Not All Snake Oil Is Digital

The head of the AMA -- James Madara -- got a lot of headlines with his speech at the AMA annual meeting last weekend that, among other things, warned of the "digital snake oil of the early 21st century."  Dr. Madara included in this category "from ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality.

Dr. Madara is frustrated with products that make care less efficient -- he cited an AMA study that found 50% of physician's time was spent on a keyboard, making them "the most expensive data entry workforce on the face of the planet" -- while interfering with the patient-physician relationship, and many of which have no proof of efficacy.  

Not surprisingly, he scorns the DIY health movement.

But, not to worry.  Dr. Madara promised that physicians will be involved in future generations of such digital products, rather than their being developed "flying on an entrepreneur's incomplete views."   He seems to believe that digital health vendors have neither consulted with physicians nor have any on their teams.  He also ignores the fact that health care providers have allowed the federal government to pay out some $33b in our tax dollars on those digital snake oil EHRs for them, rather than holding out on principle for better products.

A different take on "snake oil" in health care was a thoughtful piece in Health Affairs, by David Newman and Amanda Frost, discussing the quality measurement morass in health care.   They cite a study that estimated we spend some $15.4b annually collecting several thousand different quality measures, few of which have any meaning to consumers and all-too-few of which seem to be used to actively improve quality.

It isn't that they don't think we should be measuring quality -- far from it -- but, rather: "Patients should not be able to choose substandard quality care, and substandard quality care should not be allowed to be offered in the market."

Now, there's a novel concept!

They noted that you can't eat at restaurants that fail their health inspection, even if they were to offer lower prices to compensate for the lower quality.  They're closed until the identified issues are addressed.  Yet you can get care from providers who are known, objectively or subjectively, to be delivering substandard care.  And, oh, by the way, the people overseeing who is allowed to keep delivering care are other physicians; it is as if the restaurant association was responsible for those restaurant health inspections.

Dr. Newman and Dr. Frost want to hold providers, payors, managers, professional associations, and regulators responsible for demanding quality improvement, rather than throwing a bunch of quality metrics at consumers in hopes that they will sort it out somehow.

That's the kind of snake oil that the AMA should be targeting.

It's not just poor quality care.  It's also care of questionable -- or even no -- value.  Stat News just published an article profiling a tool that most consumers, and probably many physicians, have never heard of.  It's called "number needed to treat," or NNT.  It is a calculation that quantifies how many people would need to get a given therapy in order for one person to benefit from it.  You'd think that number would be close to one, but it rarely is.

For example, seven post-surgical patients have to wear compression stockings to save one from developing deep-vein thrombosis (blood clots).  Moreover, the downside risks of wearing them are minimal, so having them as a common practice makes sense.  On the other hand, 104 healthy people would have to take statins for five years in order to save one from a heart attack.  Almost 1,700 healthy people need to take aspirin every day for a year to prevent one heart attack or stroke.

Those are not such great odds of success.

Experts suggest that NNTs of 5 or less are associated with a meaningful health benefit, and over 15 probably at best only a small one.  The amazing thing is how many therapies have high NNTs.  The NNT website rates therapies into four categories:

• Green: clear health benefits that outweigh any associated harms.  Example -- antibiotics for open fractures.
• Yellow: the data are not clear about benefits/risks and require more study.  Example -- antibiotics for sinusitis.   
• Red: Benefits and harms are about equal.  Example -- antibiotics for acute bronchitis.  
• Black: "Very clear" associated harms without any recognizable benefit.  Example -- PSA test for prostate cancer.  

NNT also reviews diagnostic evaluations, providing a color-coded summary of how helpful they are for the particular disease conditions.  Again, there are extremely wide variations.

The question is twofold: one, why are so many of the therapies with red or even black ratings still performed, and, two, why isn't the NNT always part of the conversation with the patient?   For that matter, why isn't the NNT available for more therapies?

Yes, certainly EHRs should be better.  Yes, direct-to-consumer digital health products and apps should be thoroughly (and transparently) evaluated.  Yes, physician offices should be part of the digital data ecosystem surrounding each person, taking advantage of, and contributing to, data about that person and the broader population.  And, no, data entry is not what we want our health care providers spending the majority of their time on.

