I, Dr. Robot

Admit it: when J&J announced that its Ethicon division was teaming up with Google on surgical robotics, didn't you imagine that Google wanted to do for surgery what they are trying to do with (self-driving) cars?

I know I did.

For better or worse -- more on that later -- their ambitions are more constrained, at least for now.  It appears that Google's initial contributions will focus on using its expertise in improving the video feeds surgeon use, in and developing algorithms that add value to the images.  Wired, for example, says Google intends to "do things like highlight blood vessels and display critical information on screen."

They also cite a J&J spokesperson adding that perhaps Google's algorithms might also highlight the best places for incisions, based on the individual patient's medical history: "sort of a Google Maps for surgery," in Wired's words.

The Wall Street Journal similarly says that: "Google reckons it can use its machine-vision and image-analysis software to help surgeons see better as they operate or make it easier for them to get information that’s relevant to the surgery."  Google also told them that, "software could highlight blood vessels, nerves or the edges of tumors that are difficult to see with the naked eye."

Well, that's more like a rear view camera than a self-parking car.  Google could just give its newly patented "smart" contact lens to surgeons if that's all they are bringing to J&J.

Kevin Fogarty of Computerworld, for one, is underwhelmed by the announcement, saying that "Google's contribution will be things it is already good at, not the kind of really new capabilities robot-assisted surgical systems actually need."  As the title of his piece says, they're bringing vision to robots that need help with touch.

Touch is a surprisingly hard problem to solve.  There is work being done on it -- haptic feedback, as it is sometimes referred to -- to create what is sometimes called the "Tactile Internet."  The possibilities such breakthroughs might open up are mind-blowing.

Robotic surgery itself is nothing new.  It has been around about 30 years now, and is most often used for laparoscopic surgeries, especially for things like prostate removals.  The long time leader is Intuitive Surgical, Inc, with their da Vinci surgery product, which can cost $2 million per robot and perhaps $3,500 more per procedure than non-robotic laparoscopic surgeries.

With those kind of high capital and per-procedure costs, one would like to think there would be big improvements in outcomes and/or safety, but that does not seem to be the case.  A 2013 study in JAMA found little added benefit to robotic surgery, despite clearly higher costs.  Moreover, a Kaiser Health News special report that same year raised questions about whether anyone -- patients, providers, or regulators -- are getting the right information.

Some critics worry that the manufacturers spend more time creating consumer demand than training surgeons to use their equipment.  As one ENT told Healthline, "Intuitive are probably the worst at doing this and probably the most responsible. Their direct-to-consumer marketing is just criminal. Their lack of training, in my opinion it borders on criminal."

Yikes!  No wonder that robotic surgery was listed as one of ECRI's 2015 Top 10 Medical Technology Hazards (as it also was in 2014).

Robotic surgery started with the surgeon present, but by 2001 had already moved to telesurgery, where the surgeon was in a different location.  "Operation Lindberg" made international news in 2001 when surgeons in New York successfully removed the gall bladder of a woman in France.  Other such remote surgeries have followed.

The next logical step  would seem to be robots operating independently, starting with routine surgeries but over time graduating to more complicated ones.  Perhaps an autonomous robot would do just as well, or better.  Better vision, ability to make more precise incisions, faster reflexes, more massive and real-time knowledge base, maybe even a wide array of built-in attachments.  Perhaps humans just slow things up.

We shouldn't assume that the purpose of robots in surgery is simply to enhance our capabilities.

If we're going to have robots in health care, though, surgery may not be the area of most need.  After all, there are plenty of surgeons (although not well dispersed geographically) and we probably do too much surgery already.  On the other hand, one health care professional that we do not have enough of is personal care workers, and that shortage is only going to get worse.

Fortunately, robotics companies are already on it.  Toyota, for example, has a whole "family" of partner robots, including ones for health care  Disney even had an animated movie last year -- Big Hero 6 -- that featured such a robot.  That movie was set vaguely in the future, but let's hope the robot of personal care robots is not so far off.

The robots may be ready before we are.  A recent survey in the U.K. by The Institution of Engineering and Technology found that only 33% would use a robot to assist an elderly or disabled relative, while 17% would not even consider it.  Interest was lower when considering assistance for oneself.

As someone who has family members in long term care facilities which always seem to be short-staffed, my only question about using robotic aides to help them would be: where do I sign up?

The question is not really robotic technology will get sophisticated enough to add value in health care -- their role in manufacturing has clearly proven their ability to automate extremely complex processes -- as it is when the supporting software (dare I say "artificial intelligence"?) will allow it to operate with limited or even no human oversight.

Harvard Business Review recently proclaimed that "artificial intelligence is almost ready for business," and specifically cites health care as one of the leading applications, such as IBM's Watson.  Pittsburgh's UPMC, University of Pittsburgh, and Carnegie Mellon just announced their big data collaboration, which UPMC CEO Jeff Romoff says could lead to "doctor-less health care," a quote I bet his PR folks were trying to walk back as soon as the words came out of his mouth.  

