NYeC Digital Health: two diverging visions of a connected future (Part 1)

The New York eHealth Collaborative’s fourth annual Digital Health Conference is increasingly notable for combining both local concerns (NYeC is one of the key coordinators of health IT for the state) and nationally significant content. A major focus of the individual sessions was data in all flavors: big, international, private, shared and ethically used. Another was using this data in coordinating care and empowering patients. Your Editor will focus on this as reflected in sessions she attended, along with thoughts by our two guest contributors, in Part 2 of this roundup.

click to enlargeThe NYeC Conference was unique in presenting two divergent views of ‘Future IT’ and how it will affect healthcare delivery. One is a heady, optimistic one of powerful patients taking control of their healthcare, personalized ‘democratized medicine” and innovative, genetically-powered ‘on demand medicine’. The other is a future of top-down, regulated, cost-controlled, analyzed and constrained healthcare from top to bottom, with emphasis on standardizing procedures for doctors and hospitals, plus patient compliance.

 

click to enlargeFirst to Dr Topol in Monday’s keynote. The good side of people ‘wired’ to their phones is that it is symptomatic, not of Short Attention Span Theatre, but of Moore’s Law–the time technology is now taking for adoption by at least 25 percent of the US population is declining by about 50 percent. That means comfort with the eight drivers he itemizes for democratizing medicine and empowering the patient: sensors, labs, imaging, physical examination, records, costs, meds and ‘Uber Doc’.

  • Sensors will move beyond fitness to clinical quality devices exemplified by the AliveCor smartphone-based ECG, the wrist-worn ViSiMobile from Sotera Wireless for comprehensive vital signs monitoring and display. Lung function sensors would double as cancer diagnostics from breath and body sensors would give warning signs of a heart attack.
  • Lab tests are increasingly DIY, with smartphones capable of doing assays and Theranos’ inexpensive tests from a few drops of blood using microfluidics technology, available direct to consumer at a drugstore.
  • Imaging devices are again smartphone based–CellScope‘s otoscope, Peek (eye) and GE’s VScan ultrasound (yes, it is still around) lead to less expensive home or retail-based physical exams. And the results would be owned by the patient. The PHR doesn’t go far enough for him–the patient would own their data, all of it, from day one.
  • Medications are also expensive (in the US, the top ten drugs account for $62 bn in spending). In the Topol View, another cost down-driver is genomics. Everyone would have their DNA sequenced inexpensively, probably with tests from companies like Theranos. Before prescribing that expensive drug, we’d be using personalized genomics to analyze first for receptors–how these drugs would be processed in the body–first, with a goal of the right drug, in the right dose at the right time.
  • He expects employers first, then insurers to eventually push for reduced costs utilizing all these areas.
click to enlargeThe role of the doctor in this? For one, ‘Uber Doc’–a doctor on demand (like an Uber car) either video or personally house calling an empowered patient with all their data present. And in the long run, the ‘Doctorless Patient’ calls the shots in the model (left) with the doctor able to use all the data gathered by both the patient and personally for a treatment and healing plan. His latest book, ‘The Doctor Will See You Now,’ further expands upon this.

Leave it to Nick (a UK visitor) to bring up the most obvious statement at Question Time: “Ownership is one thing. Self-management is another.” Dr Topol posited it as an inversion of the current medical model, and that self-management was fundamental. However, it left this Editor with two disquieting thoughts. Is the average person capable in managing a mostly self-directed model and the tools needed to do so? And will the doctors of the future, so engaged in a regulated, risk-averse model of today, be able to make the adjustment?

The alternative is the regulated, programmed world of Ezekiel Emanuel, MD as presented in Tuesday’s keynote. Lately famous for his statements that he would cease personal medical interventions at age 75 since it only has a 5-10 percent effect on longevity (he is 57, so this Editor believes he will change his POV if that percentage changes in the next 18 years), he opens with what is a standard lament that we spend too much in the US on healthcare–but higher cost Switzerland and Norway are somehow ‘rational’. Our spend of $3.05 trillion is larger than the French economy, but we also have five times the population (not counting coverage to ‘undocumented residents’ and the money pit called Medicaid) and by far, a younger one. Healthcare costs have come down, which he credits to the ACA (a/k/a Obamacare), but dismisses the effect of high, punitive deductibles as dissuading that spending. He dismisses the costs of defensive medicine (against malpractice) as not adding much to overall expense, simply because states that have had tort reform have not lowered costs. (A non-solution to the problem, perhaps?) We also know that the top 1 percent of spending (and other surveys have different numbers, high and low) is for the chronic, seriously ill–and too much of it goes to hospitals especially the ‘top rated’ where proper rating metrics aren’t being used. None of this is a revelation, but he does make it seem so from the podium.