But all that is the tail wagging the dog.  In the early 21st century, we should have better data on the effectiveness and risks of what is being done to patients.  That data should be available to guide physician recommendations and patients' informed consent about their care.  Those are the discussions we deserve to be having.

If we're making decisions in the absence of such data -- or despite it -- then we're back to the "snake oil" days Dr. Madara proudly claims the AMA took care of over a hundred years ago.  This time, though, they're the ones selling it.

If we're going to be talking about "snake oil" in health care, there may be better targets than apps.

This Actually Is a Test

When it comes to health care, testing is not what it used to be, or what it is going to be in the not-too-distant future.

For example, confirmation of a cancer diagnosis is getting much easier.  The New York Times reported that blood tests -- known as "liquid biopsies" -- have now been shown to generally match the results of a tumor biopsy.  The blood tests look for DNA fragments from the tumor that signal its presence.  The liquid biopsies are useful for both detecting the presence of a tumor and its ongoing monitoring.

The current generation of tests are not perfect, with as many as 15% of tumors not generating enough DNA to be detected, but they do offer the advantage of not requiring an invasive procedure.  The expectation is that testing will get even better, allowing for earlier detection of more cancers, although the problems of both false positives and detection of tumors that would not end up harming the patient if left untreated remain.

The FDA has just given approval for one such test, and numerous companies are vying for position in the space -- STAT reports that some 38 companies in the US alone are working in it.  With direct-to-consumer lab tests becoming more of an option, we may soon have more cancer diagnoses, with more decisions required about what needs to be treated versus just monitored, and, indeed, what is "cancer," since some tumors grow only very slowly or not at all.

Still, if we have a choice -- and we soon will in many cases -- most of us would probably opt for a blood test rather than a biopsy.

The concept of what constitutes a "test" itself is undergoing some broadening.   Instead of an actual test, liquid or otherwise, Microsoft reported that they may be able to use your search history help determine if you have cancer, even before you or your doctor realize it.  They think their approach can be extended to other serious illnesses, helping catch them at earlier stages.

The Microsoft researchers used search logs to identify people whose queries strongly suggested they'd been diagnosed with pancreatic cancer.  Then they worked backwards on those people's search histories to determine what kind of queries were associated with the subsequent diagnosis.  There may not have been any actual diagnostic tests or procedures done yet, possibly just searches on symptoms, but they found "signals" in the search history.

The method isn't perfect, but the researchers claim: "We find that we can identify 5 to 15 percent of cases while preserving extremely low false positive rates."  They believe their false positives are on the order of 1 in 100,000, which compares very favorably to most actual diagnostic tests.

Gosh, if Bing can do that, imagine what Google could do

The researchers were quick to note that their research was only a proof of concept and that Microsoft has no plans to develop a product based on the discovery (which seems odd!).  Instead, they wanted to get the medical community "excited" about the approach in hopes that it could end up being used as an early warning system for serious diseases.

Microsoft researchers had previously used search data to help identify unreported prescription drug side effects, and there was also the Google effort to use search data to help predict flu epidemics, which ended up not quite working out as planned, although the approach is far from dead.  These examples all illustrate that artificial intelligence can use Big Data to find things out about our health that we might never have otherwise found, or found out too late.

One of these days you may be typing in a search and Cortana politely but firmly might suggest that you better see a doctor for a specific potential diagnosis.  It might even set up a Skype call with a specialist for you.

Some of the most intriguing changes to testing relate not to diagnostic tests, but to clinical trials.  Researchers at the Lawrence Livermore National Laboratory are developing a "human-on-a-chip" that they hope could predict the impact of drugs, viruses, or toxins on humans.  The chip, known as iCHIP, essentially models the workings of human biological systems -- currently the central nervous system, peripheral nervous system, the blood-brain barrier, and the heart.  Actual cells, such as neurons, are seeded on a chip, and microelectrodes can do real-time monitoring of electronic signals from them.

The hope is that use of iCHIP will lessen or even eliminate the need for animal or even human testing.  Use of animals for testing (particularly for cosmetics) has become highly controversial, even banned in some cases.  Congress is close to passing a bill that would encourage the use of alternatives to animal testing.

There are both ethical and efficacy questions with animal testing, so iCHIP may be an idea whose time has come.  Indeed, iCHIP's principal investigator boldly says: "The ultimate goal is to fully represent the human body," integrating all the biological systems together to create a "complete testing platform."