Oh, there will still be doctors -- but they won't be our only option, for diagnosis, treatments, even procedures and surgeries.  Not tomorrow, probably not next year, but it will happen.

Of course, the licensing cartel will be a problem.  If organized medicine puts up barriers to doing telemedicine even for physicians who have licenses in other states, I have a pretty good idea how they'll respond to robots getting in on the act.  As was true with telemedicine, I suspect that the technical barriers will be breached well before the cultural and regulatory ones are.

If this kind of future sounds impossible to imagine, keep in mind the words of robotics pioneer Rodney Brooks:

In the future, I'm sure there will be a lot more robots in every aspect of life.  If you told people in 1985 that in 25 years they would have computers in their kitchen, it would have made no sense to them.

Looking for the Future in the Past

I don't get smartwatches.

Yes, I know; they're all the rage.  Apple unveiled its Apple Watch earlier this month, to generally good if not entirely ecstatic reviews.  Not to be outdone, Google announced a collaboration with TAG Heuer and Intel for a "Swiss Smartwatch."   Samsung and Sony are close behind with their own versions, and new players like Pebble Time are also throwing their hats -- or, rather, their watches -- into the ring.

Poor Fitbit, which held the early lead in wrist wearables, is now desperately trying to broaden its product line, including the new Surge.  They must feel a little like Garmin or Nikon did when mobile phones began to incorporate GPS tracking and digital phones, respectively, especially after Apple kicked them out of is stores.   Then again, Fitbit snubbed Apple's Healthkit first.

I have to wonder why the focus on the wrist.  It isn't the ideal place to track, say, your heartbeat, your sleep, or your steps, and as a result fitness trackers have been faulted about their accuracy.  Cramming features into a smartphone makes some sense, because they have become so ubiquitous, but I'm not sure who is clamoring to add more features to a watch.  Weren't they supposed to be on their way out just a couple years ago, especially among the younger generation?

The idea goes back to at least Dick Tracy's watch, which was already old when I was young (and that was a long time ago...).  Heck, they're making/remaking movies out of about every comic book hero, but I don't see any call for a new Dick Tracy movie.  Supposedly just for his watch.

We spent the first few generations of cell phones trying to make them smaller, and in the past few years have been reversing that trend, to the point where the distinction between a large mobile phone and a small tablet have become trivial.  Now we're trying to put more information on watches whose faces are even smaller than cell phone screens used to be?  This is progress?

In an so-to-be era of The Internet of Things, in which virtually anything can be a sensor or even a computer, are watches the best device to be either?  It's as if Timex and Casio, not to mention TAG Heuer, are conspiring to create a demand so that they don't go the way of Kodak.

Now, I have to admit, when mobile phones first included cameras, I was skeptical, so perhaps I'm similarly just missing the wow of the smartwatch.

It's not that I think they are a bad idea.  If you want to wear one, more power to you, and I hope it helps you with your health goals.  My problem with them is that I think they are an example of our trying to create the future by looking in the past.  PCs, laptops, and tablets are other examples.  They're very sophisticated and grow ever more powerful, but have we seen any ideas for them that Alan Kay or Doug Engelbart didn't propose over forty years ago?  Or, to use a more familiar example: I know Star Trek: The Next Generation was set in the 24th century, but it was filmed in the 1980's, and its fans are  convinced the iPad borrowed a lot of features from STNG's tablets (just as the 1990's flip phones supposedly were inspired by the communicators of the original Star Trek).

Shouldn't we be developing truly new technologies and uses for them?

I can't help but think about EHRs in this context.  Health care providers insisted on being subsidized for what would be normal business process improvement investments for any other industry, and settled for technologies that weren't what they really needed.  What we got for all the federal spending were products that physicians don't really like, that more often hinder than help with patient care, that patients rarely have access to, and that can't easily share data.  They, and especially their interoperability, were supposed to lead to better patient care and reduced costs, but those promises haven't been realized.

A new study in the Journal of the American Medical Informatics Association  suggests that, at least when it comes to PCMHs, we may be working from the wrong health IT toolbox.  We need tools that are more collaborative, more interactive, and more proactive.  Our provider-centered EHRs aren't cutting it.

Congress is already starting to ask what it has gotten for its $35b HITECH investment, even holding hearings to demand answers.  Yes, sure, some of this is partisan bickering, a way for Republicans to take potshots at an Administration-led initiative, but EHRs used to have bipartisan support and now have fairly bipartisan disappointment.

We don't even have an agreed upon way to figure out if providers have the same patient, much less share their data about that patient.  CHIME just put out a $1 million prize to someone who can solve this problem.  The financial services industry solved similar customer-identification problems decades ago, without prizes or government mandates.  They did it because it made business sense.

