Future Health 6/18/18

Delivering care in the new virtual world…

Integrating Routine DNA Screening Into Primary Care – Patients at Geisinger Clinic will now have the opportunity to participate in a new program beginning this summer.  The Clinic intends to enroll 1,000 patients in a program where their individual DNA sequence will be completed and entered into the patient’s record with the intent of using it as a tool for informing how primary care should be provided.  Assuming the program is a success, the goal is to roll out the program to all 3 million Geisinger patients in the coming years.  Specifically, the Clinic will be analyzing the 77 most common gene mutations which have been strongly associated with disease.  The new initiative builds on a prior program, MyCode established in 2007 to collect and analyze patient derived DNA from more than 200,000 individuals.  The program was based on the whole exome sequencing approach which analyzes about 1% of the genome involved in providing instructions for the production of proteins.  By integrating the genetic testing into the primary care approach, it is anticipated that earlier interventions will be forthcoming and, as a result, better outcomes will result.  It makes sense and the time has come…from colon, lung and breast cancer screening to hypercholesterolemia to problems we haven’t even really identified – we are on the cusp of a new model of primary care.

Future Health 5/11/18

Delivering care in the new virtual world… 

Dr. Mom & Dr. Dad As Second Assists – It’s only a matter of time before the baton is passed and we get consumers more involved as “partners” in care delivery.  In a study recently report in JAMA Dermatology, pictures taken by parents of a child’s skin conditions via a smartphone camera and forwarded to a dermatologist for diagnosis were of high enough quality to allow for reliable pediatric dermatology care.  The result is that teledermatology involving parents as partners makes for better access at lower cost with comparable results. The study was completed at Children’s Hospital of Pennsylvania (CHOP).  The study involved 20 families who were given photography instructions and 20 families who were not given instructions.  The researchers then compared diagnoses made during in-person visits with photograph-based diagnoses made by a separate clinician.  The photograph-based diagnosis matched the in-person diagnosis 83% of the time with only three of the 87 images not allowing for a conclusive remote diagnosis due to poor photographic quality. In a similar study released in January from researchers at Stanford University, a computer assisted model had an accuracy level of 95+%.  So, the advent of Dr. Mom and Dr. Dad is on the horizon.  It’s an important shift especially in shortage specialties like pediatric dermatology. 

Artificial Intelligence On The Rise – For those of you who are trying to keep up with all of the changes in technology and the implications for health care, it’s rather difficult given the plethora of studies and information.  If you’re trying to understand the implications of artificial intelligence, check out the 2017 Artificial Intelligence Index completed by a multi-institutional, multi-disciplinary group of experts. At 101 pages, it is ripe with information on the future of AI.  Check it out!  The reason this is important relates to another survey study of 20+ healthcare organizations released in December 2017 by the Center for Connected Medicine.  That survey found that the healthcare organizations were marking artificial intelligence deployments as a “low” or “very low” priority in 2018.  Rather than focusing on AI, the systems are leaning towards initiatives in cybersecurity defenses, consumer-facing technologies, and leveraging predictive analytics for precision medicine.  While these areas are very important and there are only so many resources available – AI should be moving further up the technology list.  From my perspective, leaders in the use of AI as an “adjunct to care delivery” will be the successful health systems of the future.  Just watch in the coming years as the nimble AI adjudicated care delivery systems outpace the traditional care delivery organizations.  It’s going to happen – and, happen quickly.  Stay tuned!!

Then, Consider The Impact Of Artificial Intelligence On Work – As if you don’t have enough to do already, you may want to consider reading (browsing) the 20 most insightful books recommended by Upwork – an organization that monitors the impact of technology on work.  It’s very clear that technology is changing the way work gets done from manufacturing cars to mining coal.  And, if we think it will not impact healthcare we will be wrong, wrong, wrong.  In fact, the industry is at the forefront of change.  Why – because historically we’ve solved our delivery problems by throwing people at the problem.  But, that’s costly and part of the underlying problem with costs in healthcare delivery.  Couple that problem with the fact that over the next decade large numbers of our workforce will be retiring, becoming disabled or dying as the Boomers move into their last quarter – and, the industry is set for dramatic, rapid change in how work gets done!!  Here are some thoughts from Stephane Kasriel, CEO of Upwork as recently presented at the 2018 World Economic Forum

