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Thursday, January 15, 2015

Health 2.0 WinterTech 2015 in San Francisco

A long, glorious day, filled with powerful presentations and panel discussions. I left the house at 5:45, hit the BART at 6:17, read a good bit of Dr. Topols' new book "The Patient Will See You Now" on the way in from the Pittsburg/Bay Point station. Short walk from the Embarcadero station to 465 California Street and the interesting Julia Morgan Ballroom.

Below, Matthew Holt and I agree on this issue.



The subtitle of Dr. Topol's book could serve as a concise summation of the body of WinterTech topics I just saw: "The Future of Medicine is in Your Hands."

...the essence of a new era of medicine. It is powered by unplugged digitization, with the smartphone as the hub. We have seen this model already adopted in retail, travel, dining, entertainment, banking , and virtually every other industry. It’s all on demand and instantaneously executed. This has moved far beyond just having a prosthetic brain for a search or a built-in navigation GPS. In almost any endeavor , getting things done in a flash has become the norm, except in medicine. But that is now inevitable.
Getting first-rate health care will always be quite different from ordering something from Amazon. We’re talking about the most precious part of life— one’s health— not buying a book. But the common thread is the power of information and individualization. We are embarking on a time when each individual will have all their own medical data and the computing power to process it in the context of their own world. There will be comprehensive medical information about a person that is eminently accessible, analyzable, and transferable. This will set up a tectonic (or “tech-tonic”) power shift, putting the individual at center stage. No longer will MD stand for medical deity. What have been dubbed the six most powerful words of the English language—“ The doctor will see you now”—will no longer be true. Indeed you will still be seeing doctors, but the relationship will be radically altered. 

The doctor will see you now via your smartphone screen without an hour of waiting, at any time, day or night...

It might not be your primary care doctor, but it will be likely be a reputable physician who is conducting part of his or her practice through secure video consults. And those consults will involve doing parts of the standard physical examination remotely. More importantly, they will incorporate sharing your data— the full gamut from sensors, images, labs, and genomic sequence, well beyond an electronic medical record. We’re talking about lots of terabytes of data about you, which will someday accumulate, from the womb to tomb, in your personal cloud, stored and ready for ferreting out the signals from the noise, even to prevent an illness before it happens. 

The Power Shift 
 More is at play than just your “little” big data. Let’s drill down on the term democratization, meaning “to make something available to all people.” Until now, the flow of medical data has been to the doctor. If a patient was fortunate enough, their data, such as results of lab tests or scans, might arrive in the mail. More likely, but still rare, would be for the bottom line (like “everything is normal”) to be relayed via a phone call, often via a nurse or office assistant. The really lucky patient (with a less than 1 out of 10 chance in the United States) might even get an e-mail with attachments that include all their data.

But the world is changing now. Patients are generating their own data on their own devices. Already any individual can take unlimited blood pressures or blood glucose measurements, or even do an electrocardiogram (ECG) via their smartphone. The data are immediately analyzed, graphed, displayed on the screen, updated with new measurements, stored and, at the discretion of the individual, shared...
Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands (pp. 4-6). Basic Books. Kindle Edition. 
OK, well, let's start with an early panel example. Dr. Lena Cheng, and Doctor on Demand.

Lena is an internal medicine-trained physician and digital health expert with over fifteen years experience in clinical medicine and healthcare strategy. She brings her passion to Health 2.0 as she showcases the speed, efficacy, and care delivered via Doctor on Demand.
The Better Way to Feel Better
See a doctor, psychologist or other provider – from the comfort of home, or on the go
Doctor On Demand Video Visits allow our physicians, psychologists and lactation consultants to provide focused care – without you having to leave your home. With Video, they can Look, Listen, and Engage with you to diagnose your issues and provide an effective treatment plan.
Well, we'll see. I'm fixin' to try this service. I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist -- even to get a dad-gumbed scrip refilled! (He referred me to a "pain management specialist.") e.g., from one of my TCHB comments:

It's Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

Knowing that I would have another annual visit coming up, I went into Muir's portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

He refused. Had some Muir employee call me the following week with the news. Didn't respond (for the record?) to my portal email.

I told the caller to just cancel my appointment request.

Maybe Doctor on Demand won't be able to help me. The cost of finding out will be nil. I'll pay by credit card.

