Calling Dr. Algorithm

Calling Dr. Algorithm

Technology is poised to make big changes in the delivery of healthcare.

Imagine that almost every household had an inexpensive, easy-to-use, handheld gadget capable of automatically measuring key vital signs (blood pressure, blood oxygen level, heart rate, respiratory rate, temperature) as well as accurately diagnosing more than a dozen serious illnesses (including anemia, diabetes, hepatitis A, pneumonia, tuberculosis and stroke). This device would also be able to instantly share the information it collects with professional caregivers when appropriate.

Sounds like science fiction? In fact, the inspiration for this device is science fiction: the "tricorder" used by the 23rd-century members of the Enterprise crew on Star Trek.

But it looks like we may not have to wait a couple of centuries for the medical tricorder to be real. In 2011, the X Prize Foundation announced the Qualcomm Tricorder XPrize, a $10 million competition to "stimulate innovation in creating precision diagnostic technologies [to help] consumers make their own reliable health diagnoses." Ten teams from six countries have been selected as finalists in the competition to develop a device that will accurately measure five vital signs and 13 health conditions (including those listed above). In late 2015, the finalists' entries will be tested with consumers, and the winner will be announced in January 2016. The federal Food and Drug Administration is participating in the competition to help speed the approval process that will be necessary before a working tricorder can be put on the market. If all goes well with the competition, a tricorder-like device might be on the market before the end of the decade.

Disrupting healthcare

The race to develop a working tricorder is just one small aspect of a much larger movement to integrate advanced technologies into the process of delivering healthcare. Although many other fields have been massively disrupted by new technology in the past several decades, healthcare has been relatively immune to change. Unfortunately, the U.S. healthcare system (despite claims that "it is the best in the world") has serious problems: Although U.S. per capita healthcare costs are the highest of any country in the world, the U.S. lags behind many other countries in terms of key health indicators like longevity and infant mortality.

But recently there have been some encouraging signs of progress. Rather than focusing on the treatment of specific diseases, these innovations are designed to improve the efficiency and effectiveness of the delivery of care. To give a sense of what is going on today, let's look briefly at three areas: "mHealth" and remote patient monitoring; efforts to link doctors and patients electronically (known as "connected health"); and the application of advanced computing techniques to assist physicians and other providers with making complex medical decisions.

Back in 2007, I wrote a paper titled Health Care Unplugged: The Evolving Role of Wireless Technology that was published by the California HealthCare Foundation.It turned out to be the first publicly available report on what soon came to be known as "mHealth" -- the use of lightweight, wearable devices to track and support patients' health. These devices were made possible by continued progress in making medical sensors smaller, cheaper and more sensitive, along with the growth of high-speed wired and wireless networks that would enable healthcare providers to track their patients' health remotely.

The need for such technology was being driven by the aging of the population, which was shifting the focus of care from the episodic treatment of acute health problems (such as infections or injuries) to the ongoing management of chronic conditions. Given that doctors can see any one patient for only a few hours per year, the primary responsibility for caring for chronic conditions inevitably falls on the patients themselves (and their families). If they are to be successful in providing self-care, they need help in monitoring their health status and getting professional help when needed.

mHealth has emerged as one of the hot areas of healthcare in the past few years. The development of the technology has occurred mainly in the areas of wearable activity trackers (like the Fitbit and the Jawbone Up), which have been adopted by several million people to help them improve their fitness, and the growth of health apps for smartphones, which now probably number in the thousands.

Smartphone makers have also developed mHealth offerings. Earlier this year, Samsung unveiled its line of Gear Fit devices, which monitor workout activity, heart rate and sleeping habits. And Apple recently announced its iPhone Healthkit platform, which promises to increase the usefulness of mobile health apps by integrating inputs from many separate sources (including data from external devices like a scale or a blood-pressure cuff) in a single friendly interface. With the continued innovation in smartphones, it's very likely that some or all functions of the tricorder may simply be another built-in capability of our omnipresent mobile phones.

Connected health. When a sick patient needs to see a doctor, time is often a critical factor. (For example, there is a "golden hour" for stroke victims, which means that appropriate treatment needs to begin within 60 minutes in order to maximize the chances of successful recovery.) But too often, access to doctors -- and particularly to specialists -- can be a difficult challenge.

Telemedicine -- the use of teleconferencing and other network links -- to connect doctors and patients has been in use for several decades, but mostly on the fringes of healthcare (such as remote rural areas). With the growth of broadband networks, the cost and complexity of supporting telemedicine have declined, while the Affordable Care Act has created new incentives to improve the efficiency of healthcare delivery.

