The Most Important Thing

Jack Dorsey has some big hopes for bitcoin.  In a webinar last week, he said: “My hope is that it creates world peace or helps create world peace.”  The previous week Mr. Dorsey announced Square was starting a decentralized financial services (DeFi) business based on bitcoin, joining the previously announced Square bitcoin wallet.  

None of this should be a surprise.  At the Bitcoin 2021 conference in June, Mr. Dorsey said: “Bitcoin changes absolutely everything.  I don’t think there is anything more important in my lifetime to work on.”

I’m impressed that someone with as many accomplishments as Jack Dorsey picks something not obviously related to those accomplishments and decides it is the most important thing he could work on.  So, of course, I had to wonder: what might accomplished people in healthcare say was the most important thing they wanted to be working on?

For many these days, of course, it is the COVID-19 pandemic.  Not much has had a higher priority.  Highly effective vaccines have been developed, COVID-19 treatments have greatly improved, supply chains have been adjusted and readjusted, and countless public health measures have been tried.  Healthcare professionals have worked themselves to extremes.

For others, perhaps, it would be to address the extreme financial hardships the U.S. healthcare system can cause.  A new study in JAMA confirmed what is hiding in plain sight – hundreds of billions of medical debt.   Debt continued to rise despite ACA, especially in states that perversely chose not to expand Medicaid.  Efforts such as requiring hospital “price transparency” have largely failed.  Many large hospital systems continue to sue patients who can’t pay.  These hardships are unfair, immoral, and unique to the U.S.; addressing them should be important.

However, both the pandemic and financial obstacles contributed to, but did not cause, the big health inequities in the U.S. healthcare system.  People of color, people in lower socioeconomic classes, even women all face numerous inequities in the health care they receive and in the health they achieve.   These may reflect broader social inequities, but no one in healthcare should look at these without wanting to address them. 

Digital health has never been hotter. The pandemic reminded people how valuable telehealth can be, and investors are pouring money into digital health at astounding levels – some $19b in the first half of 2021 alone.  We may be in bit of a manic phase right now, but few doubt that digital health is going to be a big part of healthcare’s future. 

Then there’s artificial intelligence (A.I.).  No industry in 2021 can be ignoring it. Some well-publicized mishaps with IBM’s Watson or Babylon Health notwithstanding, A.I. in healthcare has already made impressive strides, such as DeepMind’s recent protein predictions or its successes in imaging.  A.I. is going to be built into our health care in the future, either in a supporting role or directly, and working on it has to be on many people’s wish list.  

These, and other initiatives, are all important and I sure hope people are working on them.  However, I think about some other things that Mr. Dorsey discussed in the webinar.

We have all these monopolies off balance and the individual doesn’t have power and the amount of cost and distraction that comes from our monetary system today is real and it takes away attention from the bigger problems…You fix that foundational level and everything above it improves in such a dramatic way.

Mr. Dorsey said he’s inspired by the bitcoin community: “It's deeply principled, it's weird as hell, it's always evolving,” reminding him of the early days of the internet.  I always, always, think about Steven’s Johnson’s great quote from his book Wonderland: “You will find the future where people are having the most fun,” and that certainly has to be part of what Mr. Dorsey sees about cryptocurrency.

Credit: BiotechScope

So, for me, the most interesting future for healthcare has to be synthetic biology, including biohacking.

Synthetic biology, in case, you didn’t know, is “redesigning organisms for useful purposes by engineering them to have new abilities,” and biohacking is doing that to your own body, usually to optimize or improve its functioning. 

Observers seem to think that synthetic biology seems to draw an edgy, counter-cultural crowd.  It’s on the cutting edge, and it, too, is getting record funding.  Former Google CEO Eric Schmidt said, at a 2019 synthetic biology conference: “What is changing the fastest right now? Because whatever that is determining the history of next year. There’s lot of evidence that biology is in that golden period right now.” 

Credit: Biohack the Planet/Indiegogo

Biohacking caught my attention a couple years ago because it seemed like “hacking” in the early days of PCs and the internet – not cybercriminals but amateurs just having fun exploring the medium; in this case, the medium is us.  Sure, biohacker have pulled some crazy stunts, but the #WeAreNotWaiting movement , among others, has done amazing, impressive, and important work.

When we start talking about “programming biology,” well, if that isn’t “weird as hell,” I don’t know what is.  That’s fun, and that’s the future.

