Raspberry Pi Healthcare

Like many of you, I have been intently following the war in Ukraine, cheering for President Zelensky and the Ukrainian people, while hoping it doesn’t end up in WW3.  I thought about trying to write about it, then I saw that Raspberry Pi just turned ten, and I thought, yeah, that’s more my speed. 

Credit: Raspberry Pi

And, of course, easier to relate to healthcare.

For most of us, a computer is our smartphone, tablet, or laptop.  We buy them already designed and built, complete with an operating system and other useful software.  There’s an almost unlimited range of other software that can easily be downloaded to run on them.  Ease of use is paramount. 

This was not always so.  If you are of a certain age, or have studied the history of computers, you’ll know that in the 1970’s and early 1980’s, (home) computers came in a kit.  You assembled them and figured out what you might want to use them for.  Then came Apple and the PC revolution. Our expectations about what computers could do grew as our expectations about what we had to do diminished.  Between 2006 and 2011, Eben Upton and his collaborators sought to change this.

They wanted to make a computer that was programmable, fun, affordable, and robust.  In 2012 – February 29, to be exact – they released the Raspberry Pi.  It sold for $35.  They hoped to sell perhaps 10,000 – 20,000, but sold over 1 million of them within a year. They’ve now sold over 45 million, making the Raspberry Pi one of the best selling computers of all time. It comes in many different versions and price points, but all adhering to the four basic goals.

As Mr. Upton now says: “In the ten years since, we’ve built a company, a charitable foundation, and a movement that has begun to change the world.”  The Raspberry Pi Foundation oversees the development, holds the intellectual property, and “works to put the power of computing and digital making into the hands of people all over the world.”

The Foundation is particularly focused on engaging young people:

We engage millions of young people in learning computing and digital making skills through a thriving network of clubs and events, and through partnerships with youth organisations. We enable any school to offer students the opportunity to study computing and computer science through providing the best possible curriculum, resources, and training for teachers. We work to deepen our understanding of how young people learn about computing and digital making, and to use that knowledge to increase the impact of our own work and to advance the field of computing education. We make computing and digital making accessible to all through providing low-cost, high-performance single-board computers and free software.

For example, Raspberry Pi recently released Introduction to Python path, introducing the widely used Python programming language to young coders, “designed to get young coders familiar with the underlying principles of 'true' programming languages used in the real world, such as syntax, using variables, and defining functions.” The initial projects involve games and animation to make them more familiar to young audiences. The target age range is 9 to 13.

Similarly, the European Astro Pi Challenge: Mission Zero allows young people to code experiments on the International Space Station, and/or send messages to the astronauts on it.  Fifty-four thousand young people have participated in previous Astro Pi challenges.

Their community is not just teen/pre-teen enthusiasts.  Cliff Saran, writing in Computer Weekly, points out:

It is amazing to see how the Pi has been used. From running music streaming and controlling robotics to operating high performance clusters, the Pi has fueled endless creativity and ingenuity. Some electric vehicle chargers and other smart devices use embedded Raspberry Pis. It has even been used in high performance computing.

As the Foundation brags, Raspberry Pi is now a “movement of millions of people of all ages and backgrounds.”

Some of those people are already using Raspberry Pis in healthcare, including various forms of monitoring, screening, and even MRI analyses. As Rob Zwetsloot of The MagPi 82 wrote, medical and health applications are “usually some of the most impressive displays that we see at Maker Faires, Coolest Projects, and other events where folks are showing off amazing projects.”

I love that Raspberry Pis are already being used to directly help improve health and healthcare, but I think the bigger benefit are those four principles that guide the movement -- programable, fun, affordable, and robust.  

In healthcare, as has happened in computing, most of us have grown content to get the benefits while delegating how those benefit happen to a cadre of highly trained, very smart, expensive experts – physicians and other scientists in healthcare, computer programmers and scientists in computing. 

Raspberry Pi is here to say that, no, we can be those experts. We may not be able to do everything the experts can do, our products may not be as powerful or as sleek as the ones they develop, but there is a lot we can do.  Healthcare has a fledgling DIY movement (DIY pancreas, anyone?) that is gradually getting some acceptance from medical professionals, but it’s hardly embraced. We can do more.