Not so in health care; not yet, anyway.

In theory, that kind of change will happen once we make that big move to "value-based" care, but as long as our baseline is our current level of spending, I'm skeptical.  We need approaches that attempt not just to reduce increases in spending but that aim to take big chunks out of spending.  There's no shortage of waste, duplication and unnecessary care that could be eliminated, not to mention the huge saving opportunities in keeping people healthier in the first place.

Smartwatches, EHRs, or proton beam therapy, to name a few examples, are not likely to help accomplish that.

Readers of previous posts may remember that I am fascinated by virtual reality, holograms, and artificial intelligence (yes, I realize that they, like tablets, also were featured in various Star Trek series; what can I say; I'm a sci-fi geek).  I want to see those kinds of new technologies in health care, not a smartwatch.  Technologies that help change how we think about "health" and how we treat problems with it.  I challenge health care technology gurus: show us something not just that we haven't seen before; show us something we hadn't even thought of before

As Alan Kay famously said: "The best way to predict the future is to invent it."

Better Health Takes A Village

Achieving better health, like many aspects of life these days, is rapidly becoming more social.

I'll start with the example of Facebook's apparent value in hospital ratings.  A recent study in The Journal Of General Internal Medicine found a correlation between hospital Facebook ratings and readmission rates as reported on Hospital Compare, which may come as a surprise to some.

The authors refer to using social media to track public opinion as "sentiment analysis."  They further note:

While we can’t say conclusively that social media ratings are fully representative of the actual quality of care, this research adds support to the idea that social media has quantitative value in assessing the areas of patient satisfaction – something we are hoping to study next – and other quality outcomes."

One can argue that readmission ratings themselves are at best an imperfect mechanism for evaluating hospital quality, but since a recent Health Affairs article found that four of the most commonly used hospital rating approaches -- US News & World Report, Consumer Reports, Healthgrades, and The Leapfrog Group -- didn't agree on what the top hospitals were, even using supposedly objective measures, maybe social media ratings are as good as we should expect.

I find it amusing when providers object to consumer ratings on the basis that they are subjective.  In the first place, they've had decades to come up with more objective measures that consumers -- or even other professionals -- can use, without noticeable success.  In the second place, consumers seem to be pretty happy with such "wisdom of the crowd" ratings, as used by, say, Amazon or Yelp.  The traditional pat response to such examples is that health care is "different."  Perhaps it is, but that distinction may be vanishing faster than health care experts like...or realize.

Sentiment analysis is anything but sentimental.  IBM is trying to help businesses understand public perceptions of them by analyzing Twitter, just as Nielsen is realizing it needs to co-opt Twitter's chatter about TV shows in order to stay relevant in TV ratings.   Health care talks a lot about Big Data, but may not fully realize the potential in the non-clinical sources of that data, such as social media.

Use of social media isn't all about ratings.  Social media and use of communities have been seen as a promising tool for helping people with chronic conditions for some time.  Cancer patients and survivors have a plethora of support groups and communities, Weight Watchers now uses meetings (in-person or online) as one of their key weight management tools, and the America Diabetes Association sponsors multiple communities to assist diabetics and their families.

Last year, the eHealth Initiative published A Report on the Use of Social Media to Prevent Behavioral Risk Factors Associated With Chronic Disease, covering both its promise and challenges.  While they acknowledge definitive research on its impact is yet to come, the key to its promise comes from the fact that: "Health behavior is fundamentally influenced, shaped, and defined by social networks composed of friends, colleagues, family members, caregivers, and others."

Unfortunately, that's not how medicine has usually been practiced.

The granddaddy of patient sharing sites is probably PatientsLikeMe, which began primarily as forums for patients with specific conditions, and now is a for-profit company that earns its living by sharing its member data with health researchers plus pharma or medical device partners, who don't seem to mind if that information is subjective.  Walgreens, for example, is going to use patient feedback from PatientsLikeMe to replace, or at least supplement, those nearly incomprehensible prescription side effect warnings.

Smart Patients offers a similar service to PatientsLikeMe, while Apple just announced ResearchKit, allowing Apple users to make their health data available to researchers, such as for clinical trials.  We're just starting to scratch the surface.

Even physicians are getting into the act of collaboration.  Figure1 has been described as "Instagram" for physicians, allowing them to upload photographs and patient information in order to get opinions from other physicians.  SERMO positions itself as a "virtual doctors lounge," allowing physicians to crowdsource tough cases (although I'd be curious to learn how much of that goes on versus, say, complaining about insurers).  They claim 300,000 members, all physicians, and competitor Doximity claims even more, so there obviously is significant demand for this kind of virtual collaboration. 

Health care is patting itself on the back for Open Notes, which is slowly allowing patients to at least view their own health records, including doctors' notes.  They claim 4.8 million members have such access.  I admire the initiative, but someone wake me when such sharing is the norm, instead of the exception.  I'll only start to get excited when patients' records become truly collaborative -- and it is the patient deciding what is shared, and with whom.

