Take Two Aspirin and Ping Me in the Morning

Health care: an oral future

Leslie Ziegler
Leslie Ziegler

Translating a message that might save mankind, John Nosta sounds like one of Asimov's Eternals on a collect call from upwhen: fervent and in a hurry. Leslie Ziegler speaks with the same enthusiastic tones about her "gut bacteria" self-testing kit via uBiome as she does an upcoming trip to India. Bryan Sivak apologizes for running a few minutes late between dropping his child off at a play date on President's Day and readying a crucial block of President Obama's Affordable Care Act.

These three and other innovators and presenters at SXSW Interactive 2013 took time out of their dizzying schedules during the past month to talk with the Chronicle about health care, a predominant concern of this year's conference. From a series of conversations and emails, I've recontextualized their quotes, with the aim of creating a sort of all-star super-panel, a broader discussion based on each participant's area of expertise, while at the same time covering as much programming ground as possible.

John Nosta, Ogilvy CommonHealth, Forbes.com, TEDMED: Where do you want to start? Do you want to start with the emergence of digital health? I think that the world is changing in ways that are unpredictable. And I would reference the development and the evolution of the smartphone, just over a few short years. The technology is expanding at such a rapid rate, that we are finding uses that we never even thought of. Now, play into that this sort of subconscious driver, or the science-fiction realty of health, that has so impacted inventors and developers throughout the years, going back to Star Trek and the Tricorder and all of these different devices that can scan your body. They're actually coming to fruition now. Not only is science fiction coming to life, but it's shaking the cornerstones of practice.

One testament to this is the Tricorder Qualcomm Prize. And this is a $10 million prize that is fostering the development of scanners that very simply scan your body and decipher indices that can be the arbiter of illness or health. So, what's happening now is that the rapid movement of technology is making its way into the clinical practice of medicine, but it's also making its way into the practice of wellness on the part of the consumer. And this leads to this issue of the quantified self.

Christie Hefner, Canyon Ranch Enterprises: I think that some of the early, very valuable uses of the Internet for consumer empowerment regarding health were the innovations that WebMD and others have followed around the availability of massive amounts of information regarding conditions and symptoms and research and programs. For the first time, now going back a number of years, instead of the consumer not having resources beyond a second opinion, you could talk to other people who had the same diagnosis, you could find out what pilot programs were going on in Europe, you could talk to a community of people who had loved ones facing this condition. I think that has been enormously helpful.

But where I think things are going is to allow people to move beyond just thinking about conditions and symptoms to thinking about what they can do proactively with regard to nutrition, stress, sleep, exercise, and brain health, that will allow them to feel their best, not just to intercede after they get a diagnosis.

Brad Davidson, Ogilvy CommonHealth Behavioral Insights: The Internet can help you make good decisions by directing you to people who have been in your shoes, and who have made those choices. You can see how it worked out for them, and witness some real-world possible outcomes. I think the Internet is probably the only thing that's going to help people make their own decisions in an informed way, but you gotta find the right information.

From an anthropological standpoint, what we've lost in all of this, and what you see these online health care communities of practice giving people, is the relationship aspect of doctoring. We've turned doctoring into a very transactional event. So, yes, in the sense that, we could turn our current primary care physician into the Bones McCoy Tricorder, because we don't really talk to our doctors now, anyway. But if you go back to what doctors used to be, they were something a little holier, and we're missing that now.

We're still people, and we still need that, so we're just going to get it somewhere else. The more that we turn the practice of medicine into a transactional, algorithm-based, automated, do-it-yourself health kit, the more we're going to have to find somewhere else to get the spiritual aspect of it. Because at the end of the day, we still don't know why we're alive, we still don't know why we get sick, and we still don't know when we're going to die. Those are things that in conversation and in relationship with health care providers and healers in general, we would have some of those needs met.

The current system is becoming very efficient at the mechanics of physical health, but very poor at the spiritual aspects of physical health. And I'm not trying to be touchy-feely or New Age; I'm not really that guy. But, from an anthropology standpoint, it's necessary. That's why we have priests. That's why we have shamans. That's why we have healers all over, and it's why we're scared to death to die. We've become more and more alienated from the people who provide us health care, as they've become better and better at providing the mechanical aspects of it. And the transactions. The Internet is actually giving us some of that back, but I still think there's a role for – again, big air quotes here – some sort of expert.

Nosta: There's a problem now in the market. There are people who understand technology, and you see them everywhere at South by Southwest. There are people who understand health: highly qualified physicians. But what is the conduit between technology and health? We need to establish some interpreters, if you will, who can help bridge that gap. Because oftentimes, there is this space between the two. Each of these players will look at each other almost with contempt, and not cooperation. Some physicians look at technology as robbing them of the humanity of their practice. Technology is looked at as an ill-informed algorithm that doesn't understand the complexity of the situation. These are forces that sometimes can be adversarial, sometimes for good reason.

