recognize that the health of our microbiome and mycobiome is the same as "our" health. 

Many of may think of our health as a garden, that we must tend carefully -- planting the right things, giving them enough food and water, weeding constantly, and pruning as necessary.  But that's another flawed metaphor: we are not the gardener, we are the garden.

Are We Having Fun Yet?

I think I have realized what healthcare's big problem is, and it's not what you might think. 

It's not high prices, although they certainly are a big problem.  It's not the fee-for-service model, although it gives too many people perverse incentives.  It's not the lack of useful and understandable quality measures, although it is astonishing that we don't have them.  It's not even the byzantine and often stifling regulations that healthcare operates under, although too often they seem to do as much harm as good. 

No, the big problem with healthcare is that not enough people are having fun.

Wait, what?  How could this be "the" big problem with healthcare, which has so very many problems?  Healthcare is not supposed to be fun.  It's supposed to be serious, we're supposed to take our health and our healthcare seriously, and we expect the people working in healthcare to be serious professionals.

Yes, there is a lot that is, and needs to be, serious about health and healthcare, but here's where the fun comes in -- Steven Johnson's great quote:

You will find the future where people are having the most fun. 

If you haven't read it, Steven Johnson's Wonderland: How Play Made the Modern World makes the case that innovation, and changes in society, come from people "playing" -- having fun.  Mr. Johnson is someone who knows something about innovation, his previous books also include Where Good Ideas Come from: A Natural History of Innovation and How We Got to Now: Six Innovations That Made the Modern World. 

A longer quote from Wonderland helps further explain his thesis:

When human beings create and share experiences designed to delight or amaze, they often end up transforming society in more dramatic ways than people focused on more utilitarian concerns.

So who are the people in healthcare having fun?  Where are the people in healthcare creating experiences designed to delight and amaze?  There must be some, somewhere, but they're too few and far between, and neither "fun" nor "play" are attributes that people usually even associate with healthcare.

Doctors are stressed and, increasingly, reporting burnout.  They more often advise people not to enter the profession.  Patients are frustrated and, all too often, worried or even scared.  As has pointed out, the fact that "patient-centered" even has to be discussed illustrates how it isn't true.  No one seems to like our current healthcare system, or agree on how to make it better.  We're paying too much -- way too much -- for health results that are, frankly, mediocre at best.  This is all serious stuff.

When it comes to healthcare, taking time to play seems irresponsible.  Having fun is something people are supposed to do in the rest of their lives.  So we grumble about our weight, we promise to exercise more in the future, we sit in waiting rooms for far too long for our too-short visit with our clinicians, while those clinicians end up being expected to deliver assembly-line medicine and serve as, in the words of the AMA, the world's most expensive data entry clerks. 

Certainly, there must be people in healthcare having fun.  I mean, there are people in healthcare working on robots, 3D printing, virtual reality, implantable devices, and body hacking, to name a few.  Those have to be fun, right?  No wonder, because those kinds of things are going to be where the future of healthcare are going to be.

The people working on those, though, are probably being told to make their inventions more useful, sooner, not to make them more fun.  They award Nobel Prizes in Medicine for discoveries that deliver the "greatest benefit on mankind," and the judges probably don't take fun into account.  That's how innovation in healthcare often delivers change that is, essentially, more of the same.   

But where's the fun in helping people stay healthy?  Where's the fun in making the healthcare experience fun?  When are we delighted and amazed in healthcare? 

Eating healthy often seems less fun than eating junk food.   Exercising is usually not as fun as watching television.  Most people have more fun checking on their tablet or smartphone than getting extra sleep.  Getting a procedure is almost never fun, and taking prescriptions is a chore. 

We've allowed healthy to become the not-fun option. 

If I often write about seemingly unrelated things like TikTok, WeWork, Fortnite, or e-sports, it's because people seem to be having fun there.  They're telling us something about the future.  As I said in the Fortnite article,

The future of the healthcare system is going to be participatory, cooperative, interactive, iterative, online, rewarding, challenging but fun.

Mr. Johnson would understand. 

So, yes, let's do a better job with measuring and rewarding value in healthcare.  Let's do a better job of ensuring care is affordable.  Let's do a better job of keeping people independent.  Let's do a better job preventing conditions, and managing them once they've developed.  Let's make the patient experience less arduous.  But let's not forget the fun.

Let's encourage innovation in healthcare that people find fun, whether they are clinicians, patients, or people who aren't either.  Let's look for ways to make the healthy choice the fun option.  And let's not be satisfied until we have healthcare experiences that delight and amaze the people involved in them. 

Wouldn't that be fun? 

It May Be TikTok for U.S. Health Tech

Please don't let me write about TikTok.  Please don't let me write about TikTok.  Please don't...oh, all right, I'm going to write about TikTok.

That's the kind of power it has over people.