If the EHR industry isn't careful, it's going to get supplanted by a sharing approach.  Facebook could do it, or Google, but it would be very different than traditional medical records.  Think it couldn't happen?  Ask the taxi or hotel industries.

Collaboration will really get interesting when it gets involved more directly into processes of care.  The Wall Street Journal recently profiled how some hospital ICUs are allowing patients and their families to participate more directly in what is happening to the patient during his/her stay.  Think how much more powerful this approach will be when -- not "if" -- it allows patients in an ICU to communicate with each other about common issues/questions, or even with patients in other ICUs with similar conditions.  Or allow them to ping doctors in other locations to participate in their care.

The Journal article also discussed making the various processes of care more transparent, as well as tracking progress of tasks.  E.g., not just using checklists but sharing them with patients as the tasks are happening.  Patients in many health care settings spend much of their time waiting, not knowing what is happening next or when.  Forcing the provider to disclose what is supposed to happen, when, and by whom would force radical changes that should benefit the patients.

I thought of this when I read a New York Times profile of BetterWorks.  Although The Times headlined the approach as using "computer games" to manage employees, the keys are really transparent tracking of tasks and social media collaboration from other employees (e.g., they can give "cheers" or "nudges") to help employees improve their performance.  It may have some aspects of gaming, but it sure sounds a lot like what continuous quality improvement programs are supposed to do   I would love to see some health care organization implement BetterWorks or a similar approach.

Imagine if patients also got to weigh in.

Social media, patient (or provider) sharing and collaboration, and other 21st century social strategies won't, in themselves, ensure our better health, but it's hard to see that they won't be part of the process towards it.

The Sky Is (Still) Falling

Everyone seems to be writing about the Apple watch, which had its dog-and-pony show this week, but I'll leave that to others for now.  Instead, I want to talk about why it seems to be so hard to fill health care jobs.

Gloom and doom abound, as they have for decades.  The Association for American Medical Colleges (AAMC) just reported that by 2025 we'll face a shortfall of between 46,000 and 90,000 physicians.  Even more startling is that the shortfall is expected to be even larger for specialists than for primary care physicians.  Their 2010 projections predicted a shortfall of 130,000, so perhaps we should take these new projections as progress.

Similarly, a report by Georgetown's Center on Education and the Workforce predicts we'll face a shortfall of nearly 200,000 nurses by 2020, through a combination of newly created jobs and jobs open due to retirements.  According to the report, nurses account for nearly thee out of every five health care jobs.

Not to be left out, the American Association of Colleges of Pharmacy predicts a shortfall of 157,000 pharmacists by 2020, while HRSA projects a shortage of 15,600 dentists by 2025.  I suspect that it wouldn't take a lot more effort to find ominous projections for other health care professions.

I look at the explosive growth of retail clinics, or the increased emphasis on population health management and patient-centered-medical homes, all of which seem to require at least nurses, if not nurse practitioners, physician assistants, or even physicians, and the shortages seem to be understandable.

Still, I'm wondering: in a supposedly capitalist economy, why would there be these kind of shortages?  After all, these are relatively well-paying jobs, in one of the largest sectors of the economy and one of the few that promises to continue to have steady growth.  Shouldn't people be rushing to fill these jobs?

People in these professions might cite factors such as dealing with the competing demands of government, third party payors, and patients themselves.  As enviable as their salaries might appear to many other workers, many of these professionals have faced pressures on their earnings.  Plus, there is the economic burden -- both due to direct costs and due to missed alternative opportunities -- posed by the long period of education and training (up to 14 years in total for some physicians).  All these may be daunting to potential entrants.

Perhaps part of the answer was given, oddly enough, by the Supreme Court in a recent case, North Carolina Board of Dental Examiners v Federal Trade Commission.  It found that licensing activities can have the effect of being anti-competitive.

I mentioned the case in a recent post.  In short, it revolved around the Board's efforts to keep teeth whitening services limited to dentists.   The Supreme Court found that such state licensing boards were subject to antitrust suits unless any anti-competitive actions are specifically sanctioned by the state, and were under "active supervision" by the state.

This case seems somewhat far afield -- teeth whitening?  Dentists? -- but the implications are not trivial at all.  Rebecca Haw Allensworth and Aaron Edlin wrote an op-ed last week applauding the ruling, noting that 30% of the U.S. workforce is now subject to occupational licensing and that such licensing can have the effect of limiting competition.  The duo had previously written an in-depth analysis of the licensing mania -- Cartels By Another Name: Should Licensed Occupations Face Antitrust Scrutiny -- that was cited in the SCOTUS opinion.

Their use of the word "cartels" should not be taken lightly.