  1. AI and robotics will create more jobs, not mass unemployment — as long as we responsibly guide innovation – There have been several doomsday scenarios presented including Entrepreneur Elon Musk’s notation that artificial intelligence is “our biggest existential threat” to mankind. I’m not sure that’s going to happen.  In fact, it may be the biggest leap forward for mankind – depending on how it is used!  As Kasriel noted in his WEF presentation, society needs to “guide innovation responsibly [by] opening up new windows of opportunity, not eliminating them.”  AI requires new skills and capabilities.  Simply doing work the way we’ve done work for the last 150+ years will create job loss.  However, adaptation of the professions to these new capabilities will actually enhance our capability rather than diminish our presence and opportunities.
  1. Cities will compete against other cities in the war for top talent – we are seeing this one play out real-time as Amazon strings many cities across the USA along with the opportunity to be the “second Amazon headquarters city”. The Metropoles across the US cities are competing aggressively for Amazon’s attention which will invest over $5 billion in building a second headquarter.  
  1. The majority of the US workforce will freelance by 2027 – In today’s world, about 36% of the US workforce (= 57 million workers) work in freelance situations. It is projected that over the next decade, the majority of USA workers will become freelancers according to the report Freelancing in America: 2017.
  1. Education breaks out of the silo – I sit on the board of a major distributed graduate university and it is safe to say that we are reassessing the future of higher education.  We are coming to the recognition that the approach we’ve taken toward education is no long sufficient in preparing the workforce for the challenges they will face.  Something needs to be done.  I personally believe that education will no longer be an “dedicated, time-focused experience” but rather will require that the workforce engage in an “ongoing, continuous learning environment”.  The approach to such a situation requires vastly different models, processes and business models from the tradition of higher education.  

Managing 23, Me, Myself and I – Several weeks ago, the genetic testing company, 23andMe, announced that the FDA had finally given the go-ahead for launching a direct-to-consumer (D2C) testing kit for cancer. Consumers will be able to pick up the kit without a prescription for tests like BRCA1 and BRCA2, which have been genetically linked to a higher risk of ovarian, break and prostate cancer. The only problem is that the results of the test will provide data and the value of the data is in the interpretation.  Managing that piece of the equation is where the challenges will no doubt arise.  Keep your eyes on this one for it is the future but the path is unclear…

Future Health 5/1/18

Delivering care in the new virtual world…

American Biomedical Research Is Losing Its Leadership Position – A new study was recently published in JCI Insight revealing that the USA is losing ground in its leadership role in biomedical research.  While still the unquestioned leader, there are a lot of other countries that have made substantial gains in the last few years.  The study reviewed ten renowned medical journals over the period of 2000 to 2015, noting the nationality of the research and the authors.  American leadership continued in the Journal of the American Medical Association (JAMA), the Lancet, the New England Journal of Medicine (NEJM)CellNatureScience, the British Medical Journal (BMJ)JAMA Internal MedicineJournal of Cell Science, and FASEB Journal. However, the percent of papers in the top six journals decreased from 44% to 37% by 2015.  The UK came in at #2 but also lost ground going from 9% to 4%. The reason this is very important is that the Trump Administration has proposed cuts in the National Institutes of Health (NIH) budget which is one of the core drivers of USA leadership. In fact, funding for NIH has been flat over the period of 2008 – 2015, although it was increased in FY17. But, the trend is disconcerting. The importance of the investment cannot be overstated from my perspective.  It drives very important research related to discovery, prevention, usage and a whole range of ideas that ultimately prove to improve health and health care

So, who’s assuming leadership?  The Chinese are one of the primary new points of research and development.  What was particularly interesting is that many of the Chinese authors received their advanced education at American institutions, returned home, and continued prior research projects.  This is not bad but, it simply reflects that China – through its government and other sources – is offering substantial support to advance the position of the nation in biomedical research. 

Is there a concern?  Not on the face of it.  However, I’m just finishing the book Sapiens by Yuval Noah Harari which points out quite aptly that the marriage of science and ideology (p. 274) or religion has been a very important point of leverage for nations providing leadership in the world.  The ideology of an open, free society dominated by the rule of law (yes, there are some of us who still believe very strongly in this concept) is the type of leadership that we should be encouraging throughout the world.  While I love the Chinese, their focus on government control of all societal elements is concerning at best.  As for India, it is a great nation with wonderful people who also have a troubled leadership and governance that lacks transparency and accountability on far too many levels – not just at the national level but in all aspects of government from local municipalities all the way to the national legislature.  In sum, it’s good that other nations are investing more but that should not translate into the USA investing less. 

 Telehealth Services Continue To Grow – In a recently released white paper by FAIR Health, a not-for-profit organization focused on bringing transparency to health care cost, the use of telehealth services have increased substantially in the last few years, especially in the area of mental health services. Over the period of 2011 – 2016, telehealth services increased by 643%, especially in the rural areas (960%) – a phenomenon I’ve discussed several times over the last couple of years.  In urban areas, the growth was 629%.  And, the fastest growth has been in the urban areas where in some places the growth has matched or surpassed that of the rural areas. Needless-to-say, impressive in all areas.  The geographic areas with the fastest growth have been Massachusetts, California, Texas, South Dakota and Minnesota.  From my perspective; however, it is not only about “telehealth” services which are the delivery of services at the point of acute or chronic need but also the use of “telecare” services that will alter our whole approach to care delivery.  If you’re interested in my thoughts on the issue – let me know.  I can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it..  I’ve given a lot of thought to the issue and the health care “system” is about to be upended…

More On The Microbiome – Two studies were recently published in the online journal Science noting that the “composition” of gut bacteria could potentially have a very significant impact on the efficacy of certain cancer drugs. There have been a lot of studies in recent years showing that the microbiome can affect the treatment of chronic diseases. However, the new findings on the impact of drugs takes care delivery decisions into a new realm.  Specifically, the research related to the impact on PD-1 inhibitor drugs which are used in the treatment of melanoma, lung, bladder and stomach cancers by freeing the immune system to attack the cancer cells. This is an area of research that we are going to see many more results in the coming years.  The impact will no doubt be very significant (I’ve stopped using the word “huge” :-) ). 

