This is the third installment in a five-part series on the fallacies and gaps in America’s healthcare debate.
One of the pleasures of my job is speaking regularly to and with medical professionals (not just doctors). They are some of the brightest, most talented people I’ll ever meet. When I consider the breadth of their knowledge and the miracles that comprise their daily routines, I’m profoundly humbled. And yet, there are often surprising gaps in their knowledge. These gaps diminish the national healthcare debate and stymie the sorts of changes that can bring better health to more people at lower cost.
The gaps often concern new healthcare technologies and institutional structures and their potential to do good. For 19 years, I taught mid-career healthcare professionals—up to and including medical school professors. (I’m on a teaching break this year.) My classes always included segments in which the students were asked to imagine what healthcare might look like ten or twenty years later—how the production of care might change and what that might mean for patients’ health and pocketbooks. In a recent panel discussion, I asked the question this way:
Imagine traveling back in time a mere 25 years, to 1993, and trying to explain your iPhone and its apps: email, Internet access, GPS, Kindle, Google Translate, Skype, Apple Music, iMovies, YouTube, a high-quality still and video camera, Facebook, Twitter, online banking, and—in my case—a device to administer a clinical-quality electrocardiogram and analyze its patterns in 30 seconds. Explain, too, how inexpensive the phone is and how most of the apps are free (or nearly so).
In my view, there’s relatively little about [mainstream] 2018 health care that would be particularly astounding to a 1993 audience. But I suspect that health care in 2043—25 years from now—would surprise the denizens of 2018 as much as an iPhone would surprise those 1993 listeners.
If healthcare innovation achieves its potential over the next 25 years, what developments do you think might be most surprising to us primitives here in 2018?
At several universities, students told me that mine was the only course that asked them to look forward in that manner. The other classes focused on present-day procedures and technologies and institutional structures. Some looked back a few years to explore how we got where we are.
But, they said, there was precious little effort to think forward and imagine which developments might render aspects of today’s care obsolete. My lectures and readings often deal with technologies that are already up and running or seem likely to come online in the not-too-distant future. I’m often surprised by how unfamiliar healthcare professionals are with these developments.
In this essay, we’ll explore some of those existing marvels and some that seem likely to arrive before too much time elapses. And we’ll look at the makers—the creators of these stunning innovations, large and small. Links will offer some articles I’ve written and some that others have written for those interested in diving deeper into each example.
Let’s take a whirlwind look at twenty healthcare innovations that I’ve written about:
1. My favorite go-to story is one that deals with my own health. After an episode of atrial fibrillation (afib) landed me in an emergency room in April 2016, I’ve carried an AliveCor Kardia, a $99 device affixed to my iPhone. The AliveCor, invented by Oklahoma physician Dave Albert, lets me perform a clinical quality electrocardiogram (EKG) in 30 seconds and receive an instantaneous analysis of whether my heart is beating normally or lapsing into afib.
On at least two occasions, this device has allowed me to avoid unnecessary visits to the emergency room (each of which would have cost my insurer around $5,000). On the other hand, one day, the device may help me to avoid a debilitating and abominably expensive (or lethal) stroke. Ironically, the day before my afib episode, I lectured 250 insurance executives on the AliveCor device and as far as I could tell, not one had heard of it.
2. I also wear a FitBit—part of the wearables revolution encouraging people to monitor their health and act on the wearables’ data. Recently, Apple announced that its new AppleWatch 4.0 would include an around-the-clock afib monitor. The mere announcement of this new device appears to have significantly heightened public awareness (and medical professional awareness) about this technology.
3. These are but a few of the patient-operated diagnostic devices already up and running. Cellscope enables parents to determine whether their child has an ear infection and, if they so desire, to send the results of the test to a physician or other provider.
4. The ease and low cost of creating and distributing medical devices are sparking something of a revolution out on the fringes of regulation. A group of computer programmers with diabetic children have created NightScout. This device, produced and disseminated free of charge, hacks into the children’s insulin pumps and transmits the data to devices maintained by the parents (a smartwatch, for example). In this way, continuous monitoring becomes possible. NightScout is an example of what my colleague Adam Thierer refers to as permissionless innovation and technological civil disobedience—a willingness to conduct innovation, even if regulatory authorities balk at approval. NightScout’s motto, #WeAreNotWaiting, sums up this stance quite well.
5. The smartphone revolutionized consumer electronics by putting many devices into one small package. My iPhone takes the place of a telephone, still camera, video camera, GPS device, library, map book, video conferencing unit, music collection, calendar, calculator, and on and on. Very likely, medical devices will go the same way. In 2017, a multimillion XPrize was awarded to teams developing a “Tricorder”—named after the medical diagnostic device featured in TV’s Star Trek.
The Tricorder accurately diagnoses over a dozen health conditions (including afib, COPD, pneumonia, and diabetes) without requiring a healthcare professional. The diagnoses are more than 70 percent accurate, and the device weighs under 5 pounds.
6. A few years back, the least expensive functional prosthetic hand cost around $5,000. Then, Richard Van As (a South African carpenter who lost several fingers in an accident) and Ivan Owen (a Washington State puppet-maker) developed 3D-printed hands and posted software online enabling anyone to manufacture prosthetics. Their enterprise became known as e-NABLE. Soon, Jon Schull (a Rochester, NY professor) created a Google+ group matching individuals willing to make hands with those needing prosthetics. e-NABLE spread worldwide, and makers began enhancing the hands with new functional and aesthetic features.