Chimpanzees everywhere may be breathing a sigh of relief.

If Microsoft is using Big Data to take the place of many standard diagnostic tests, a company called Insilico Medicine is trying to do the same with clinical trials.  They use deep learning and artificial intelligence to predict how a drug will impact human cells, rather than relying on animal trials.  

Alex Zhavoronkov, Insilico's CEO, believes that:

"...animal testing is not very representative of what the human outcome will be...We need something better, and something better is creating a virtual human to simulate the activity of many drugs on many tissues at once.  That can only be done using really deep data."  

Creating a "virtual human" or putting all the human biological systems on chips are ambitious goals, especially given our increased recognition of both the complexity and importance of our microbiome (whose cells outnumber ours).  On the other hand, no one is particularly happy with the cost and timeliness of clinical trials, animal or human, and identifying health issues sooner and less invasively is certainly desirable.

OK, so maybe we're not getting a tricoder anytime soon, but, all in all, we're making real progress on testing.

Fewer Moonshots, More Walks

In a provocative op-ed piece, Jarle Breivik, a professor of medicine at the University of Oslo, takes aim at the National Cancer Moonshot Initiative announced earlier this year by President Obama.  Nice try, he concedes -- but the reality is: "We’re a lot better at fighting cancer. We just can’t cure it."

Is this stereotypical Norwegian pessimism or just some badly needed Scandinavian bluntness?

Dr. Breivik points out that cancer is fundamentally a disease of aging, and none of us is getting any younger.  All our efforts to improve lifespan end up putting us at risk of living long enough that we'll get some form of cancer.  We've gotten a lot better at treating cancer, and there are new developments that promise to make even greater impacts (more on that later), but as Dr. Breivik points out: "Every time we cure a person of cancer, we produce a person with an increased probability of getting cancer again. It is the Catch-22 of oncology."

We love to use terms like "moonshot" -- even Google uses it for their most ambitious projects -- but Baby Boomers are the last generation to whom it actually carries any real meaning.  That same generation is also getting into the years when cancer becomes more of a risk, so perhaps the use of it is no coincidence.  We spent the equivalent of around $200b on the Apollo program, which certainty makes the current (supposedly) $1b cancer moonshot look like doing it on the cheap....or for the PR.

 In Dr. Breivik's analysis,

The different actors are outbidding one another for attention and funding, and for more than half a century the public has been told that the cure is just around the corner....Confronted with these forces, there is little incentive for our democratically elected leaders to question the goal of the ultimate cure.

At the very least, we owe ourselves more straight talk about what we're doing.

Because, in the midst of our "war on cancer," things seem to be getting lost in the fog of the war.  A new study found that only 5% of advanced cancer patients actually understood their prognosis.  These were people who had approximately four months to live.  Thirty-eight percent had never even discussed their prognosis with their oncologist.

The lead researcher said: "We were astonished to learn that only 5 percent of this sample had sufficient knowledge about their illness to make informed decisions about their care."  "Astonished" would be a good word to use; "appalled" might be another.

It's not clear if this is due to patients not asking, or to their doctors not telling.  It is most likely some of both.  Two oncologists illustrate their dilemma in a poignant column, How Much Do You Want to Know about Your Cancer?   They can give numbers, they can speak in generalities, they can help their patients make plans, but they can't read their patients' minds about how -- or if -- they want to hear the bad news.

And it is often bad news.  In their words, for many patients they say it boils down to: "Spoiler alert: Despite all the exciting stories about progress against cancer that you’ve heard about in the news, there is no cure for most types of cancer once they have spread to other organs."

We talk about wanting to be informed patients, about taking more responsibility for our health, about being partners with our doctors and other health care professionals, but when things get scary, as they can uniquely do when it comes to our health, maybe not so much.

Maybe all this is too pessimistic.  We are making progress, to the point when many cancer patients whose post-diagnosis survival might once have been measured in months are now living for years -- sometimes apparently cancer-free.  There is particular excitement around so-called checkpoint inhibitors that help unleash the body's own immune system to fight cancer.  

Even more promising, German researchers have just published results that they believe represent a "very positive step" towards  creating a universal vaccine against cancer -- not just curing but immunizing against cancer.  That is truly the Holy Grail of cancer research.

