Future Health - 9/14/18

Delivering care in the new virtual world…

 Let’s Be Careful – You will not find a bigger fan on the use of artificial intelligence and machine learning as a tool for “augmenting clinical intelligence” among providers.  At the same time, I took pause at a recent issue of JAMA Network Open (2018;1(3): e180926.doi: 10.1001 – 2018-0926) which report on the application of machine learning as an approach toward assessing short-term mortality among cancer patients who were starting chemotherapy.  The study included a cohort of 26,946 patients with cancer who were starting a wide variety of discrete chemotherapy regimens.  With the use of machine learning and AI, those patients who were at high risk of 30-day mortality were accurately identified across palliative and curative chemotherapy regimens and across many different types/stages of cancer. The researchers also compared the computer algorithm to more conventional tools such as predictions based on randomized clinical trials and population-based registry data. The algorithm did a far better job.  Their conclusion is what drew my attention.  It said:

“A machine learning algorithm accurately identified individuals at high risk of short-term mortality and may help to guide patient and physician decisions about chemotherapy initiation and advance care planning.” [emphasis added]

Lest we forget, it is an imperative – from my perspective – to always keep in mind their conclusion that the use of machine learning and AI is a “guide” – not the definitive approach.  In our enthusiasm to embrace new technologies, we always need to keep at the forefront that computers and machines still do not think – and, until they do, we should always hold their outcomes as support for “clinically augmented intelligence”.  Make sense?

Bioprinting Your Medications – The new HP D300e Digital Dispenser BioPrinter technology is being tested by the company and the CDC on the effectiveness of printing (i.e. making and dispensing) and testing antimicrobial resistant strains of “super bugs” which is an increasing problem.  The idea is to provide a select number of hospitals access to the technology nationally to cut down on the drug resistance problem by identifying the bugs earlier and dispensing the appropriate medications quicker.  In addition to identifying resistant strains, the HP BioPrinter can also dispense medications in many doses thereby alleviating the frequent “wait” in pharmacies who need to obtain the correct dose prescribed by the clinicians. Soon, the antimicrobial resistance testing will become a common place component of dispensing medications for patients with the end result being a reduction in the 23,000+ people that die in the USA every year from infections by super bugs that are not treated as rapidly as can be managed using the new HP Bioprinter devices.  But, the use for drug dispensing is only the beginning of a revolution in the “printing” business.  Bioprinters are also being explored for use in human tissue and organ production, drug research and other clinical areas.  Amazing!!

Future Health - 8/17/18

Delivering care in the new virtual world…

Keeping Up Or, Not – The explosion in medical knowledge is daunting.  Last year, more than 2.5 million clinical studies were published, and the rate of increase is accelerating.  For example, in 1950, it took 50 years for medical knowledge to double.  By 1980, that had reached just 7 years. In 2020, the projection for the doubling of knowledge in medicine is 2.5 months.  Imagine that!!  I think it is amazing how much has changed since I graduated (a ways back :-)  ) but those changes pale in comparison to what the future physicians will be managing.  It’s all happening because of artificial intelligence, machine learning and the like.  AND, it’s one of the reasons that we need to reconsider the medical school curriculum to integrate the use of information technologies as a core component of medical school training.  I don’t believe doctors will be replaced anytime soon – unless they don’t learn how to use these new and evolving tools which provided “clinically augmented intelligence.”  Those skills are as important – if not more important – than the biochemistry, physiology and anatomy of yore. 

GAFABAT – Have Your Heard About It? – There’s a new term that’s beginning to float around the ethernet = “GAFABAT”.  If you have not heard about it, you should know about it because GAFABAT is working to change your life in both direct and indirect ways – at home, in the office while working, while sleeping and even while simply contemplating.  So, what is it?  It is short for “Google, Apple, Facebook, Amazon, Baidu, Alibaba and Tencent or, GAFABAT.  This small group of seven companies is all about artificial intelligence and changing the way work, life, living is done.  These companies have attracted the very best talent in the world to help them make changes across the board in our lives.  Their data sets are massive – so massive that you are most likely not even able to comprehend their increasingly ability to not only understand any number of work-related activities but, also to understand you.  While I am a big believer in artificial intelligence and machine learning, I’m also increasingly of the opinion that we need to keep a watchful eye on the developments of this field.  For example, in China there are all sorts of reports on the use of government surveillance to manage the populace that are powered by computer vision and face recognition technologies. In that nation, you can be followed anywhere.  But, it’s not just China.  The same applies to London and increasingly in many urban areas throughout the world.  And, it’s not just our faces.  It’s what we buy, what sites we visit on the Internet, what programs and songs we download from Apple, what items we buy at the grocery store.  In essence, what we do every minute of every day in our life.  While there is incredible good that will no doubt come of this knowledge there is also the potential for “not so good”.  We should consider those issues.  We should debate them.  We should deal with them rather than brushing them aside.  I offer these thoughts after two cups of coffee on a Saturday morning.  Imagine what my thoughts will be by this afternoon…

The Reality Of Our Reality – There is an evolving technology that is likely to change health care in some very substantial ways.  It’s been primarily a focus of the gaming industry but all of that is about to change.  Specifically, Virtual Reality (VR) and Augmented Reality (AR) are coming of age.  These two technologies are increasingly being used in various industrial sectors and only now coming to health care.  While it’s clear that the technology has a bit of further development and is only at the very formative stages of development, it’s also clear that it could very easily alter our whole notion of how, where, who and when care is delivered.  Let’s consider just two examples: 

  • Training – The process for educating health professions students and for orienting our staff to the workflow of our organizations hasn’t changed much until recently. We’re clearly at the formative stages of a disruption in how training will occur through the use of VR/AR technologies. Some non-health care examples include Walmart’s introduction of Strivr – a VR tool that helped to prepare employees for its Black Friday sales in 2017. It created an alternative, lifelike environment that immersed the new sales associates in experiences with long queues and crowds in order to prepare them for all sorts of happenings that occur on Black Friday at Walmart stores throughout the nation.  Or, consider another VR training tool, Oculus VirtualSpeech which helps users hone their public speaking skills in a simulated environment. Distractions and other occurrences that are part of engaging with people are built into the Oculus experience.  Imagine how these two tools could be used in health care to help workers learn how to manage busy emergency rooms and to engage with patients who are experiencing health problems in the acute care setting.  In particular, the VR/AR tools will enable healthcare professionals to practice in a risk free environment.  Think it’s not possible?  Think again.  Children’s Hospital of Los Angeles (CHLA) is already using Oculus to train staff for pediatric trauma cases.  And, there are more opportunities on the horizon. Beyond these ideas, we are now seeing VR/AR used for training surgeons in the OR, technicians for all types of procedures, and administrative/clinical personnel for enhancing their interactions with patients. 
  • Building Care Delivery Facilities – The construction of health care facilities continues to be one of the most expensive efforts in the building business. The use of VR/AR offers a host of benefits for reducing costs, creating efficiencies, avoiding construction mistakes and enhancing the end-user experiences once the facility is opened.  The technology actually lets the future patient and clinician walk through the environment so that the architects can finalize their designs before construction starts.  It provides the bridge between the imagination of the architect and the reality of end users who will live in these facilities. 

It’s a new day in health care.  Keep your eye on the VR/AR world.  It’s going to change how we prepare everyone for doing everything in health care.  The imaginary worlds are becoming reality and, if you can imagine it, you can create it and, prepare for it!

 

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. 

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