In fact, telemedicine is starting to go mainstream. A company called Specialists on Call (SOC) is using high-quality teleconferencing systems to enable smaller hospitals to have on-demand access to specialists such as cardiologists and neurologists. The service is obviously good for patients with an urgent need for specialized care. It also is beneficial for specialists, who can fully utilize their skills by seeing more patients via the service than they could if they were based at a smaller hospital with a limited number of patients.

As telemedicine becomes mainstream, there are still some regulatory and policy barriers that inhibit the advancement of solutions for patients. Two key barriers are interstate licensure for doctors and reimbursement restrictions.

First, in order to provide telemedicine services across state lines, healthcare providers are required to obtain multiple state licenses and adhere to multiple state rules. Patients are restricted from receiving remote medical services from physicians if they are unlicensed in the patient's own state, even if they are licensed in other states. While intended to protect patients, these laws are now limiting the advancement of telemedicine. (In the case of SOC, the company works with participating physicians to get them licensed in multiple states, which adds to the company's costs.)

Second, under today's Medicare regulations, less than 1% of healthcare providers receive reimbursement for telemedicine services. Medicare rules currently limit reimbursement for telemedicine services to rural areas and do not provide adequate incentives for providers to embrace these technologies.

Making healthcare more intelligent. Our knowledge of the mechanisms of health and disease is growing very rapidly thanks to expanding research efforts globally. Insights from fields like genomics and proteomics (understanding the mechanisms of disease at the molecular level) are opening exciting new vistas for the development of highly personalized medical treatments.

But this growth in scientific knowledge is creating a problem for care providers. The total amount of information that can be used to inform medical decisions is doubling every five years, while the capacity of human beings to process this information is not increasing. What this means is that all relevant information is not taken into account in clinical settings by most practitioners most of the time. The result is that the quality of care that is actually being provided is highly variable and often less than ideal: According to Bob Brook, distinguished chair for healthcare services at the RAND Corporation, half of what patients really need in the way of treatment they don't receive, and 20% of the care they do get they don't actually need.

Can digital technology make healthcare smarter? The evidence to date is encouraging. A number of interesting experiments are under way, but perhaps the best-known "face" (if that's the right word) of intelligent medical technology is IBM's cognitive computing system, Watson. After winning at Jeopardy! in 2011, Watson has been put to work on more serious challenges, including healthcare.

Over the past few years, IBM and its medical partners have been giving Watson a medical education that includes access to more than 600,000 pieces of medical evidence, more than 2 million pages from medical journals and the ability to search 1.5 million patient records. Initial medical uses include a research project with Sutter Health and Geisinger Health Systems (with $2 million in funding from the National Institutes for Health) to identify early signs of heart disease, and an effort by WellPoint and Memorial Sloan Kettering Cancer Center to improve decisions about cancer care using big data analytics. According to WellPoint's chief medical officer, Samuel Nussbaum, Watson has the potential to improve the rate of making optimal decisions about cancer treatment from the current rate of 50% to at least 90%.

Other approaches to making healthcare more intelligent and more reliable are also being explored. For example, collaboration at Stanford University between the Clinical Excellence Research Center and the Artificial Intelligence Laboratory is developing an AI-Assisted Care system to visually monitor activities in locations like hospital intensive-care units to ensure that all critical workflow protocols are being followed properly.

Getting policy right

The combination of broadband connectivity, smart devices and intelligent healthcare applications holds enormous potential to transform the way that healthcare services are provided to everyone. To accelerate this transformation, policymakers will need to appreciate the disruptive impact that the convergence of the healthcare and communications will have on the future of healthcare delivery and take steps to ensure that our nation's healthcare and communications laws are modernized to reflect this new paradigm.Assuming that the right policies are in place, these technologies that seem avant garde today are likely to become parts of mainstream healthcare sooner than we imagine. mHealth applications will become standard treatment for virtually all at-risk patients. While services such as SOC are currently focused on hospitals (partly because of reimbursement policies), telemedicine services will move steadily to other places, including homes. Already, the Veterans Administration is using a relatively simple technology to monitor the health status of some 100,000 sick, frail or disabled veterans at home on a daily basis. Eventually, telemedicine will deliver medical care whenever and wherever it is needed.

And someday in the not too distant future, as we begin to realize the full benefits of new technology, the idea that doctors had to make critical diagnoses and treat patients on their own without intelligent assistance may seem as old-fashioned and even as barbaric as healthcare in the time when no antibiotics were available for treating infections and surgeries were conducted without anesthesia.


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