His vision is standardized care at all levels with a high degree of patient–and physician–compliance. His four things we need for ‘digital medicine’ demonstrate what his vision entails:

  • Mining data from EHRs, payer claims, patient monitoring data–predictive analytics. A wave of the future that is at present a concept truly in the distance, as merging together data streams that are so disparate when EHR workflows don’t cross-check each other (as in the unfortunate Dallas Ebola patient) only can be. Analytics companies have chunks of this, and this Editor saw presentations today from NYeC’s 2014 Digital Health Accelerator graduates Clinigence and iQuartic in this area, but it is early, early days till this enters the healthcare workflow in a widespread, affordable way.

click to enlarge

  • Clinicians would be profiled and measured on improved performance. He sees EHRs as having defaults which tell doctors what to do, which is an idea from the care management side where defaults for vital signs monitoring ranges in reports (and telehealth) are routinely used. Doctors and clinicians would also be dependent on machine learning, but Dr Emanuel interestingly did not say the usual term ‘decision support tools’ or mention IBM Watson. (Perhaps because the decisions would already be made?) Radiologists would be fewer, presumably because the scans would be digitally read. LEAN manufacturing processes would morph to healthcare, as in this slide from Denver Health (left), but how that would translate wasn’t explained.
  • Patients would be monitored on their improved compliance. Compliance, particularly drug compliance, has been a goldmine for new companies in digital health and Dr Emanuel is an enthusiast, but approaches vary widely. Telehealth vitals would be monitored and recorded. Social media would be used to encourage compliance. Not much from him on getting to the causes of non-compliance, such as drug interactions and side effects, and nothing about proactive care before disease strikes. Underlying this is not much respect for the patient’s intelligence or responsibility as a partner in their care.
  • Enhanced convenience. Now the appeal of this is that urgent care may not even be in person, but online. Through EHRs and presumably PHRs, the doctor would have access to data for care anywhere. (Finally, a point of agreement with Dr Topol!)

Dr Emanuel also had some predictions which this Editor will list and leave for the reader to investigate if so inclined:

  • The diffusion of VIP care for the chronically and mentally ill–to this Editor, closer to the VA model of standardized care along quantitative lines and outside of the hospital. However (and the VA struggles with this even as a leader in ‘telemental health’), behavioral health and its patients resist standardization.
  • The expansion of digital medicine and the closure of hospitals
  • The end of insurance companies as we know them (a quick mention of ‘single payer’)
  • The end of employer-sponsored health insurance (whizzed by)
  • The end of health care inflation
  • The evolution of Academic Health Centers

The open question, which no one (including this Editor) dared to ask was: what entity would be imposing all this order on medicine, and enforcing all these ‘you will’s? What happens to the people who need healthcare while all this change is percolating through?

One must be wary of presenters and ‘big thinkers’–and these doctors define the latter, especially Dr Emanuel who looks in the mirror and sees an iconoclast staring back. Fitting evidence selectively into a Weltanschauung is an occupational hazard and we in the field are often taken with ‘big pictures’ at the expense of what can and needs to be done now.

Both Drs Topol and Emanuel, in this Editor’s view, have gaps in vision. Dr Topol glosses over the existence of the less technology savvy, the needs of older adults, the less intelligent and/or unable (the physically, developmentally or cognitively disabled) and those simply unwilling to manage their health. Dr Emanuel fails to recognize that his view stifles innovation, that doctors and clinicians treat cookbook medicine as a pejorative, may opt out (or never enter the field), and that there is an undercurrent, clearly felt by this Editor, of disrespect for the patient’s intelligence. The patient has minimal say other than following directions. Both agree on genomics, the power of data and moving healthcare out of the hospital setting. But their views on how this happens could not be more different. In short form:

Emanuel–Top Down. Process centric. Programmed, formula, rule based, cookbook medicine, stifling innovation, frozen. Dependence on metrics and medication. Goal: the Perfectly Processed, Compliant Patient.

Topol–Bottom Up. Individual centric. Personalized medicine, participative, innovative, individually focused (clinician and patient), fluid. Dependent on learning, technological savvy and a responsible patient. Goal: the (largely) Doctorless Patient, the Doctor as Partner.

 It was certainly daring on NYeC’s part to have them both keynoting.

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Comments

  1. That’s a really interesting summary of two conflicting world views about Digital Healthcare. Interestingly they seem to mirror the difference between the US insurance based approach and European socialised approach to healthcare more generally. No doubt in the real world we will see bits of both systems being applied and end up with a messy compromise.

  2. Donna Cusano

    Hi Greg, I would agree with that. We may very well get the worst of both worlds!

    In rereading this article on my depiction of the Emanuel goal as the ‘perfectly processed, compliant patient’, the brain cell that activated was a memory of my travel industry marketing days. At Avis we had some long debates about how our goal had been ‘perfectly processing’ reservations and rentals, but not giving renters–particularly high-value (larger cars, longer length of rental) ones a reason why to choose Avis rather than Hertz, Budget (before Avis owned them), Dollar (in some markets), Enterprise etc. We particularly analyzed Enterprise’s very hands on, somewhat sloppy (manual rental agreements! personal car delivery!) operations and their absolute genius at upsell. That is where that came from. Of course, the debate became moot when the shopping process went fully online for the vast majority of rentals and car rental (along with airline and hotel) went fully commoditized, rate driven and mostly mediocre.

    The parallel to this in healthcare is not perfect, In a single payer system which is what Emanuel is driving at, you have no alternatives. The next stage in ‘perfect processing’ of course is restriction and rationing of services, because that gets in the way–or imperfect processing, because the patient has nowhere to go. Consider: the US Veterans Administration.

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