Their analysis listed the various licensing boards in Florida and Tennessee as examples, and it should come as no surprise that they include not just ones for dentists but also physicians (both M.D. and D.O.), nurses, pharmacists, chiropractors, podiatrists, and various other health care professions, not to mention cosmetologists and barbers, among others.  Health care has a lot of silos, each of which guards its own domain tightly and some of which occasionally try to encroach on others'.

The question that the members of the various Boards in every state should be asking themselves is: if we had to go to court, how many of our licensing requirements could we prove were strictly to protect consumers' best interests?

Think about, say, requirements that physicians licensed in one state can not "see" a patient in another via a tele-visit without a license from the patient's state, that a nurse practitioner must be overseen by a physician, or that a pharmacist can't prescribe (as they can in some countries)?  There certainly are arguments Boards could make for such restrictions, but let's hope the burden of proof for them is higher than "well, they're not physicians."

A lot of our health care licensing serves to mask the facts that (a) we don't really know how to measure quality, or value, (b) much of what is done is not based on empirical evidence (or, in some cases, has actually been shown not to work), and (c) we don't do a very good job of monitoring performance.  Having the requisite education, passing a initial examination, and doing some continuing education are used as proxies for actual evidence of providing value.

If I'm on that jury, such proxies would not suffice.

The various projections of shortages suggest not that we need to pump more money into the training and support of the existing professions, but rather than we're approaching the problem from their standpoint, instead of rethinking how we can provide health care services and support differently.

I would argue we need to see several things:

• Performance-based licensing: make the Boards require proof of unique value in return for any licenses that restrict others from performing certain services.  "Only we should do this" is not sufficient.
• Revamp medical education: as I've written before, our approach to medical education is too disjointed, too academic, and too long.  It's no surprise prospective applicants are not rushing to get trained.
• Health versus medical care: Our health care system is really a medical care system, too often addressing health issues only after they've manifested.  We should be catching problems earlier, helping people manage more on their own, and supporting them with professionals trained specifically to do lifestyle coaching.
• Be more open to new types of providers: I'm not just talking about so-called physician extenders.  I mean truly different kinds of approaches, like tinkering with the microbiome or gene therapy, that may be best suited for scientists who may not be physicians.  I'd go so far as to advocate a role for artificial intelligence in certain circumstances, and believe those circumstances will rapidly widen as AI learns more.  These new types of providers must still prove their value to be licensed themselves.

If the sky is, indeed, falling, let's be clear upon whom it is falling.  In any event, we probably shouldn't be standing still.

Cutting the Cords

I've been reading about various ways consumers are starting to "cut the cord" from many traditional sources of services, and I keep wondering: what's the equivalent in health care?

Let's look at some of the trends:

1. Landlines: Mobile phones (increasingly smartphones) are pretty much universal; a year ago Pew said 90% of adults had a mobile phone, and 58% a smartphone. As a result, landlines may be on their way out; already some 46% of U.S. households don't have a one.  Two-thirds of those 25-29 are exclusively mobile.  
2. Mobile carriers:  Mobile carriers have to look at the landline trends with both glee and dread, the latter because they may be next.  Ryan Knutson of The Wall Street Journal recently recapped his attempt to rely solely on Wi-Fi only service, which he deemed "definitely doable." So doable, in fact, that there's already a market.  In January Cablevison announced their low cost Wi-Fi only service, and Comcast has hinted it might not be far behind.  Companies like Republic Wireless are already offering Wi-Fi/cellular hybrids that are priced lower than most wireless carriers, a path that Google just announced they will follow
3. Cable: Streaming may be the new cable for watching TV or movies.  Many predict 2015 is the year that significant numbers of households will start getting rid of cable service in lieu of OTT (over-the-top content) options, which are starting to include such premium content as ESPN, HBO, and Nickelodeon.   Amazon, Dish TV, Hulu, and Netflix are all eager to replace your cable TV service.
4. Taxis: It's likely you've heard of Uber, and if you are under 30 and/or live in a large metropolitan area, you've probably used it instead of a taxi.  Uber claims it is a technology company, not a transportation company, an argument the taxi companies find frustrating in their attempts to equalize regulation.  Amazingly, Uber is already projected to be worth at least $40b and may be soon worth as much as $80b.  In some markets, like its home of San Francisco, it's already bigger than the entire local taxi industry.
5. Hotels: Airbnb is taking the hotel business by storm, doing for it what Uber is doing for taxis.  Airbnb's most recent investment round values them at $20b, and their million rooms is more than any of the traditional hotel chains.  Heck, even Warren Buffet recommends using them.

While Uber and Airbnb avoid investing in their own taxis or hotel rooms, respectively, in health care we're continuing to spend billions to make hospitals nicer, or at least prettier, despite a new study from Johns Hopkins researchers that indicate such new, supposedly patient-centered improvements have little impact on patient satisfaction.  As the study's lead author Zishan Siddiqui, M.D., said: "Hospital leaders will have to stop blaming poor patient satisfaction on aging buildings and units."