The theme for me is to solve health issues at the source code level.  Not to take a pill that may or may not address my condition but probably will have side effects, or to have a surgery that will assault my body along the way, but to fix the errant cells/genes/structures at the root level.  Fix things, as Mr. Dorsey said about bitcoin, “at the foundational level.”

Mike Brock, who will head up Square’s DeFi business, tweeted: “Technology has always been a story of decentralization. From the printing press, to the internet to bitcoin – technology has the power to distribute power to the masses and unleash human potential for good, and I’m convinced this is the next step.” 

I want the same for our health – use technology to decentralize, and to distribute power to the masses.  That offers the promise of taking control from the traditional healthcare structures – not relying on hospitals, health insurance companies, or even medical professionals. 

As Mr. Dorsey thinks about bitcoin, “I don’t think there is anything more enabling for people around the world.”

Healthcare Should Go (Micro) Nuclear

I think of hospitals as the healthcare system’s nuclear power plants.  They’re both big, complex, expensive to build, beset with heavy regulatory burdens, consistently major components of their respective systems (healthcare and electric generation) yet declining in number.  Each is seen to offer benefits to many but also to pose unexpected risk to some.

Interestingly, there’s a “micro” trend for each, but aimed towards different ends.

Doc Brown may have had it right/Credit: Back to the Future

Micro hospitals have been with us for several years.  They usually have only around ten beds, along with an emergency room, lab and imaging.  Dr. Tom Vo, CEO of Nutex Health, says: “We position ourselves between urgent care and a big hospital.”  A micro-hospital Chief Medical Officer admits: “We still partner with our larger hospital partners for patients who might require surgery or intensive care.” 

They’re not trying to reinvent hospitals so much as to support them and offer more convenience to patients.  Not so with micro reactors; they’re looking to revitalize their industry, which is in trouble.

According to the U.S. Energy Administration (E.I.A.), there are 94 U.S. nuclear reactors, at 56 nuclear power plants, in 28 states.  Only one new reactor has gone active in the U.S. since 1996, while almost two dozen are in various stages of decommissioning and only two new ones are under construction.  Overall, the U.S. gets about 20% of its power from nuclear reactors, while 13 countries get at least a quarter of their electricity from nuclear, with France leading the pack at 75%.     

We talk a lot about transitioning away from using fossil fuels to generate electric power, but none of the renewable options currently offers a realistic path towards replacing them.  Nuclear power is the proven alternative, but, as Dan Van Boom wrote in CNET, nuclear power has a PR problem.  No one wants a nuclear power plant in their backyard, no matter how big that backyard is.

When most people think about nuclear power, they think of disasters, especially Fukushima (Japan, 2011), Chernobyl (Russia, 1986), or Three Mile Island (U.S., 1979).  Nuclear power, many people feel, is dangerous, expensive to build, and something we should be moving away from, not embracing. 

Proponents of nuclear power point out that, as scary as they were, deaths from the three disasters listed above were actually very small.  Moreover, they argue, almost every other form of power generation is much more dangerous than nuclear. 

Artist rendering of Oklo facility.  Credit: Oklo

Enter micro reactors.  CNBC reported on Oklo, a start-up that is selling mini-reactors that are small enough to fit in an A-frame structure and – get this! -- powered by the waste from conventional nuclear reactors.  They only produce around 1.5 megawatts of electric power (MWe), compared to conventional ones that can produce as much as 8,000 MWe.  Perhaps most importantly, though, instead of taking a dozen or more years, and as much as $20b, to build, these will take less than a year, and are substantially cheaper.

 This is not pie-in-the-sky stuff.  “These reactors have been built and operated before. So they’re ready to go,” Oklo co-founder Jacob DeWitte told CNBC.  Mr. DeWitte expects “a number of plants operating by the mid-2020’s,” with potential customers including utility companies, industrial sites, large companies, and college and university campuses. 

Oklo has already signed a deal with bitcoin mining company Compass Mining for 150 MW of power, at a cost Compass believes is considerably lower than it is paying now.   Mr. DeWitte sees this as a “beacon” for how to supply power for cryptocurrency.

There are still some regulatory barriers for Oklo to overcome, not the least of which is to have the plans operate without any onsite human oversight.   

Not to be outdone, China has started construction of its own “small modular reactor” (SMR), Linglong One, build by China National Nuclear Corporation (CNNC).  It will produce 125 megawatts, enough to power 526,000 households.  It can also be used for heat supply for cities, industrial steam, seawater desalination, and oil exploitation.  CNNC believes SMRs offer miniaturization, high safety, short construction period and flexible deployment. 