The biggest problem is that, to date, the cost of cancer drugs has been astronomical (pun intended).  Some of the drugs can cost over $100,000 annually, making those longer lifespans not look quite as rosy, at least for the people paying that bill (that would be us, folks, one way or another).  Indeed, recent research confirms that the U.S. is getting less bang for its cancer bucks compared to other countries.  Maybe a "vaccine" will upend all the current cost-benefit calculations -- or maybe it, too, will get caught up in the big money arms race.

Imagine what a Valeant might charge for such a vaccine.

When it is us or a loved one with cancer, it often seems like no drug is too expensive, no treatment too experimental, even if it might buy only a few more months of life -- and not necessarily months with a very high quality of life.  Many of us would be willing to spend all of our savings on such options.  The problem is, we're often willing to spend everyone else's money too, and that's just not a choice we should get to make unilaterally.

All the talk of moonshots, better survival rates, and promising new treatments sometimes can lull us into a false sense of optimism.  But, hey -- Baby Boomers may not live long enough for many of them to worry about cancer.  They'll be too busy dealing with the impacts of diabetes and obesity, making them "sicker seniors" than previous generations, as NPR reported.  Unfortunately, we can make equally dubious choices about those as well.

We know our behavior can help us be healthier.  For example, new research has associated exercise with lowering the risks for 13 cancers, adding to the array of similar research findings about the impacts of healthy behaviors.  Yet the CDC says only 6% of US adults are engaging in the five health-related behaviors that are associated with preventing chronic diseases.

No wonder that Dr. Brevik concluded that, instead of moonshots against cancer, "many more lives can be saved by doing the boring stuff, like getting people to stop smoking, eat healthfully, exercise and put on sunscreen."

"Boring stuff" just doesn't get headlines the way "moonshots" do.

Practicing in an Age of Uncertainty

If you've ever had a hard time trying to decide what's best for your health (e.g., Sorry, There's Nothing Magical About Breakfast), perhaps you can take comfort in the fact that physicians often aren't so sure either.

Or perhaps not.

A new study in Annals of Surgery, and nicely reported on by Julia Belluz in Vox, focused on surgical uncertainty.  The researchers sent four detailed clinical vignettes to a national sample of surgeons, seeking to get their assessment on the risks/benefits of operative and non-operative treatment, as well as their recommendations. You'd like to think there was good consensus on what to do, but that was not the case.

In one of the vignettes, involving a 68 year-old patient with a small bowel blockage, there was fairly universal agreement -- 85% -- that surgery was the best option.  In the other three vignettes, though, the surgeons were fairly evenly split about whether to operate or not, even on something as common as appendicitis.

So, there may be a "right" answer but you might as well flip a coin in terms of getting it, or there may just not be a right answer.  Both options are troubling.

The authors believe that surgeons are less likely to want to operate as their perception of surgical risk increased and the benefits of non-operative treatment increased, and more likely to want to operate as their perception of surgical benefit increased and non-operative risk increased.  The problem is that surgeons vary dramatically -- literally from 0 to 100% -- on their perceptions of those risks.

Vox quoted Ashish Jha, a physician and professor of health policy at Harvard, as saying: "The truth is that most of the surgeons in their sample are quite experienced, and yet have wildly different assessments of risks and benefits among similar patients."  Dr. Jha called the findings "deeply disturbing," noting that most of us are bad at evaluating risk -- and surgeons are no exception.

Most surgeons based their estimates of risks/benefits on their experience, their training, and -- if you're lucky -- on whatever literature might be available, but it is doubtful that we can usually expect an objective, quantifiable assessment.

The American College of Surgeons has developed a "surgical risk calculator" to help surgeons better gauge these risks, using data from a large dataset of patients.  However, an earlier related study from the same team of researchers found that it doesn't make much difference.  The calculator did narrow the variability of surgeons' assessment of risk, but: "Interestingly, it did not alter their reported likelihood of recommending an operation."

Oh, well.

The lead author told Medscape that 45% of the physicians surveyed had not been previously aware of the calculator's existence, even though it has been available for several years.  And only 6% of those who had been aware of it reported using it routinely.  All in all, it would appear that risk assessment may not be the core of the problem.

It is not just surgeons who aren't always sure of the right course of action, of course.  A study in the American Journal of Managed Care found that 62% of physicians reported that they found the "uncertainty involved in providing patient care disconcerting."  The discomfort with uncertainty did not vary appreciably between type of specialty.