Had I the right iPhone apps (suitably QC vetted, of course, for clinical accuracy and precision), I'd prick my finger, pee in a cup, and run the specimens for my own labwork. Maybe most patients aren't competent to evaluate them. That is not the case with me. I know what to look for, what safely seems negligible, and what needs MD attention.

Dr. Topol:
Patients are intrinsically remarkably smart—they know their own bodies and the context of their lives—and no one has a bigger interest in their own health. That doesn’t mean, however, that they do all (or any of) the right things to stay healthy, but when things do go wrong, they are pretty darn good at detecting a problem. But we’ve learned that, in general, doctors don’t like smart patients. In fact, a recent study of physician attitudes found that: “patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions.” 
Those attitudes won’t be enough to hold back a whole new generation of even smarter patients and hopefully more supportive and smarter doctors. Indeed, they’re already all around us. [ibid, pg 8]
Coming up:, Hi.Q, Food Scores, and more. Oh, and, I gotta have one of these:

Dr. Tejash Shah of Samsung. Presenting wristband telemetry.


I would think so. And, audit-proof 45.CFR.164.3, .4, and .5 compliance are no cakewalk. On the ePHI security side, things begin with 45 CFR 164.308 - Administrative safeguards ("Core 15" in MU-speak). Which commits you to the gamut of 164.3, including physical and technical safeguards. 164.4 goes to breach notification, and 164.5 goes to privacy. -- which is complicated by the fact that, unlike prevailing "federal primacy" in general, HIPAA regs are subordinate to state privacy laws and regulations where the latter are deemed more strict. All of HIPAA Security and Privacy now apply equally to Covered Entity Business Associates.



Pretty good summary of EWG's Food Scores app.


I've surfed around for a bit. Most of the docs that pop up in my area are affiliated with Muir. Our service area is increasingly dominated by Kaiser, Muir, and Sutter. Kaiser is a non-starter for me, given my insurance, notwithstanding that it would be my preference clinically. I may have to expand my search geography. But, independents are a vanishing breed generally here in the Bay Area.
Regarding my frustrating $436 Muir visits. A long-standing joke in Las Vegas: "Q: Where do you go when you need medical attention in Las Vegas? A: The airport." I just checked my Expedia account. I can get round-trip airfare, a decent hotel (3 nights), and a rental car for $280 inclusive. Add to that a bit of gas, and my Senior discount BART Clipper card fare to SFO and back home. ~$300 total. I can go see my old pals at The Palms, hear some great music, shoot some new shots of them, and go see my old Primary, Dr. Gong for a checkup and get my friggin' scrip renewed.
Vegas as a "Medical Tourism" destination? LOL. Who'da thunk?


My New Yorker just arrived in the mail. Powerful, poignant cover art.



"Health Literacy" app. Very cool, a nuanced, detailed (but entertaining) approach. Presented by co-founder and CEO Munjal Shah.

Impressive presentation. One of my favs of the day. Definitely getting this app.
"Hi.Q is an innovative self-care example of how we should be approaching health today. Regardless of any disease or condition a person might have, knowledge is extremely influential in preventing future health risks and hospitalizations."
- Dr. Isaac Kohane, MD
Their website is beautiful, surf it at length.


When you hear the word “empowerment,” it’s code for “You’re on your own, pal.”
Health care leaders are starting to recognize that consumers are becoming a major decision-making force. Let’s be clear at the outset: The rise of the consumer is not the panacea that will solve all our problems. It is a reality that hospitals and health systems must respond to. For the foreseeable future, consumers will pay more for health care and be more involved in picking plans, providers and individual treatment options. This development means significant financial consequences for consumers (unlike almost any other developed country)...
Click the title. A long post worthy of your time and attention amid all this fawning celebration of ostensibly salvational technology and innovation.
"As more of the market moves to exchanges, as high-deductible health plans and narrow networks proliferate, and as managed care in public programs such as Medicare and Medicaid become the norm, so consumers will be asked to make more decisions, increasingly with their own money."
Yeah. And to their credit, a number of the panelists today emphasized the ultimate question of value (vs "valuation") -- will people actually pay for this stuff?


A day-long, intense parade of smart, eloquent, committed people spanning the breadth of the space, from tech to policy to investment.