7. Some 3D printers use living cells as their medium instead of plastic, metal, or concrete. Laura Bosworth’s TeVido BioDevices is attempting to 3D-print human organs, using cells from the transplant recipients—thereby reducing the need for donors and the incidence of organ rejection. TeVido’s first transplantable organ is likely to be a nipple for breast reconstruction.
8. A few years back, Ian Tong of Doctor on Demand, a nationwide telemedicine company, spoke (at my invitation) to a national gathering of legislators—many or most of them physicians, and many skeptical about telemedicine. He described how he had saved the life of a young woman who had contacted him via laptop or tablet—by observing the appearance of her eyes and fingernails. Very likely, she would have died had she waited for a conventional office visit to her doctor. (A few years later, my 92-year-old mother’s life was similarly saved by a Facetime video conversation with her grandson—an emergency room doctor.)
9. Telemedicine can also be asynchronous—the patient uploads data, which is evaluated later by a physician or other provider. Jason Hwang (co-author of the classic book, The Innovator’s Prescription) helped create a company called Lemonaid Health. Lemonaid enables patients to order certain prescription medications online 24/7/365. Requests are reviewed by physicians over the next workday—including rigorous due diligence about patient identity, eligibility, and potential drug interactions. A clinical study showed that, rather than the traditional labor-intensive process of administering prescriptions, one doctor can handle roughly 1,000 prescriptions per hour via Lemonaid’s techniques.
10. Another asynchronous provider is Opternative, founded by Aaron Dallek and Steven Lee. Opternative allows individuals to be measured and fitted for eyeglasses from home, using a laptop and smartphone to administer the test. Later, an ophthalmologist certifies the results before providing the patient with a prescription.
11. Scott Cousino, who suffered from debilitating depression, and Mike Sopcich, who lost a brother to suicide, founded myStrength, a smartphone-based app to expedite therapy for those suffering from depression, PTSD, and other mental health issues.
12. Heal, a California-based company founded by Dr. Renee Dua and her husband, Nick Desai, uses an Uber-like app by which patients can summon doctors to their homes or workplaces.
13. In Rwanda and Tanzania, California-based Zipline has built the world’s first nationwide networks of unmanned drones to deliver lifesaving drugs and blood products to widely scattered clinics at high speed.
14. Augmedix, founded by Ian Shakil, uses Google Glass to free primary care doctors from computers and tablets. Patient encounters are live-streamed to medical scribes who compile electronic health records (EHRs) in real-time.
15. Speaking of EHRs, they’re widely despised by physicians today. Darcy Bryan and I argue this is because current EHRs are designed to benefit governments and insurers, rather than patients and providers. We’ve begun building a vision of what next-generation EHRs might look like and do. To differentiate this vision from today’s EHRs, we refer to the vision as Digital Health Biographies (DHBs).
16. Big Data is becoming a central component of healthcare. Cerner, a giant medical data companies, created software called St. John Sepsis Agent. Using real-time patient hospital data, this software “sniffs” the presence of horribly expensive and potentially lethal superbug infections hours before any human would perceive its onset. Strangely, the software can also predict suicidal tendencies and PTSD.
17. Recently, a Japanese woman failed to respond for some months to leukemia treatments. After encounters with multiple doctors, IBM’s Watson computer was corralled into analyzing her case. Her patient and DNA data were fed into Watson, which then read 20 million medical journal articles on leukemia. Watson revealed that doctors had misidentified the type of leukemia. After changing treatments, the patient went home. Watson’s entire reading and analysis took 10 minutes.
18. Direct Primary Care (DPC) is changing the relationship between patient and primary care provider. Patients typically pay modest monthly fees (often $60-$70) rather than paying on a per-service basis. In turn, they receive access to physicians in-person, by phone, by email, or by video conference. DPC practices also assemble teams of physicians and nonphysicians to help coordinate patients’ health and care. One DPC pioneer, Rushika Fernandopulle, CEO of Iora Health, has built dozens of clinics in the Northeast US.
19. An agonizing aspect of US medical care is the complexity of billing. Surgical costs, for example, are rarely provided in advance, and unreadable bills stream in for months afterward. Dr. Keith Smith’s Surgery Center of Oklahoma, in contrast, provides exact costs in advance (often much lower than other providers’ costs). Prices of hundreds of procedures are listed on the clinic’s website. Keith’s success and drive for transparency have spawned a nationwide movement.
20. Transparent pricing is also on display at Health City Cayman Islands, where, for example, a cardiac bypass operation is in the $30,000 range, versus over $100,000 in the US. HCCI is owned jointly by Ascension (the largest Catholic hospital chain in the US) and Narayana Health (a chain of 20 or so for-profit hospitals in India). Founded by Dr. Devi Shetty, Narayana’s hospitals in India perform cardiac bypasses for $1,000-$2,000–and their patient outcomes equal or exceed those of most hospitals in America or Europe. Their success comes from the hospitals’ use of lean manufacturing techniques commonly associated with Toyota’s production methods.
Here’s a challenge—a little experiment. Peruse some of the links offered here and others you find. Then sit down over lunch or coffee with some physician whom you know. Ask whether he or she is familiar with the innovations described above. If not, consider whether our national healthcare debate is missing some critical elements.
Photo credit: Mel Evans/AP/Shutterstock