Raspberry Pi is also here to say, start them early.  Kids love their screens, at ever younger ages. The Foundation’s work has shown that young people can be encouraged to tear themselves away from their slick devices in order to program for themselves. In a time when the health of our young people seems to be getting worse, where’s the equivalent movement to get kids more involved with, and excited about, their health?

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I first wrote about Raspberry Pi six years ago, when the Raspberry Pi Zero came out, priced at $5. A computer for $5!  I asked, “Where’s our $5 EHR?  Where’s our $5 MRI?”  People in healthcare scoff at such idea, but people at Apple or Microsoft probable scoffed at the idea if a $5 computer too.

I just read today how “China has embarked on a technology-led revolution to create a brand-new health care ecosystem.”  For example, it has “internet hospitals” whose services “are almost entirely online.”  Those are approaches Raspberry Pi could understand, but not, apparently, U.S. healthcare.    

Some look at Raspberry Pi and see a toy.  I look at it and wonder if what it can tell us about the future of healthcare.

Get Ready for (Healthcare) Microgrids

We depend on it.  Indeed, our daily lives are unimaginable without it.  The trouble is, it’s become unreliable.  Lives have been lost because it wasn’t performing when it needed to be.  It’s built around large facilities that are often decades old.  Parts of it don’t communicate/coordinate well with others.  Its workforce is aging and burnt out.  There is no person or agency charged with ensuring its resiliency. It badly needs to be rethought for the 21^st century.

Credit: Microgrid Knowledge

Oh, you thought I was talking about our nation’s power grid?  I was talking about our healthcare system. 

The parallels are striking, and concerning.  They’re huge industries, based on early 20^th century approaches, and beset by 21^st century challenges to which they may not be easily adaptable.  If we don’t manage their evolution to the 21^st century right, we’re dead.  Literally. 

The power outages in Texas last year caught everyone’s attention.  Texas prides itself on being an energy producer, but its power industry was caught flat-footed by “unexpected” winter weather that many had, in fact, predicted.  People went for days or even weeks without power. 

Oh, that’s Texas, people elsewhere might say. They hate regulations, they love low prices, their power grid isn’t (for the most part) connected to other grids, so the failures were not really surprising. Maybe, but it’s not just Texas.  The Wall Street Journal reported:

Large, sustained outages have occurred with increasing frequency in the U.S. over the past two decades, according to a Wall Street Journal review of federal data. In 2000, there were fewer than two dozen major disruptions, the data shows. In 2020, the number surpassed 180.

In fact, the article says, “Utility customers on average experienced just over eight hours of power interruptions in 2020, more than double the amount in 2013.”  Our power plants and transmission lines are aging badly, we have a phobia of nuclear that is also starting to apply to coal as well, climate change is throwing more extreme weather at us, and many of the renewable options (solar, wind, geothermal) are not quite ready for prime time yet. 

So, get a generator.  In fact, many people are.  That’s fine, if you have the money (often $10,000+), can get the fuel and can keep the generator in working order, and will only need them for limited amounts of time.  That’s a lot of “ifs.”

That’s where microgrids come in.

According to Microgrid Knowledge,

A microgrid is a self-sufficient energy system that serves a discrete geographic footprint, such as a college campus, factory, hospital complex, business center, military installation or neighborhood. Microgrids can operate independently from the grid using power generated on-site; they can also be used for backup power. Microgrids are designed to operate consistently in both “blue sky” and emergency situations supported by a range of energy resources, such as renewable energy, energy storage, combined heat and power or generators.

Their definition somewhat snidely concludes: “It’s easy to know which buildings have microgrids. They are the ones lit up during grid outages, while surrounding buildings remain in the dark.”

Credit: Illinois Institute of Technology

A Chicago neighborhood is about to become “the country’s first neighborhood-scale microgrid” – one that proponents believe “could serve as a model for utilities and communities across the country.”  The US Army plans to have microgrids on all of its 130 bases world-wide by 2035.  Many universities, hospitals, airports, and business parks have already developed microgrids.  They are an idea whose time has come.

Healthcare needs to literally join in.  If there’s a hospital, nursing home, pharmacy, dialysis center, or other health care facility that hasn’t already become part of a microgrid, it’s time.  Those 1960’s-era backup generators are not going to cut it.