Maybe we need an Airbnb for hospitals.

In health care we're also still walking telemedicine just ahead of the sheriff, as the saying goes.  The Texas Medical Board is considering restrictive rules, which telemedicine vendor TelaDoc is fighting in court; new research confirms that state licensing requirements continue to be a burden; the AMA seems more concerned about protecting physicians from liability than in increasing patient options.

Organized medicine is still fighting to avoid cutting that in-person cord.

Roy Smythe, writing in Forbes, warns that health care is going to have to learn to operate differently. He believes health care must embrace "losing potential revenue and being progressively demonetized by technology."  As an example, he quotes Peter Anderson, Chief Strategy Officer for Sutter Health: "lab tests in the future will be home-based, and this will be both more convenient, and much cheaper than the current model"

That's not in the far-off future; Smythe cites Theranos and Diagnostics for All, both of whom are already upending lab testing.  Theranos can perform a full array of tests using just a few drops of blood or other bodily fluids.  DFA has a unique paper-based approach that can be used and interpreted even in the most rural areas, without needing a lab or a trained professional.

It shouldn't be surprising that Theranos is already teaming up with Walgreens to deliver their solution more conveniently to consumers.  Indeed, Tom Greene argues in Venture Beat that retail clinics, such as Walgreens' healthcare clinics or WalMart's primary care clinics, could do to health care what Uber is doing to taxis.  He notes that retailers know a lot more about customer loyalty than most health care organizations, and believes that to succeed health care also "...will have to embrace an Uber-like ecosystem that places a premium on convenience, availability, and access."

That's nice to think about, but I've written before that I worry that new entrants in health care may be more interested in getting their share of its bloated spending than in revamping how the system works for patients.  We really need fresh approaches.

I don't know who the Ubers of health care will be, but when I think about "cutting the cord" in health care there are two cords that I think are going to have to go:

• Third party payments: We've become lulled by the premise that other people -- e.g., health insurance or Medicare -- pay for our health care, and that fantasy has allowed the ridiculous prices and excessive utilization we see in health care.  We do need mechanisms to protect people from truly catastrophic expenses, and to help finance care for low income people, but most health care should be financed directly.  Note to health care innovators: figure out services that provide enough value to consumers that they will pay out of their own pockets for it.
• Practice of medicine regulations:  These exist ostensibly for the protection of patients, and have been part & parcel of health care for so long that we think of them as inviolate.  The fact that they are used, among other things, to prevent patients from doing a video consult with outstanding physicians who happen to live in other states, or even in other countries, illustrates that what they end up doing is protecting the providers who practice nearby.  That is not to say that physicians and other health care professionals don't and won't continue to add value, but we've allowed them to claim that value more on their simply having a license than on any demonstrated results.  That won't work in the 21st century; value may come from non-traditional sources.  Note to health care regulators: let's focus more on actually demonstrating value and less on the type of degree or license the person delivering it has.  

The health care system isn't going to get overturned all at once.  Change is most likely to come first for less complicated conditions and types of care.  And that's OK.  Once consumers see how different health care can be, it's going to be hard to avoid that tidal wave from reaching the rest of the health care system.

Cutting the cord can be scary, but if we do it right it will be liberating. 

Doctor, It's You, Not Me

We tout the physician-patient relationship as the cornerstone of our health care system, but it turns out it may not be particularly solid after all.  A recent survey by Vitals found that 70% of patients have a somewhat tenuous relationship with their physician.

Fifty-four percent described their relationship as "good enough for the moment," while 14% said "I'm not really into him/her," and 4% complained their physician was "cold and emotionless."  The remaining 30% claimed their relationship with their physician was "the one and only" (it should be noted that Vitals released the results around Valentine's Day).  Half of patients are already stepping out, using alternative sources of care like retail clinics.

Non-clinical factors are leading sources of complaints: lack of professionalism from the physician's staff (57%), difficulty getting an appointment (47%), long wait for the doctor (45%), and the condition of the doctor's office (41%).

Honestly, it's amazing that only half have gone elsewhere.

In-network status was the leading reason for choosing a physician (63%), far surpassing even location (37%).  Factors ostensibly related to quality trail: bedside manner (34%), education/credentials (30%), years of experience (18%), and patient reviews (16%).  I've said before that the approach of using provider networks is not only outdated but also contrary to patients' best interests.  Is in-network status really how we want people to choose their physician?

And we wonder why the physician/patient relationship is fraying, or why patient engagement is a problem.

It's interesting how health care is attacking patient engagement.  A recent report on patient engagement from Chilmark Research looked at the various technological options providers could, but usually don't, use in improving engagement.  For example, staying connected with patients between and after visits through patient portals, apps, or telemedicine.  That's all good stuff, and needs to be part of any solution, but such tools support but don't drive engagement, or relationships.