The study looked at how the Choosing Wisely initiative has helped physicians reduce use of unnecessary tests and procedures, and the answer appears to be, not very much.  Ninety-six percent of physicians who were aware of Choosing Wisely did agree that it was a legitimate source of guidance, but almost 60% of physicians weren't aware of it.  Moreover, even among physicians aware of Choosing Wisely, almost 30% (46% of surgeons) felt it hadn't "empowered" them to reduce such tests and procedures.

Physicians want to do the right things.  Ninety-seven percent agreed that doctors should limit unnecessary services, 98% believed they should be aware of/adhere to clinical guidelines, and 92% felt physicians have responsibility to control costs,  Only 31% felt there was too much emphasis on costs, and only 28% agreed that doctors were "too busy" to worry about cost.

On the other hand, only 37% felt they understood the costs of the tests and services they order, and only 21% thought "physicians across specialty are likeminded in their commitment to reducing unnecessary treatments."  Physicians reported also pressure from patients, both for ordering more tests and procedures (68%) and for referrals to consultants (52%).  Almost half (46%) admitted ordering tests/procedures out of malpractice concerns.   The problem isn't just with physicians.

Then there is the example of PSA tests.  In 2008 the US Preventive Services Task Force recommended routine PSA tests not be given to men over 75, and in 2012 broadened that recommendation to all ages.  Yet data suggest that the group least likely to need the tests -- men over 75 -- had the smallest declines in rates of testing.  Almost 40% of this age group are still getting the test, which is not far from the previous rates.

As one researcher told The New York Times,   "That’s just insanity...bad medicine, poor use of health care resources and poor decision-making.”

There's all too much of that in our health care system.

We all share in the problem.  As Dr. Jha said, humans are usually not good about evaluating risk.  We're especially bad when there isn't good -- and understandable -- information to help inform our decisions.  Health care is just not an industry that uses data well, nor one that is very transparent about the data that does exist.

Look at the recent controversy over CMS wanting to move to a simpler, star rating for hospitals, which the industry managed to block.   As noted health policy guru Michael Millenson recently wrote, "Individual hospitals and the industry remain quick to point out flaws in others' report cards to the press and policymakers while keeping mum about the wealth of comparative quality information they use internally."        

It's not so clear to me that there is such a "wealth" of information already available, especially not at the individual hospital/physician/condition levels, but there should be, and it should be better used.  Until then, we'll have to keep living -- and dying -- with the uncertainty.

Figuring Out the Code

Three stories about computer programming caught my attention this week.  Admittedly, this is out of my wheelhouse; while I like to think I could have learned to program, the fact is that I never did, which probably makes me like a lot of you.  We all use products and services that rely on such programs, but most of us probably don't give them much thought.

I promise I'll relate this to health care, but first the three stories.

The first was in Wired, about something called the Mover Kit.  The Mover Kit is made by an interesting organization called Technology Will Save Us, whose mission is "to spark the creative imagination of young people using hands on technology."  Their previous efforts let kids create their own electronic music or their own games, but they've just announced a Kickstarter campaign for the Mover Kit, which allows kids to make and code their own wearable devices.

As they describe it, "The Mover Kit is an intuitive way for kids ages 8 and over to learn the fundamentals of electronics, programming, and solve problems creatively.  It encourages kids to learn by doing what they do best -- being active and playing!"  TinyBop's Infinite Arcade uses a similar approach, letting kids design and build their own video games.

Pretty cool huh?

CIOs are wailing about the shortage of IT talent, calling it an "existential threat" to their companies' futures.  They are realizing that they need new strategies to attract this talent.  Getting kids to learn how to program while they think they are having fun sure seems like a good one.

The second article was an op-ed in TechCrunch by Basel Farag, Please Don't Learn to Code.  On first blush, it would seem to be giving the opposite message that the Mover Kit and Infinite Arcade are promoting.  However, Mr. Farag's message is more nuanced than that.

He concedes that programming skills are important, but not for everyone.  As he says, "I would no more urge everyone to lean to program than I would urge everyone to learn to plumb" (alas, yet another skill I never acquired).