I'll try to caption the above with names where I can. My apologies to those whom I may have missed. I was busy trying to make lemonade of the relatively uneven, inadequate lighting (I counted 7 front/side parcans, no backlighting). Yeah, I'm spoiled.

BTW- I accorded Vik Khanna a permanent link for his new book in the upper right links column. I'd reviewed it in a prior post. "Empowerment," "personal fitness/wellness responsibility," "consumer education," etc. The topics certainly fit with many of the themes expressed at WinterTech 2015.

Done for now. I'm baked. Gotta go practice my guitar. Thanks to Health 2.0 for the press pass. Your conferences are always top-shelf (with the exceptions of the skim and soy milk).


I'd intended to blab on a bit tying together the thematic elements I took away from Thursday's conference, alluding to some of the topics I'd not addressed in the foregoing, e.g., mental health issues, Big Box health retailing, "omics" developments, the "fashion" and "gamification" nudging aspects of health/fitness wearables, "Big Data" implications, etc. "Social Determinants of Health"? The implications of all things "Upstream" (including the socioeconomic)?

But, my new Harper's arrived today. Perhaps some thoughts from it will serve the larger picture just as well.

From the (paywalled) issue:
The Melancholy of Anatomy
By Wendell Berry

We need to acknowledge the formlessness inherent in the analytic science that divides creatures into organs, cells, and ever smaller parts or particles according to its technological capacities.

I recognize the possibility and existence of this knowledge, even its usefulness, but I also recognize the narrowness of its usefulness and the damage it does. I can see that in a sense it is true, but also that its truth is small and far from complete.

In and by all my thoughts and acts, I am opposed to any claim that such knowledge is adequate to the sustenance of human life or the health of the ecosphere.

Do even the professionals and experts believe in it, in the sense of acting on it in their daily lives? I doubt that they do.

To this science, the body is an assembly of parts provisionally joined, a “basket case” sure enough. A mountain is a heap of “resources” unfortunately mixed with substances that are not marketable...

We may know the anatomy of the body down to the anatomy of atoms, and yet we love and instruct our children as whole persons. And we accept an obligation to help them to preserve their wholeness, which is to say their health. This is not an obligation that we can safely transfer to the subdivided and anatomizing medical industry, not even for the sake of cures. Cures, to industrial medicine, are marketable products extractable from bodies. To cure in this sense is not to heal. To heal is to make whole, and is not so ideologically definable or so technologically possible or so handily billable...

A proper attention to our language, moreover, informs us that the Greek root of “anatomy” means “dissection,” and that of “analysis” means “to undo.” The two words have essentially the same meaning. Neither suggests a respect for formal integrity. I suppose that the nearest antonym to both is a word we borrow directly from Greek: poiesis, “making” or “creation,” which suggests that the work of the poet, the composer or maker, is the necessary opposite to that of the analyst and the anatomist. Some scientists, I think, are in this sense poets.

But we appear to be deficient in learning or teaching a competent concern for the way that parts are joined. We certainly are not learning or teaching adequately the arts of forming parts into wholes, or the arts of preserving the formal integrity of the things we receive as wholes already formed.

Without this concern and these arts, our efforts of conservation are probably futile. Without some sense of necessary connections and a competent awareness of human and natural limits, the issue of scale is not only pointless but cannot even enter our consciousness.

My premise is that there is a scale of work at which our minds are as effective and even as harmless as they ought to be, at which we can be fully responsible for consequences and there are no catastrophic surprises. But such a possibility does not excite us.

What excites us is some sort of technological revolution: the fossil-fuel revolution, the automotive revolution, the assembly-line revolution, the antibiotic revolution, the sexual revolution, the computer revolution, the “green revolution,” the genomic revolution, and so on. But these revolutions — all with something to sell that people or their government “must” buy — are all mere episodes of the one truly revolutionary revolution perhaps in the history of the human race, the Industrial Revolution, which has proceeded from the beginning with only two purposes: to replace human workers with machines, and to market its products, regardless of their usefulness or their effects, to generate the highest possible profit — and so to concentrate wealth into ever fewer hands.

This revolution has, so far, fulfilled its purposes with remarkably few checks or thwarts. I say “so far” because its great weakness is obviously its dependence on what it calls “natural resources,” which it has used ignorantly and foolishly, and which it has progressively destroyed. Its weakness, in short, is that its days are numbered.