A perspective from Dr. Thpmas Lee in NEJM  was perhaps closer to targeting the problem.  Dr. Lee wants to reduce patient suffering, in all its many forms -- not just physical but also emotional suffering, such as through thoughtless interactions.  He urges providers to think more from the patient's perspective.  It sounds an awful lot like primum non nocere -- first, do harm -- that is supposed to be one of the guiding principles of medicine.

Still, reducing patient suffering seems somewhat of a necessary but not sufficient goal.  It won't sustain a relationship, and our goals for patient health should be more than "less suffering."

Many physicians, such as those involved in PCMH or ACOs, are using health coaches to try to stay connected with patients.  Health coaches are often nurses, sometimes might be physician assistants or nurse practitioners, but almost never are physicians themselves.  They are a good idea, but they sort of delegate the physician-patient relationship to the health coach.

Again, we should be aiming higher.

Many physicians complain that EHRs are adversely impacting their relationships with patients.  This has caused, among other things, a boom in the medical scribe industry, which some physicians feel allows them to interact with patients more directly.  Only in health care would anyone think having a third person present to take notes during an intimate encounter like an exam might help a relationship.

Opponents of scribes -- and you can include me in that number -- believe that they merely mask the EHR usability issues, instead of addressing them.  Researchers from UC San Diego have developed a "lab-in-a-box" to help do the latter.  It uses sensors and software to track physicians-patient interactions while using EHRs.  The lead researcher, Nadir Weibel, noted:

"With the heavy demand that current medical records put on the physician, doctors look at the screen instead of looking at their patients.  Important clues such as facial expression, and direct eye-contact between patient and physician are therefore lost."

Really, do we need sensors to identify what hampers physicians from connecting better with patients?  It strikes me that if the physician-patient relationship was paramount to physicians, then we wouldn't just now be scratching at the surface of how the EHRs impact that relationship.  Physicians have neither articulated well what makes the relationships work, nor demanded that EHRs support them better.  EHRs vendors should be falling all over themselves to differentiate themselves on how they can help improve patient interactions.

More on the right track, I think, is a tool called SHARE-IT, developed by researchers from McMasters University.  The concept isn't revolutionary at all; it simply allows physicians to present clinical information to patients in an interactive format at point-of-care.  As Thomas Agoritsas, one of the research fellows involved in its development, said:

"The process should be more about the discussion you have with your doctor and about enhancing the conversation, not overwhelming patients with too much information. It's less about showing the evidence than showing it in a way that it becomes a discussion."

Now we're getting somewhere.

Of course, the success of a such a tool depends on the physician taking the time to have that interactive discussion, rather than delegating it to a nurse or telling the patient to look at it later and let them know if they have any questions.  Sad to say, but it is hard to see that happening as often as it should.  Patients are lucky to get fifteen minutes with physicians, as physicians feel increasingly pressured to meet patient (revenue) quotas.

That, my friends, is why we have a physician-patient relationship problem.

We've gotten muddled about what we want from physicians.  They're trained to diagnose and to treat, and somehow the latter has become transactional: prescribe a pill, perform a procedure, refer to some other specialist.  Those are not the kinds of interactions that foster relationships, yet they are what consume physicians' time and drive our payment mechanisms.

With about half of us suffering from one or more chronic conditions, and as much as three-fourths of spending associated with chronic conditions, helping patients manage those conditions is one of the most important roles for physicians, especially for the rapidly vanishing primary care physicians.  They should be teachers (or coaches, mentors, whatever we want to call them) who help people make better lifestyle and other health choices on an ongoing basis, rather than being tasked with maximizing patient transactions episodically.  We need fewer transactions and more conversations.
 
The traits that make physicians great at diagnosis are not the same as those that make them great surgeons, and neither ensures they can help teach patients how to live healthier lives.  We lump all those skills together into what we ask of physicians, and that's a mistake.

Famed physician leader William Osler once said: "The good physician treats the disease, the great physician treats the patient who has the disease."  If we truly want better patient health, we need stronger physician/patient relationships, and so we need to figure out how to help more physicians become great.

How the Mighty Haven't Fallen

I recently read an article that speculated on how even the mighty Google could fade into irrelevance faster than we might think.  It made me wonder why that kind of change doesn't seem to happen in health care.

The Google article, by Farhad Manjoo in The Wall Street Journal, cited one-time technology leaders like Wang and DEC (for those of you with long memories), and pointed out that other long-time powerhouses such as Hewlett Packard and even Microsoft are furiously trying to reestablish themselves after decades of (relative) decline.  Most companies would love to have Microsoft's product position, revenue, and cash, but in 2015 most people would probably bet on Apple over Microsoft.  Manjoo quotes tech analyst Ben Thompson, who believes Google will lose out on brand advertising, which will go to companies that can create "immersive experiences" for consumers, engaging them for long periods of time.