His key point is that the crucial skill is understanding the problem, especially since programming methods and languages can change rapidly.  There may be a shortage of people who can program well, but I'm willing to bet that there is a far greater shortage of people with the analytical skills to truly get to the bottom of problems.

I've already written about how this may be especially true in health care.

The third story suggests that the fuss about programming may be short-lived.  Writing in Wired, Jason Tanz predicts that the rise of artificial intelligence and machine learning means that soon we won't program computers; we will "train" them.

He gives an example.

If you want to teach a neural network to recognize a cat, for instance, you don't tell it to look for whiskers, ears, fur, and eyes.  You simply show it thousands and thousands of photos of cats, and eventually it works things out.  If it keeps misclassifying foxes as cats, you don't rewrite the code.  You just keep coaching it. 

Gosh, and I thought debugging a program was hard; imagine trying to coach it!

This is not futuristic, pie-in-the-sky thinking; this is already happening.  Ask Google, Apple, or Facebook.  One consequence of computers, in essence, programming themselves is that their supposed masters -- i.e., us -- don't and won't always know exactly what they've done or how it works.  As Google's Andy Rubin told Mr.  Tanz: "After a neural network learns how to do speech recognition, a programmer can't go in and look at it and see how that happened."   The programs become, as Mr. Tanz says, a "black box."

It may sound scary to have our society relying on programs that we didn't write and can't understand, but Mr. Tanz views this optimistically.  He sees it as democratizing programming; it no longer will depend on nerds writing in arcane computer languages, but rather on people figuring out how to get programs to learn what we want them to do -- e.g.,  "It will be accessible to anyone who has ever taught a dog to roll over" (something I have, yet again, never done).
  
For me, the commonality of all these articles is the importance of figuring things out.  We tend to view programming as a hard thing we leave to other people, but it's easy to forget that programming isn't the problem itself, but merely a means towards solving the problem.

Health care is full of black boxes.  As much as we think we've learned about the human body over the last hundred years, we're still constantly reminded about how little we actually understand its working (e.g., the microbiome).   As much time and money we spend training physicians, much of how they diagnose and design treatments for patients remain a mystery.  And does anyone know why we always have to fill out so many damn forms?

The many organizations working on applying AI to health care are trying to figure out some of these black boxes, although their solutions may come at the price of new black boxes.  I hope, though, that we don't just turn things over to AI.  We still need people to figure out the problems.

That's why I love reading about initiatives like MakerHealth, about which I could have written an entire post.  It started out as MakerNurse, based on founder Anne Young's realization that front-line nurses could design tools to help improve patient care.  Launched out of the Little Devices lab at MIT and supported by the Robert Wood Johnson Foundation, it now has mobile spaces in numerous hospitals and a dedicated MakerHealth Space in the University of Texas Medical Branch in Galveston.  Their goal is to empower not just nurses but all staff.

They believe in "democratizing the tools health making around the world.  Whether it's an hospital bed, or a smart pill bottle, or a improved triage mobile phone app we believe that design should be transparent, hackable, and enabling for everyone to be the designers and makers of their own healthcare solutions."  The word that often seems to be associated with them is "MacGyver."

Health care could use fewer programmers and more MacGyvers.  

DIY Health to the Rescue

Experts often compare how slowly the health care system is "reforming" to how hard it is to turn a battleship.  They're so big that they can't turn on a dime (much less on $3 trillion!), and there is as much risk in trying to oversteer as in not turning at all.  Things are changing, we're assured, but it will take time to get on the desired new course.

Maybe.  But maybe it is time to jump off the obsolete battleship onto something more nimble.

Some call it Do-It-Yourself Health (there are both .org and .com sites devoted to the topic, among others).  PwC declared it to be one of the top ten trends of 2015.  Dave Chase believes that "DIY health reform is now leading the way for the highest performing reform" -- not Medicare, health insurers, not even employers.
 
Americans spent some $34b on "alternative and complimentary" medicine way back in 2009, even without firm proof that they work, so imagine what we might be willing to pay for "traditional" care that was more convenient, more self-directed, and faster.  