Healthcare needs to figuratively join the microgrid movement.  Think of hospitals as the traditional power plants, the loci of the healthcare system.  Everything revolves around them, especially as they’ve bought physician practices, developed more outpatient facilities, and consolidated.  They control how healthcare is practiced and at what cost in their community/region. They power the system.

That’s worked for us, in our dysfunctional U.S. healthcare way, but the cracks are showing. We don’t like how much we’re paying, we’re not seeing that monopolies/oligopolies are getting us higher quality care, and in the pandemic hospitals did not prove to be enough.  Their staffs – which had already been stressed by staffing issues/EHRs/other problems -- were overwhelmed, and started leaving.  Patients stacked up in hallways, there wasn’t enough of some critical equipment/supplies, dead bodies had to be held in refrigerated trucks. 

We’re effectively seeing healthcare’s versions of brownouts, or even blackouts.  If there is one thing our healthcare system is not, it is resilient.

A healthcare microgrid would more effectively keep people out of hospitals.  It would rely less on physicians, especially specialists.  It would be community-based.  It would be available 24/7, and be able to flex capacity as needed.  It would be “smart,” and incorporate as many 21^st century technologies as possible, such as home monitoring.  Unlike actual microgrids (but more like most power grids) and unlike current medical practice, it would freely cross city/state/regional lines.

Credit: Getty Images

Telemedicine is an example of what should be included in microgrids.  The pandemic taught us the value of telehealth, but lots of existing rules had to be waived for that to happen.  Those rules are being reimposed, just as many of us are going back to seeing physicians in person. Some hospitals are bold enough to impose facility fees for telehealth visits. Those are all signs that telehealth is not part of a microgrid; it’s being coopted by the power plants – er, hospitals.

Similarly, are we really taking advantage of nurse practitioners or physician assistants can do?  Why do we even think of nurse practitioners as “nurses” or PAs just as assisting physicians?  Do we give pharmacists as much authority as their training would allow for? 

And, of course, when are we going to get AI that can be our first line of medical advice, and perhaps more?

These are microgrid questions. They’re not questions we should only be considering during times of extreme crisis, like the current pandemic; they are questions we should be answering for the next crisis.   

The analogy is not perfect. I don’t know exactly what a healthcare microgrid would look like.  But, just as I know traditional power grids are not going to be enough for our energy needs, our traditional healthcare system is not going to be enough for our healthcare needs. We need something more resilient and more localized.  We need healthcare microgrids.

Imagining a Different Future

Two articles have me thinking this week.  One sets up the problem healthcare has (although healthcare is not explicitly mentioned), while the other illustrates it.  They share being about how we view the future. 

Credit: Sanofi

The two articles are Ezra Klein’s Can Democrats See What’s Coming? in The New York Times Opinion pages, and Derek Thompson’s Why Does America Make It So Hard to Be a Doctor? in The Atlantic. Both are well worth a read. 

Mr. Klein struck a nerve for me by asking why, when it comes to social insurance programs, Democrats seem so insistent on replicating what has been done before, especially in Western Europe.  He asks: “But what about building here what does not already exist there?”  He worries “that the Biden administration’s supply-side agenda is stuck in the past and not yet imagining the future.”

Those are exactly the right questions we should be asking about healthcare.

Our most ambitious healthcare reform proposals seem to either be the catch-all “Medicare For All” or the simplistic single payor. Both are rooted in the past, and in what has been done elsewhere.  We debate what coverage for which things who should have, how much they should have to pay at point-of-care versus upfront in taxes/premiums, and how much we should pay healthcare providers.  They are the same questions we’ve been debating since the 1940’s. 

They’re not the questions for the 21^st century. 

Mr. Thompson takes on what a mess our medical education and training “system” is, and wonders why on earth we make it so hard for people to become physicians.  It’s harder, longer, more expensive here than almost anywhere else, and we end up with fewer physicians per capita than most other developed countries. We even make it hard for doctors to immigrate. “No matter what the pandemic future holds,” he asserts, “we need more doctors to be part of America’s health-care system.”

I’ve written previous on reforming medical education and on rethinking primary care, so I heartily applaud those aspects of Mr. Thompson’s article, but I stop short of endorsing the call for an “abundance” of doctors.  What we need, as I’ve argued before, is not more doctors but fewer patients. 