Having squandered nature’s “resources,” it will finally yield to nature’s correction, which in prospect grows ever harsher.

We have formed our present life, including our economic and intellectual life, on specialization, professionalism, and competition. Certified smart people expect to solve all problems by analysis, dividing wholes into ever smaller parts. Science and industry do give room to synthesis, but by that they do not mean putting back together the things that they have taken apart; they mean making something “synthetic.” They mean engineering the disassembled parts, by some manner of violence, into profitable new commodities. In such a state of things we don’t see or, apparently, suspect the complexity of connections among ecology, agriculture, food, health, and medicine (if by “medicine” we mean healing). Nor can we see how this complexity is necessarily contained within, and at the mercy of, human culture, which in turn is necessarily contained within the not very expandable limits of human knowledge and human intelligence.

We have accumulated a massive collection of “information” to which we may have “access.” But this information does not become knowledge by being accessible. We might find, if such a computation were possible, that the amount of human knowledge over many millennia has remained more or less constant — that is, it has always filled the available mental capacity — and therefore that learning invariably involves forgetting. To have the Renaissance, we had to forget the Middle Ages. To the extent that we have learned about machines, we have forgotten about plants and animals. Every nail we drive in, as I believe C. S. Lewis said, drives another out.

The thing most overlooked by scientists, and by the enviers and emulators of science in the humanities, is the complicity of science in the Industrial Revolution, which science has served not by supplying the “scientific” checks of skepticism, doubt, criticism, and correction, but by developing marketable products, from refined fuels to nuclear bombs to computers to poisons to pills.

It has been remarkable how often science has hired out to the ready-made markets of depravity, as when it has served the military-industrial complex, which is solidly founded on the hopeless logic of revenge, or the medical and pharmaceutical industries, which are based somewhat on the relief of suffering but also on greed, on the vicious circles of hypochondria, and on the inducible fear of suffering yet to come. The commodification of genome-reading rides upon the same fears of the future that palmistry and phrenology rode upon...

There are, we know, scientists who are properly scrupulous, responsible, and critical, who call attention to the dangers of oversold and under-tested products, and who are almost customarily ignored. They are often called “independent scientists,” and the adjective is significant, for it implies not only certain moral virtues but also political weakness. The combination of expertise, prestige, wealth, and power, incapable of self-doubt or self-criticism, is hardly to be deterred by a few independent scientists.

Scientists in general, like humanists and artists in general, have accepted the industrialists’ habit, or principle, of ignoring the contexts of life, of place, of community, and even of economy.

The capitalization of fear, weakness, ignorance, bloodthirst, and disease is certainly financial, but it is not, properly speaking, economic.

Criticism of scientific-industrial “progress” need not be balked by the question of how we would like to do without anesthetics or immunizations or antibiotics. Of course there have been benefits. Of course there have been advantages — at least to the advantaged. But valid criticism does not deal in categorical approvals and condemnations. Valid criticism attempts a just description of our condition. It weighs advantages against disadvantages, gains against losses, using standards more general and reliable than corporate profit or economic growth. If criticism involves computation, then it aims at a full accounting and an honest net result, whether a net gain or a net loss. If we are to hope to live sensibly, correcting mistakes that need correcting, we need a valid general criticism.

Scared for health, afraid of death, bored, dissatisfied, vengeful, greedy, ignorant, and gullible — these are the qualities of the ideal consumer. Can we imagine an education that would turn passive consumers into active and informed critics, capable of using their minds in their own defense? It will not be the purely technical education-for-employment now advocated by the most influential “educators” and “leaders.”

We have good technical or specialized criticism: A given thing is either a good specimen of its kind or it is not. A valid general criticism would measure work against its context. The health of the context — the body, the community, the ecosystem — would reveal the health of the work.
"[W]e appear to be deficient in learning or teaching a competent concern for the way that parts are joined. We certainly are not learning or teaching adequately the arts of forming parts into wholes, or the arts of preserving the formal integrity of the things we receive as wholes already formed.

Without this concern and these arts, our efforts of conservation are probably futile."
Goes maybe to "the Art of Medicine"? The art of simply living well? (Something we should wish for -- and work for -- all people.)

Great essay. Get a subscription (or just buy a newsstand copy) and read all of it.

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