Frank Moss, MIT Media Lab: Even if you did know everything as a doctor, you couldn't deal with that volume of data being generated from patients themselves, or from the monitors and sensors that are now becoming available. I think it's physicians and others becoming aware that their jobs could be different. Take, for example, chronic care, which I think is the most interesting area right now: The doctor needs to play a different role; the doctor can't be involved in every decision, particularly as this data becomes more important. The doctor needs to become more of a strategist, setting goals that a team can follow.

Physicians are starting to realize that unless they begin to empower patients and begin to engender a team environment around the patient, their job is miserable. They don't have the time to concentrate on what they're doing; they're already burdened by insurance and administrative work. They've got to find a way to redefine what it means to be a doctor. My student, John Moore, who is my co-founder at Atelion Health, quit the practice of medicine to come to MIT. He just found during the practice of ophthalmology that he didn't have the time to dedicate and listen to his patients. ... Primary care as we know it today is probably going to change significantly. The real change is going to be that doctors are going to involve themselves as mentors, and see themselves as educators in kind of a mentor-apprentice relationship with their patient.

Dan Diamond, NogginStorm: Some doctors feel threatened by patients going on the Internet for information. I look at the Internet as a resource that helps me form a better "partnership" with my patients. When patients are engaged, they are more likely to have positive outcomes. Part of my job is to direct people to reliable information and apps. When it comes to the patient experience, I'm not at all shy about looking up information. I find that I'm able to give much more meaningful input to the patient if I'm willing to jump online to one of my trusted resources, like Uptodate.com, or the application that I use most frequently, by far, Epocrates. It's on my iPhone, so it's always available. It's efficient, unbiased, and delivers the level of information that I need about 90 percent of the time.

Leslie Ziegler, co-founder, Rivet: Fifty percent of doctors are below average. Wouldn't it be better to standardize some of the care? We're seeing this major shortage of primary care professionals, and it's not going to be filled, because it's much more lucrative to specialize after taking out all of these loans as a medical student. Primary care is falling short. But the personal touch and the humanity of health care is something that we've got to be careful to preserve.

Diamond: The flood of information is overwhelming and confusing. As a physician, one of my roles is to be a guide and an interpreter. In the world of medicine, the most effective providers are the ones that can sift through the information and make it meaningful for the individual patient. As we enter into the world of universal health care, we are going to have to address the severe physician shortage that we have in the U.S. Physicians have intense time demands on their schedule and patients are, therefore, experiencing shorter and shorter office visits. Rather than taking a holistic approach, many physicians will limit the number of concerns that they will address during an office visit because their "productivity" is under tremendous scrutiny. As such, the risk of misdiagnosis increases. There are two major problems that are preventing medical excellence: time and depth.

Ziegler: Education and health are something that all of us have, and all of us experience. They're also two things that are rising in cost, but not rising in efficacy. If you look at health care costs, it's going to be 20 percent of our GDP very shortly. Global spending is up, as well. Yet no one has figured out how to make it more efficient. While we have all of this technology, it's not like it's doing us a tremendous amount of good right now. You look at [Electronic Medical Records]: They don't talk to each other. They're going to have to soon, because the government said that they would. When I was at Rock Health, we had a woman who had a cavernous malformation, and it was a traumatic thing. She went into a coma for almost two weeks. How long do you think it took to get her medical records from UCSF to Stanford? It's 30 miles away. It took three days. And she was in the ICU. So, you look at what's happening, you look at the problems and opportunities, and it touches everybody, right?

Diamond: In order for this to work best, we need to have a universal Electronic Medical Record. As a front-line physician, I'm continuously frustrated by EMRs that do not talk with each other. Patients should be able to complete the medical history – including their present illnesses – online and have them directly populate their Electronic Medical Record. There is a tremendous amount of work to be done in the area of the EMR, including improving efficiency. Most of the providers that I've known that have implemented an EMR have said that it limited their efficiency to the point where they were not able to see as many patients per day. On average, I would estimate that there is a 20 percent decrease in productivity. ... We must figure out how to solve these problems in a manner that will allow providers to become even more efficient and accurate.

Nosta: One of the linchpins to this will be the evolution of the Electronic Medical Record, in that our medical records will be something that exists either on the Cloud or in our access for consultative care, but also for emergency care. If you have an abnormal EKG, and it just happens to be your abnormal EKG, which is not a problem, but it's just something your doctor knows about and really doesn't worry about. If you all of a sudden have chest pain while you're on vacation in the middle of the country, that abnormal EKG can be cause for tremendous alarm to a physician who may not know about it.

So, access to your medical record, knowing what your clinical profile looks like, could be a tremendous advance to care, because you could basically be carrying your medical records with you. If you've ever gone to another doctor for a consultation, oftentimes you have to bring along your X-rays, or bring along all sorts of complicated documents and pieces of paper, and it's a pain. It's a hassle. The EMR can help facilitate a much higher level of engagement, and therefore a much higher level of care, too.

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