In case anyone still needs confirmation about how slowly our health care system is edging towards reform on its own, some cases-in-point:

• A new study has updated the famous IOM 1999 estimate of 100,000 annual deaths due to avoidable medical errors, believing that the number is more like 250,000 -- making medical errors the third leading cause of death in the U.S.
• The Senate Finance Committee has issued a report warning that physician with ownership interests in medical device distributors are -- what a surprise! -- much more likely to perform surgery using those devices, .  This is coming from a bunch of Republicans, mind you, so the problem must be bad.
• The U.S. has spent some $35b to move providers to EHRs, but as Vice President Joe Biden just said, "we didn’t realize five [EHR] companies would create their own silos. What the heck are we doing?"
• The move to value-based purchasing is supposed to help combat our perverse incentives, but early indicators are not so positive.  Two new studies looked at Medicare's Hospital VBP program, and found that (a) it ended up rewarding not just low spending but also low quality hospitals, and (b) it doesn't seem to actually have any positive impact on patient mortality.  

What the heck are we doing indeed.

I'm increasingly thinking that the solution will not be to reform the system, but to work from outside it.  I offer a few examples:

The Wall Street Journal wrote about one in Tech Savvy Families Use Home-Built Diabetes Device.  It profiles how, by WSJ's count, some 50 families have developed their own artificial pancreas device to help themselves or their children manage their diabetes.  Fifty families in a big country like the U.S. doesn't sound like many, but, hey, I'm amazed there are 50 families bold enough and capable enough to build such a device.  Put those specs on the Internet, and maybe an instructional YouTube video or two, and that number could easily skyrocket.  

It wasn't prescribed by their doctor, and it wasn't purchased from a medical device company, because such devices aren't yet on the market.  Several medical device companies are working on similar devices, and the FDA says approving them will be a priority, but nothing is through the regulatory process yet.  The FDA can't stop individual families from building their own, as long as they don't them sell or further distribute them.  

So, it is a device highly desired by the market, and the technology is simple enough that people can literally build them at home, yet it is not available within our health care system.  Something is wrong with that picture.  

Then there are hearing aids.  If you know anyone with a hearing aid, you're probably heard them complain about how expensive they were, on average about $5,000 for a pair.  The New York Times reports how those prices are under attack from the consumer electronics industry, which is selling products under the unwieldy name of "personal sound amplification products," or PSAPs.

To escape FDA regulation, PSAPs can't be marketed as hearing aids or even purport to be used for hearing loss (which would make it a medical condition), but canny consumers are looking at what PSAPs can do, weighing their much lower cost, and using them anyway.  The audiology profession warns about such self-diagnosis and the limits of PSAPs, but it's not like they're doing such a bang-up job already: it is estimated that less than a third of the people who could benefit from hearing aids actually use them.  

The competition seems to be working; The Street reports that hearing aid prices are starting to tumble.  

If only we had "competition" for other services from outside the traditional health care system.  Oh, wait, we do.  For example:

• You can now use your smartphone to monitor lung function in lieu of going to a doctor's office to use a spirometer.  
• You may soon be able to use your smartphone to monitor heart palpitations  instead of using existing event monitors.
• You can use your smartphone to monitor your blood pressure.  

I'll bet medical device manufacturers, the FDA, and even some clinicians are eager to wrap these in under the cloak of our existing health care system, which would no doubt end up making them both more expensive and harder for us to obtain.  Let's hope they are not successful (although we still need to demand proof of efficacy).    

Some see a future where we sequence our own DNA to identify genetic risks, have implantable health monitors, do at-home diagnostic tests, even 3D print our own prescriptions.   Throw in peer-to-peer financing for big bills (more on that in a future post) and more providers selling their services DTC (like direct primary care or concierge medicine), well, I'm not sure we'll even need to be on the stodgy old battleship anymore.  

You have to believe that Walmart, Walgreens, and CVS are preparing for a DIY future.  Other health care providers are going to have to decide if they will do so as well -- or risk going down with the battleship.

Health Care Is Better as a Game

So many counter-intuitive findings recently.  For example, a new study claims 7 of the 10 most profitable hospitals in the country are "non-profit."  Let me say that again, most profitable hospitals in the country are usually nonprofit.  Or, despite the drive to improve surgical quality by limiting surgeries at low volume hospitals, it appears that the relationship between volume and patient outcomes is not as clear as had been thought, once "more advanced statistical modeling" is used to analyze the data.  Wait, what?

Either one of these would be a good topic to write about, and many others have done so already (e.g., KHN and Modern Healthcare, respectively).  Instead, I'll talk about something equally counter-intuitive but more fun: how important games might be for health care.