Manhoo thinks Facebook is well-positioned to take advantage of the advertising shift, I'm thinking Twitch, but either way, it illustrates how even dominant market leaders in technology can get usurped almost overnight, the way Google did to 1990's search leaders like Inkatomi, Excite, AltaVisa, or Yahoo.  There's already a new DARPA-developed search engine called Memex which some say can do things Google search can't.  It is currently being used primarily for law enforcement activities (e.g., combating human trafficking), but perhaps in ten years we'll all be Memexing things on the Web instead of Googling them.

Then there's health care.

Just out of curiosity, I looked at share of spending by type of service in the National Health Expenditures, from 1960 to 2013.  Here's what I found:

Pretty astounding, isn't it?  For all our many clinical and technological advances, the same three health sectors that dominated health care spending in 1960 still command virtually the same shares in 2013 -- over 60% of our overall spending.  They've "lost" less than 2% of share to other types of spending during those decades.  

It hasn't all been smooth sailing, of course.  Hospital spending reached almost 40% of the total in the early 1980s (pre-DRG!), dipped below 30% in the early years of the 21st century, and has rebounded in this decade.  The physician share has been steadier -- a peak of around 22% in the early 2000's, a low of 18.3% in 1978, but mostly stayed around 20%.  Prescription drugs spending, on the other hand, got to as low as 4.5% of the total in 1981 and 1982, reached a peak of 10.4% in 2006, and now seems to be on a slow decline, despite various ominous warnings about the impact of expensive drugs.  But, all in all, the composition of Big 3 of the medical-industrial complex remains unchanged over a very long time.

It's as if the Big 3 U.S. auto manufacturers still maintained their 1960 dominance today, or the 3 TV broadcast networks still had their pre-cable/Internet share of viewers.  Both trios still have hefty market shares, still play key roles in their respective industries, but are nowhere near their historical dominance.  New competitors emerged to give consumers more options, and took away significant shares of those markets.  

Unlike what has happened in health care.  

To be fair, it is apples and oranges to contrast loss of market share for a single company with market share for a category of spending within a sector, but I think the point is illustrative.  I could look at share of, say, advertising spending for search engines in 1960 versus now but -- oh, that's right -- the search engine industry didn't even exist in 1960.  In most other parts of the economy, change comes so rapidly the past doesn't much resemble the present, but in health care that's not the case.

Hospitals, physicians, pharmaceuticals, and the health care industry generally have certainly evolved significantly in the past 50+ years, but it is more incremental evolution than the kind of "punctured equilibrium" Steve Jay Gould and others posit that result in rapid changes that overthrow species.  You'd think that the many crises our health care system has faced over the years would have offered opportunities for that kind of unexpected change, yet here we are, with a health care system that a time traveler from 1960 would easily recognize..

I don't have anything against hospitals, doctors, or prescription drugs, at least not in principle.  It just doesn't feel like progress that we're not coming up with radically new care and delivery options that don't rely on them.  

For example, IBM is trying to convince the FDA that it shouldn't regulate Watson, its "cognitive system" that it has used in a variety of health care and other contexts, in the same way it regulates medical devices.  I'm not holding my breath for the FDA to open things up.  I don't think the FDA has quite caught up with the concept of medical software (which could also include a number of apps), and I suspect the health care establishment is not going to be too supportive of allowing more latitude for such approaches.  Look at the ongoing battle about how to regulate telemedicine, despite overwhelming patient interest.  

Unlike most markets, health care isn't really driven by consumer demand.  A couple years ago, JAMA published a survey of physicians, in which  they blamed rising costs on pretty much everyone else but themselves, more than half even blaming patients.  A new study has cast doubt on the view that patient demand is driving unnecessary spending.  Looking at cancer patients, the authors found that only 1% of patients asked for clinically inappropriate care.  The saddest thing for me from the study was that only 8.7% of patient encounters included a patient demand.  We're a long, long way from informed patients taking responsibility for their own care, or their own health.

Having control over what constitutes the "practice of medicine" is certainly an effective way of forestalling new kinds of competitors.  That control has been placed in the hands of the providers practicing care, ostensibly to safeguard patients' interests,. but it's getting harder and harder to believe those interests are primary.  It seems more like protecting turf.  Our convoluted system of medical education similarly seems both old-fashioned and needlessly parochial.  If we don't address these kinds of self-serving mechanisms, the 2065 health care system might not look that much different than 2015's.  

A couple months ago I wrote a post that raised the question of whether, in a world where microbiome treatments, gene therapy, even nanobots may emerge as prevailing types of treatment, we'll even need physicians, at least in the same way we do now.  I received a number of comments that were aghast at the notion that we might not always need physicians to deliver our care.  I believe it is this kind of thinking that has allowed the Big 3 of health care to retain their dominance.  

If we can't even imagine a health care system that doesn't solely rely on the traditional sources of care, we'll certainly never achieve one.