Artificial Intelligence (AI): Moving From Influence To Managing – AI is infusing its capabilities into every imaginable part of our lives.  From redirecting the ads we want on Facebook, to helping us find the books or products we want on Amazon, to creating music, to making clinical diagnoses – AI is now a part of life as we know it.  Underlying all of the apparent parts of AI; however, is an even more striking change that will continue the unrelenting march of AI services across all industries.  For example, at the recent Neural Information Processing conference – the premier artificial-intelligence summit –Tesla, the electric-car maker, discussed its partnership with AMD, a microprocessor manufacturer where they are working on AI decision algorithms that can be used across all sorts of industries. Nvidia, another chipmaker, is doing the same. There were other examples as well.  The long and short is that the “use” of data in becoming optimized and it is not just coming from the health care industry.  In fact, some of the more interesting developments are coming from the “outside-in” – which is an increasingly common refrain I see in the technology field.  The health care community needs to keep an eye on other industries outside of our mainstream efforts as well as a focus on inside to stay abreast.  My mantra continues – embrace the change. 

Future Health 12/12/17

Delivering care in the new virtual world...
 "Virtualist" Health Care - For the last several years, I've been giving talks about the use of technology in health care and promoting the notion that we need to develop, support and train "Healthcare Virtualists".  So, at the urging of a number of colleagues, I worked with a couple of like-minded individuals to develop an article on the subject which we dutifully submitted to the various journals.  Unfortunately, we were pre-empted by an article in the JAMA Network on the promoting the idea of creating a new specialty, the "Medical Virtualist".  I agree and disagree.  On the notion of "virtualist", I absolutely agree.  We need to develop criteria, training, educational requirements and the like to support this very important addition to medical and health care practice.  On the notion of "medical", I absolutely disagree.  Some element of virtualist training should be a requirement for all clinical specialties (i.e. physicians, nurses, pharmacists, medical social workers, psychologists, etc.) and all clinicians should have the opportunity to become specialists in the use of virtual care delivery.  It is not a physician only specialty.  On the whole, a very important topic.  Read the JAMA article.  I've obviously got more to say on the topic but, I'm submitting yet another article J.  More later...

Future Health 2/15/18

Delivering care in the new virtual world...
Considering Automation of Health Care Delivery - In the last several months there have been a number of articles appearing in various journals and newspapers on "the future of work". These articles focus on the impact of robotics, machine learning, automated delivery, artificial intelligence and the like. The advocates for these technologies point toward "transformative changes" that will be derived from the deployment and implementation of these new tools. I'm one of those advocates. But, what gets lost in the debate is not "what" but "how soon?" Some of these technologies will be disruptive over the next several years. Others will not come to fruition for a couple of decades.
In the last several months, I have advocated that we need to seriously reconsider the scope of training we provide our future health care providers. For example, we are clearly moving in a very rapid way toward the use of "virtual" technologies for the delivery of care. In the same breath, I will argue that the skills, talents and knowledge required for providing virtual care is different than that provided in in-person environments. What do I mean? The nuance of communication, the detection of subtle signs, the inflection of voice, the comparative data analysis to other patients with similar problems are but a few of the markers where in today's world health care students get very little, if any, training. These types of skills will become essential - even at a rudimentary level - in the not too distant future. So, do we need to reconsider how we train our future work force? I think so...  More on this topic in the future.
More On CRISPR - The advances in health care derived from the use of CRISPR are occurring at an incredibly rapid pace. New companies seem to spring up on almost a daily basis using CRISPR-based therapeutic approaches. The intent is to "solve" problems by "fixing" the genetic errors in our DNA. One example that I've been following is from CRISPR Therapeutics, Inc. based in Cambridge, Massachusetts. The company recently submitted a request to the European Union oversight body for permission to start a new trial on beta thalassemia (an inherited blood disorder) The company uses CRISPR technology to edit the thalassemia gene and fix the defect...permanently. Assuming the technology works - and, all the indicators are that it will - they can initiate a trial using the same methodologies for treating sickle-cell disease, a far more prevalent blood disorder. Some would say we are in the "hype cycle" for this technology. It will not be the panacea, but it will have a massive impact on certain diseases. This technology is going to totally reshape our approach to care delivery over the next decade. Mark my word...
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