Credit: Defense One

Similarly, the U.S. Office of Nuclear Energy asserts: “Advanced Small Modular Reactors (SMRs) are a key part of the Department’s goal to develop safe, clean, and affordable nuclear power options.” It cites multiple advantages, including “relatively small physical footprints, reduced capital investment, ability to be sited in locations not possible for larger nuclear plants, and provisions for incremental power additions. SMRs also offer distinct safeguards, security and nonproliferation advantages.”

As if this isn’t eye-opening enough, the Defense Department is working on transportable nuclear reactors, and some engineers are proposing small reactors that they refer to as “nuclear batteries.”  Of the latter, MIT Professor Jacopo Buongiorno told MIT News: “It's so small that the whole power plant is actually built in a factory and fits within a standard container.”

CNNC and ONE overlap on many of the characteristics they like about mini-reactors: small size, cheaper and faster to build, flexible deployment, and high safety.  All of those would be desirable in healthcare, particularly for hospitals.   But no one (that I know of) is building a hospital that can be built in a factory and easily transported.  No one is actually proposing to replace full service hospitals with a network of micro-hospitals.

Last year, in response to the pandemic, CMS launched both the Hospital Without Walls program and the Acute Hospital at Home program. Both are laudable, but both were aimed more at reduce the strain on hospitals, not reinventing them (and neither is permanent). 

Hospital-at-Home programs are already gaining traction, as evidenced by Kaiser Permanente and The Mayo Clinic jointly investing in the Medically Home Group, along with a host of other hospital-care-at-home deals.  John Halamka, M.D., president of Mayo Clinic Platform, believes:

We can advance the well-being of patients by catalyzing innovative, collaborative, knowledge-driven platform business models to redefine the standard of high-acuity care for patients with serious or complex illnesses who currently receive care in hospitals.

 Amen. 

If we can replace massive nuclear power plants with micro-reactors that can fit in a suitcase or shipping container, we can do better than micro-hospitals that just look like scaled down hospitals.  If we can aim to run those reactors without onsite personnel, we find more ways to reduce staff in micro-hospitals.  If micro-reactors can both significantly reduce carbon emissions and be cheaper than traditional power sources, micro-hospitals should help reduce health care costs and improve outcomes. 

When the nuclear power industry is out-innovating healthcare, it’s a good sign that healthcare is way off-track.

Up, Please

 When I think of elevator operators, I think of health care.

Now, it’s not likely that many people think about elevator operators very often, if ever.  Many have probably never seen a elevator operator.  The idea of a uniformed person standing all day in a elevator pushing buttons so that people can get to their floors seems unnecessary at best and ludicrous at worse. 

But once upon a time they were essential, until they weren’t.  Healthcare, don’t say you haven’t been warned. 

Elevators have been around in some form for hundreds of years, and by the 19^th century were using steam or electricity to give them more power, but it wasn’t until Elisha Otis debuted the safety elevator that they came into their own.  New engineering techniques such as steel frames made skyscrapers possible, but safe elevators made them feasible; no one wanted to climb stairs for 10+ stories. 

Those generations of elevators weren’t quite like the ones we’re used to.  The speed and direction had to be controlled manually, the elevator had to be carefully brought to a stop at a floor, and the doors had to be opened and closed.  Managing all this was not something that anyone wanted to entrust to passengers.  Thus the role of the elevator operator.

But, of course, technology evolved, allowing for more automation.  According to elevator engineering expert Stephen R. Nichols: 

Elevator buttons were introduced in 1892, electronic signal control in 1924, automatic doors in 1948, and in 1950 the first operatorless elevator was installed at the Atlantic Refining Building in Dallas. Full automatic control and autotronic supervision and operation followed in 1962, and elevator efficiency has steadily increased in other ways.

Elevator operators gradually transitioned from being mechanical operators to concierges, helping passengers find the right floors and making them more comfortable.  A 1945 elevator operators strike in New York City had a crippling effect.  As Henry L. Greenidge, Esq. wrote on Linkedin, “The public refused to go near the controls despite having watched the operators work the levers numerous times. The thought that a layperson could operate an elevator was simply an outrageous thought.” 

Within five years, as Mr. Nichols pointed out, the first operatorless elevator debuted, and within two decades the profession of elevator operator was almost extinct.  Indeed, a 2016 paper by economist James Besson found that, of 271 occupations that existed in 1950, “In only one case—elevator operators—can the decline and disappearance of an occupation be largely attributed to automation.” 