Let's start with what's going on with tuberculous.  About one-third of the world's population is infected with TB (many of whom don't know it).  It is one of the leading infectious disease killers.  Surprisingly, though, it is not particularly easy to diagnose, and researchers at Stanford think a video game could help with that.

The game is Eterna Medicine.  The first version of Eterna was released five years ago, and it allows anyone to try to design bio-molecules.  Seriously.   Apparently learning to fold RNA molecules can be fun, a real-life kind of puzzle, Something like 100,000 players have tried it so far.  As one of them, Jeff Anderson-Lee, told NPR: "You can start out not knowing any of the science.  You start to get a sense for what things go together to make an RNA design fold the way you want.  While you're doing that, you're gaining points and rising in rank."

Fun or not, it has proved to be meaningful.  In February, Mr. Anderson-Lee and fellow gamers used their Eterna learnings to publish an article (check it out: "Principles for Predicting RNA Secondary Structural Design Difficulty") in Journal of Molecular Biology, an eminently legitimate, peer-reviewed scientific journal.  It is believed to be the first such "citizen scientist" publication, although it probably will not be the last.

As Peter Venkman might say, "no studying."

With Eterna Medicine, the goal is to try to figure out what particular configuration of RNA designs is most likely to mark the presence of TB.  Players "vote" on designs, and the winning designs will actually get synthesized to see if they work.  If they do, testing for TB could become as easy as using a home pregnancy test.

The Wall Street Journal profiled not just Eterna but also several other game approaches to health care research.  These include:

• EyeWire, which maps neural connections in a mouse's retina;
• Phylo, which cross-indexes disease-related DNA sequences;
• Project Discovery/Eve Online, which classifies human cell proteins.

If people got bored with those, there are games that allow users to play with quantum physics.   They've published too.  

I wrote about the use of games in health care a couple years ago, and it has continued to fascinate me.  After all, some 155 million Americans admit to playing video games, spending some $23b annually.  It is particularly common among -- but not unique to -- younger people.  Health care experts have seen ways to utilize games or gaming principles in health education, motivating better health habits, even training of medical professionals.  

I got a little more interested when Microsoft bought the popular game Minecraft for $2.5b in 2014.  I got even more interested when they announced they were expanding into education with Minecraft Education Edition.  As the announcement said: "We've seen that Minecraft transcends the differences in teaching and learning styles and education systems around the world.  It's an open space where people can come together and build a lesson around nearly everything."  The Education Edition is now in beta and will be released for free in an early access program this summer.  

And I got really interested after reading Isaac Kohane's great post What Minecraft can teach the health care system.  Dr. Kohane reports watching with awe as a group of 11 year-old children worked together in the game to get through the complex virtual environment-- and managed to have fun doing so.  As he says, "It was a remarkable demonstration of using technology to coordinate teams in complex tasks without prior training."   

He goes on to note, perhaps superfluously, "I can tell you with assurance that the use of team technology in the American health care system lags decades behind the seamless coordination that Minecraft players take for granted."

Dr. Kohane sees three substantial (but not insurmountable) obstacles to changing that:

• Unique systems: Health care thinks it is so unique that its systems need to be, making them "less secure, less versatile, and more expensive than they have to be."
• Billing gets in the way: this needs no explanation, but I'll say it anyway.  Our system is  more about making sure providers get paid than on achieving better patient outcomes or experiences.
• Clinicians only: Patients have not historically been involved in the decision-making, so no wonder communication flows are at best siloed.

He is optimistic that -- if we can overcome "institutional inertia -- "there will be no reason that a patient's history, diagnoses, and next steps can't be presented in a way that makes as much sense to adults as Minecraft intuitively does to 11-year-olds." 

I love his optimism, but that's a powerfully big "if" he qualifies with. 

By far the most viewed post I've written was one I did a couple years ago on Twitch, the hugely popular online service that doesn't even let people play games, just watch others play them.  I'm old enough that I rarely play video games but young enough to at least understand the appeal, but Twitch confirmed for me that there are younger generations that see them in entirely different ways than us older generations do.   My conclusion is that if the health care system doesn't recognize and adapt to gaming's technology and its users' preferences, it is going to become obsolete.  

Perhaps I'll go try to fold some RNA sequences...