TikTok, in case you aren't (yet) aware of it, is a new(ish) social media platform, featuring short videos.  Think of a more successful Vine (now defunct), or a maybe Instagram with videos.  Another comparison might have been Musical.ly, but that was acquired by TikTok's owner, ByteDance Ltd., in November 2017 and was merged with TikTok last summer. 

TikTok makes it easy to create and view short videos, often with music or other sound effects, and to view videos that others have created.  It, too, uses #hashtags to create memes.  The word that is often used -- at least by those not on the app -- for many of these creations is "cringe," and the more cringeworthy, the better.

It is wildly successful, with over 1 billion downloads on Android and iOS -- and that doesn't count all of its downloads on China.  It had more downloads in 2018 than Instagram, if you're keeping track, and last fall its monthly downloads started surpassing not just Instagram but also Facebook, YouTube, and Snapchat, even in the U.S.  By last summer it had already claimed 500 million users across 175 countries. 

If all that isn't impressive enough, ByteDance secured funding last fall that would value it at $75b, which, at the time, was more than Uber was valued at, and I'll bet you've heard of Uber.

Two things attracted my attention to TikTok.  First, the mainstream media is starting to be all over it.  Without much effort, I found recent articles in The New York Times, NBC News, The Conversation, TechCrunch, Rolling Stone, Business Insider, CNN, and Quartz, among others.  The New York Times discussed "How TikTok Is Rewriting the World," The Conversation described it as "TikTok: the world's most valuable start-up that you've never heard of," and TechCrunch warned "It's time to pay serious attention to TikTok."

TechCrunch was blunt about TikTok's significance:

 Here comes the new new internet, folks. It’s big, dominated by emerging markets, mobile, video, meme-ified, and goes viral both online and off. 

So if you haven’t been paying attention to TikTok, you may want to get started.

Second, ByteDance is a Chinese company, and TikTok began as an app in China (where it is known as Douyin).  China has its own constellation of apps and tech companies that rival any that the U.S. produces, such as WeChat, but most of their success has been in China, where outside competition is often constrained.  TikTok is one of the first to really break through internationally.  Financial Times speculates that it may provide a "roadmap" for such international success. 

TikTok is different than other social media platforms because it is not really built around your social network or celebrities you've chosen to follow.  John Herrman, writing in The New York Times, says TikTok:

has stepped over the midpoint between the familiar self-directed feed and an experience based first on algorithmic observation and inference...It’s full of things that you seem to have demonstrated you want to watch, no matter what you actually say you want to watch.

It is important to note that ByteDance's other main holding is news app Toutiao, which uses A.I. to learn user's preferences and create customized news feeds for them.  It uses similar A.I. algorithms to produce video feeds for TikTok. 

By its own admission, ByteDance is not a social media company, it's an A.I. company.  Facebook and Google may be going there, but ByteDance is starting there. 

TikTok's success hasn't been all smooth sailing.  It's still trying to figure out more Western markets, and earlier this year was hit by the FTC with a "record fine" for violations of the Children's Online Privacy Protection Act (COPPA) due to its its collection of personal data on children younger than 13. 

All that may (or may not) be interesting, but what does it have to do with health or healthcare?  Nothing about TikTok is aimed at our health, our use of healthcare services, or our healthcare system(s).

Yet. 

For example, more recently, Mr. Herrman noted that: "It’s an app that’s unapologetic about wasting your time. It’s also, apparently, a good way to waste some time at work," citing a number of videos done by people in their workplace.  If you don't think there are cringeworthy videos to be done about our healthcare, you haven't been paying attention.  

It may be that the current TikTok users tend to be too young to have much interaction with the healthcare system, but when they do -- and they will -- we can expect that some of them will produce some TikTok content about those interactions.  #ThisIsStupid or #CanYouBelieveThis.  

More importantly, TikTok may just be the trailblazer for other Chinese apps, as Financial Times suggested.  Healthcare is one area where China is investing heavily, and much of that investment revolves around A.I.  A.I. is not constrained by geography or by borders on a map; if you can build it, they can come.

When Baidu or other Chinese leaders in A.I. healthcare become more successful, it will be tempting for them to follow TikTok's lead in venturing overseas.  They may view U.S. regulations about the practice of medicine differently than a U.S.-based corporation might. 

Telemedicine within the U.S. may still be struggling to deal with the many licensing and regulatory barriers that exist, but a Made-in-China A.I. telehealth app may leap them entirely, forcing regulators to try to figure out who should attempt to deal with them how under what existing laws.  It'd be Uber all over again; the game may be up before the regulators realize what is happening.  

It may not be TikTok, but it could be ByteDance, or it could be one of many other Chinese A.I. leaders.   But in a world where we are used to speculating on the healthcare ambitions of U.S. tech giants, it'd be prudent to pay attention to China's ambitions as well.  

TikTok may mean Tick Tock for many U.S. healthcare companies.