Yes, many people have to wait too long to see doctors, while others never get to see them at all, and most of us pay way too much for all kinds of health care.  Certainly our healthcare system is severely flawed, with huge gaps and inequities at every turn. But more Band-Aids, more-of-the-same is not what we need.  We need to be, as Mr. Klein urges, “imagining the future,” not simply patching up our rickety 20^th century healthcare system.

Umm, yes. Credit: Harvard Health

Here are some thoughts:

Data: if the pandemic has exposed anything, it is that we really have no idea what is really going on with our health or in our healthcare system.  We don’t really know how many have contracted COVID, how many have been tested for it, how many have been vaccinated against it, or even how many have died from it.  People have valiantly done their best to estimate all of these and more, but, let’s not kid ourselves, they’re estimates. And COVID is something we’ve been paying a lot of attention to, and spending a lot on. Imagine the rest of our data.

A 21st century healthcare system needs to start with data, at every stage, from self-monitoring at home to everything that happens to us in the healthcare system. It needs to be built to collect that data, to ensure that it flows easily, and that it is collected in ways that are actionable. Data cannot be the afterthought of care; it needs to be built-in at the ground level, designed into the system.

It’s already 2022, and we don’t have the right data, much less the right ways to capture and use it.

Health, not Medical: it has been oft said, but it bears repeating – we don’t have a healthcare system, we have a medical care system. Things that happen outside of a physician’s care are usually outside of the system too.  We talk about social determinants of health, but they mostly remain outside the system.

Public health has taken a beating during the pandemic, after years of benign neglect, but if we were serious about addressing our health needs, we’d be spending a lot more on it and expecting a lot more from it. Most of our health issues start with public health issues. 

The trick will be reinventing public health for the 21^st century, not just grafting 21^st technology on top of 20^th century public health structures, from physical infrastructures to information campaigns to staffing.

DIY: the miracles of 20^th century medicine further elevated physician to near god-like reverence, but the miracles of 21^st health are going to level that playing field, much more than the internet has already done.  Innovations like AI, 3D printing, synthetic biology, and nanoengineering are already showing how radically different our health care can be, and we’re only scratching the surface of what each can do and how they can be applied to healthcare.

Let the biohacking begin! Credit: Yetisen

Each is going to both get more powerful and cheaper, and each will be in the hands of more people.  We’ll know earlier when we have a problem and how to address it, and we’ll usually have the means to “fix” it.  A topside down healthcare system isn’t going to cut it. Moreover, our healthcare spending is going to be significantly different – lower! -- when we’re using what will essentially be consumer goods instead of taking trips to the healthcare system.

The 21st century healthcare system needs to foster/expect DIY.

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Alec Stapp, cofounder of the Institute for Progress, told Mr. Klein: “This isn’t about government controlling the means of production. It’s about government controlling the ends of production. Deciding what we are producing toward, what we are building for.” Those are the decisions we really need to make when thinking about healthcare reform.

E.g., I’d rather the government be building that data infrastructure instead of spending more on graduate medical education.  I’d rather the government be directing more money to public health infrastructure than in bumping up Medicare payment levels.  I’d rather the government be giving tax breaks to biotech companies than to “non-profit” hospitals. 

Be bold.

As long as our healthcare system looks familiar to those of us born in the 20^th century, we’re not thinking boldly enough. We should be imagining a future that does not yet exist, and that will look familiar to people who will still be alive for the 22^nd century.

Take a Tip From Domino's

If you’re already thinking ahead to next Sunday’s Super Bowl, you might be thinking about Domino’s, because, as everyone knows, pizza and football go together like mom and apple pie.  I’m thinking about Domino’s too, but not because I’m planning my order.  It’s about their new program to reward customers who do more of their own work. 

Ahem, healthcare: pay attention.

Credit: Domino's

Last week Domino’s announced that customers who picked up their own orders, rather than using delivery, would earn a $3 tip.  Art D’Elia, Domino’s executive president and chief marketing officer, explained:

It takes skill to get pizza from a Domino's store to your door. As a reward, Domino's is giving a $3 tip to online carryout customers who take the time and energy out of their day to act as their own delivery drivers. After all, we think they deserve it.

The program – Domino’s Carryout Tips – isn’t quite as rewarding as it might sound.  The $3 is actually a credit on your next order, and that credit has to be used by the following week.  There’s a $5 minimum to qualify, and orders have to be online.  The program was announced in time for the expected Super Bowl surge, and is scheduled to end May 22. 