So, what does this have to do with health care? 

For most of the time we’ve had medicine, we’ve replied on experts, such as physicians, to guide us in our health.  To paraphrase Mr. Greenidge, the thought that a layman could manage their own health was simply an outrageous thought. 

It’s no longer such an outrageous thought.  People have access to an enormous amount of information – of varying degrees of quality – and an array of DIY options.  No one is likely to do their own cardiac catheterization anytime soon, but, for example, people with diabetes have done amazing DIY, including artificial pancreas.  If you haven’t heard of synthetic biology or biohacking yet, you will.  They’re like putting buttons on elevators, giving the “passengers” more direct control. 

Add artificial intelligence to the mix, well -- it’s a different healthcare system.

Right now our health care experience is like going into a strange skyscraper.  There’s a directory, of sorts, but it’s very hard to read and not intended for us to read it.  The “elevator” we get onto has buttons, but the numbering system might as well be Greek.  We need elevator operators, in the form of health care professionals, to tell us where we need to go, on which floors, and to press the right buttons for us. 

It’s not an experience intended for us to self-manage, or designed for us to make it easy to do so.  The technology is available, but not embraced.  Our healthcare experiences have not, like elevators, become fully automated, but it’s a future we should anticipate.

Mr. Greenidge was drawing the parallels of elevator operators not to healthcare but to self-driving cars, but some of the parallel applies to healthcare nonetheless.  For example: “In both instances automation was available during the periods in which human operation was popular. Additionally, there were safety concerns from a skeptical public who hadn't quite accepted the technology yet.”

Similarly, Mr. Nichols is interested not in elevators per se but in the physical-human and digital interfaces.  He writes:

Many of the challenges in modern passenger experience involve providing intuitive interactions and behavior solutions, and these can largely be achieved through new technologies and the application of connected and Internet of Things (IoT) technologies from other industries (Gulan et al. 2016). Digital interaction technology such as smartphones, wearables, video analytics, and other sensors, as well as advances in physical-human interfaces (e.g., touchscreens instead of buttons), will greatly improve intuitive behavior.

Technologies can be combined and introduced to lower anxiety and increase convenience and efficiency. Ensuring that passengers feel safe, trust equipment reliability, reduce or eliminate their wait time, get to their destination faster, and travel in a secure, comfortable, personalized space is of paramount importance to elevator technology well beyond the early physics-based problems.

We should be applying all that to healthcare as well.  Improving intuitive behavior, increasing convenience, ensuring we feel safe, having a comfortable, personalized space – isn’t that the health care system we want?

AI in healthcare is going to give people more autonomy.

Back in 2008, Audrey Boguchwal, then a student at Columbia University and now a Product Manager at Autodeak, wrote:

…the best elevators are the ones we notice the least. They transport us safely and efficiently to our destinations and we rarely think about them. It is only when an elevator is broken, or too slow or too fast that it becomes present in our lives.

So it should be with healthcare.  Our best experiences should be the ones we notice the least.  They get the job done efficiently and unobtrusively.  Unfortunately, in healthcare, too often something is broken, or moves too slow or too fast.  We’re too aware of them.

I’m not saying healthcare professionals are gong the way of elevator operators, but we should be designing a healthcare system in which we need fewer of them and in which we can do more on our own. 

Make Mine Bioresorbable

I learned a new word this week: bioresorbable.  It means pretty much what you might infer -- materials that can be broken down and absorbed into the body, i.e., biodegradable.  It is not, as it turns out, a new concept for health care – physicians have been using bioresorbable stitches and even stents for several years.  But there are some new developments that further illustrate the potential of bioresorbable materials. 

Bioresorbable pacemaker. 
Credit: Northwestern University/George Washington

It’s enough to make Green New Deal supporters smile.

Bioresorbable stents and stitches are all well and good – who wants to be stuck with them or, worse yet, to need them removed? – but they are essentially passive tools.  Not so with pacemakers, which have to monitor and respond.  Medicine has made great progress in making pacemakers ever smaller and longer lasting, but now we have a bioresorabable pacemaker. 

Researchers from Northwestern University and The George Washington University just published their success with “fully implantable and bioresorbable cardiac pacemakers without leads or batteries.”  What their title might lack in pithy is more than offset by the scope of what they’ve done.  Fully implantable!  No leads!  No batteries!  And bioresorbable! 

Most pacemakers are, of course, designed to be permanent, but there are situations where they are implanted on a temporary basis, such as after a heart attack or drug overdose.  Dr. Rishi Arora, co-leader of the study, noted: “The current standard of care involves inserting a wire, which stays in place for three to seven days. These have potential to become infected or dislodged.” 

Dr. Arora went on to explain:

Instead of using wires that can get infected and dislodged, we can implant this leadless biocompatible pacemaker. The circuitry is implanted directly on the surface of the heart, and we can activate it remotely. Over a period of weeks, this new type of pacemaker ‘dissolves’ or degrades on its own, thereby avoiding the need for physical removal of the pacemaker electrodes. This is potentially a major victory for post-operative patients.

The device is only 15 millimeters long, 250 microns thick and weighs less than a gram, yet still manages to deliver electric pulses to the heart as needed.  It is powered and controlled using near field communications (NFC); “You know when you try to charge a phone wirelessly? It’s exactly the same principle,” GW’s Igor Efimov, a co-leader of the study, told StatNews. 

It dissolves over a period of days or weeks, based on the specific composition and thickness of the materials.

Watch it dissolve:

The researchers are pretty pumped. Dr. Efimov says:

The transient electronics platform opens an entirely new chapter in medicine and biomedical research.  The bioresorbable materials at the foundation of this technology make it possible to create whole host of diagnostic and therapeutic transient devices for monitoring progression of diseases and therapies, delivering electrical, pharmacological, cell therapies, gene reprogramming and more.

They’re not the only ones.  Moussa Mansour, director of the Atrial Fibrillation Program at Massachusetts General Hospital, who was not involved in the study, told StatNews: “It seems to be a very revolutionary idea. I believe it’s going to be well-received in the field. It targets an unmet need, and I believe it’s going to benefit patients… not only because it targets a temporary patient application, but because of its potential to be expanded to other applications in medicine.”

Northwestern’s John A. Rogers, who led the device development, predicts: “Transient technologies, in general, could someday provide therapy or treatment for a wide variety of medical conditions — serving, in a sense, as an engineering form of medicine.”

Let that sink in: “An engineering form of medicine.”

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The FED.  Credit: Jason Daley/UW

Then there is a fracture electrostimulation device (FED).  Researchers at the University of Wisconsin have developed an implantable, self-powered, bioresorbable device that stimulates bone growth and healing, then dissolves when its job is done.  The device gets its power by converting mechanical energy generated by tiny movements into electric power, which then stimulates the bone.  In some situations, they admit, “We may need the device to respond to other types of internal mechanical sources, like blood pressure changes.”

As with the pacemaker, the device can be “fine tuned” to last from weeks to months by “tweaking” the make-up of the materials. 

Right now, the device has only been tested on rats, but lead researcher Xudong Wang is eager for the next steps: “It will be very interesting and impactful to address the development from animal to human.” 

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If you think those are cool, then hold still for bioresorbable 3D printed tissue scaffolds.  Tissue scaffolds, if you didn’t know (I didn’t) are used in tissue engineering to provide structures for tissue growth/repair/regeneration, such as after breast cancer treatment.  The study concludes:

We have demonstrated that it’s possible to produce highly porous scaffolds with shape memory, and our processes and materials will enable production of self-fitting scaffolds that take on soft tissue void geometry in a minimally invasive surgery without deforming or applying pressure to the surrounding tissues. Over time, the scaffold erodes with minimal swelling, allowing slow continuous tissue infiltration without mechanical degradation.

Bioresorbable tissue scaffolds
Credit: University of Birmingham

These new scaffolds offer several advantages over current approaches, including better elasticity, more ability to retain “shape memory” after compression, compatibility with tissues, and, of course, being bioresorbable.  The researchers describe them as “4D” materials because how the materials change over time is a factor.

The researchers believe: “By focusing on the design of a material with a unique combination of features, we have been able to achieve a minimally invasive 4D structure that could reduce surgical impact while enhancing rates of healing and patient recovery.”

Again, they’re not yet testing on humans, but a separate study – the INSPIRE study – has tested a Neuro-Spinal Scaffold that is made of a bioresorbable polymer on patients with a severe spinal cord injury, demonstrating “that the potential benefits of the NSS outweigh the risks in this patient population and support further clinical investigation in a randomised controlled trial.”

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I love the idea of using bioresorbable materials in health care.  I love the idea of an engineering form of medicine, just as I love the idea of a biochemical form of medicine.  Much of the history of medicine has involved inserting foreign substances/materials into us, with varying degrees of violence and success.   Bioresorbable approaches should give us better options.