But still.  I don’t like waiting for deliveries, I do like pizza, and if I ordered a lot of Domino’s (which I don’t), the $3 tip would be decent discount, even if I had to order even more Domino’s to actually get it.

Domino’s once was famous for it’s “30 minutes or it’s free” delivery guarantee, until it lost a $78 million lawsuit in the early 1990’s, as the court agreed the promise resulted in reckless driving (and even, it was claimed, multiple fatalities).  Still, during the 1980’s that promise catapulted the chain to be the biggest pizza chain in the U.S., a position it still holds (it now is also the largest in the world).

Although the tip initiative was portrayed as a customer reward program – Mr. D’Elia is, after all, the chief marketing officer – most analysts believe it is more about labor shortages.  Domino’s, like many companies and especially those in the food service industry, is struggling to attract/retain enough workers, including those delivery drivers.  So if customers want to be their own delivery driver – Domino’s ad literally shows that – hey, that’s worth a $3 credit, right? 

In 3Q 2021, Domino’s suffered its first decline in same store sales in over a decade; initially the pandemic had been very good for pizza sales, but the combination of of fewer workers, higher supply prices, and ongoing competition took its toll.  At the time, Chief Executive Richard E. Allison, Jr. noted: “The carryout business will continue to be a focus of ours, given the significantly lower amount of labor involved in those transactions, We’re going to continue pushing there.”

Thus, Carryout Tips.

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Healthcare has its own share of pandemic woes, most of which exacerbated existing problems.  Healthcare workers are burnt out, and many are simply leaving – about one in five, according to some estimates. Patient data continues to be siloed despite huge gains in electronic health records; not only do different EHR vendors not communicate well, different health systems using the same vendor have problems.  Patients not only often don’t have good health habits but a surprising number don’t follow their doctor’s orders, including medication adherence.  Health inequities abound.

Credit: Mighty Casey Media

Somebody needs some $3 tips.  Well, actually, given health care prices, there better be a lot of zeros after the number, and I’m not talking decimal points.  We’re doing way too much of the work, for free.  For example:

·       Have you ever filled out a form in a healthcare office that you’d already filled out previously, either there or in another office?  You get a tip!

·       Have you ever had to carry some of your health care records (either on paper or on a CD) from one healthcare office to another?  You get a tip!

·       Have you ever had to take time off work to sit in a healthcare office or facility, waiting long past your scheduled appointment?  You get a tip!

·       Have you ever had to fight with a healthcare organization about incorrect bills, or with an insurance company over incorrect payments?  You get a tip!

·       Have you ever been a caregiver for someone with acute or ongoing health care issues?  You get a tip!

You get the idea, and you probably have your own suggestions.  We’ve all had encounters with the healthcare system that felt way too hard, during which we felt we were doing more of the work than we should have had to.  Frictionless, it is not. 

The healthcare industry would say, well, nice idea, but there’s no money for that.  We could do that, it might say, but, of course, we’d have to charge more in order to pay for all those tips.  I would say, balderdash.  There’s plenty of money; it’s just going to the wrong places.

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I’m not naïve.  Domino’s is not offering its tips because it truly wants to reward its customers.  It’s doing it mainly because delivery drivers are scarce and too expensive.  If it can persuade more customers to be their own delivery drivers by offering a $3 credit, better for Domino’s, and if the $3 engenders some extra customer loyalty, better still for Domino’s. 

Similarly, healthcare workers are expensive and becoming increasingly scarce.  There weren’t enough of them before the pandemic, and there certainly aren’t not enough of them now.  Given the way they’re leaving the industry, there aren’t going to be enough of them once the pandemic becomes endemic and things reach a “new normal.”

Healthcare better find ways to incent patients to take on more of the work.  Appeals to “more self-service” or even to “managing your own health” aren’t going to be enough.  Healthcare organizations need to be thinking about financial incentives.  Call it a tip, call it a credit, call it a customer loyalty reward, but they should find some way to acknowledge, and reward, patients for the various ways they provide unpaid work in our healthcare system.

A healthcare “thirty minutes or its free” promise wouldn’t be a bad start either.

Maybe healthcare organizations could at least order pizzas for patients…although they’d probably expect them to pick them up.