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Sunday, September 20, 2015

The future of Healthcare Futurism

I have not the slightest doubt that the occupation of "futurism" has a stable future. We all love to speculate about what's to come. Proffer enough prognostications, some of them will turn out to be correct, just by accident.

I first heard of the designation "Healthcare Futurist" when I became aware of the writings and presentations of Joe Flower. I reviewed his first book in my May 2012 post "Let a Thousand Flowers Bloom."

Great guy. Deep and broad knowledge of the healthcare space, and a totally charitable man. I've cited him elsewhere, e.g., November 2014, "A damning Health IT quote from Joe Flower."

He'll be at Health 2.0 in a couple of weeks in Santa Clara, where he'll be a Keynoter for the Sunday symposium. He has a new book out that is well worth your time.


Carlton runs his EKG, and talks to his cardiologist about it — on his cell phone, while sitting on a bench at the park. 

Alicia’s mother is recovering from surgery in her own bedroom. Alicia and the hospital can continuously track how her mother is doing via the cell-phone-sized ICU-style monitor strapped to her mother’s wrist. 

Dexter calls his own personal doctor, whom he has on retainer, for an appointment that afternoon. Dexter is on Medicaid. Eva needs a new hip, and her co-pay will be pretty big. But her employer’s HR department offers her a deal: They will fly her to California; put her up in a hotel; have the hip redone at a top-flight facility; pay her part of the tab, pay for her drugs, her rehab, everything; and throw in a $5,000 bonus — all because the California facility will do it better and at one quarter the price of the local facility. 

Gareth picks up his cane and hobbles to answer the door. He is obese, his joints are inflamed, his lungs seem to be going, his diabetes is out of control, and he still hasn’t signed up for insurance. The woman at the door introduces herself: she’s his own personal nurse case manager, sent over by the hospital after his third appearance at the emergency department in the last month. 

Healthcare tomorrow will look little like healthcare today. The hospital as we know it will deconstruct into something far more varied, personal, and smaller. Prices for many parts of healthcare may drop by 50 percent, 75 percent, or more. Much medical care will happen where you are, not where the doctor is. Many healthcare organizations that miss the twists and turns of adaptation will fail, their ruins absorbed by others...

Section 1: 
The Ideas We can’t get to real change without a solid grounding in the problem. How did we get here? What are the threads and currents and connections of the tangled mess that we are in? Only when we understand that can we see how pulling this thread or that one, remaking a connection or shifting a power flow, will cause the system to fairly rapidly reconfigure itself...

Section 2: The Levers of Change 
There are seven identifiable levers of change in healthcare right now. Each one of them could, by itself, cause significant change. Together they have enormous power, feeding each other. They are: 
  • Shopping 
  • Transparency 
  • Results 
  • Prevention 
  • Targeting 
  • Trust 
  • Tech 
For each “Lever” I first lay out the problem, then identify the emerging solutions specific to each of six groups: 
  1. Purchasers (employers, pension plans, and other large private purchasers of healthcare) 
  2. Consumers (the end users of and eventual payers for the whole system) 
  3. Health plans (the middlemen in the private financing of the system) 
  4. Entrepreneurs, inventors, and investors (people and organizations creating new products to make healthcare work better) 
  5. Providers (the hospitals, physician groups, and health systems who actually provide us the medical care we need) 
  6. Government (federal, state, and local legislators and policymakers who define the ground rules under which the whole system works)
Flower, Joe (2015-07-30). How to Get What We Pay For: A Handbook for Healthcare Revolutionaries: Doctors, Nurses, Healthcare Leaders, Inventors, Investors, Employers, Insurers, Governments, Consumers, You (Kindle Locations 94-156). Kindle Edition.
I am flattered that Joe included me among a group of pre-publication reviewers. It was time well-spent. (And, btw, full-disclosure: when his book was recently released, I bought my own copy. I cite and review works on this blog based on my assessments of their merits. I don't ask anyone for anything.)

My only significant pre-pub observation was that there'd been no deep discussion of the major, indelible role of government and "regulators" more broadly amid the stakeholders. He subsequently fully addressed that. e.g.,
Healthcare is over-regulated. More important, the regulations are a mess. They overlap, and every agency demands its compliance information in slightly different ways, using slightly different definitions of each measurement. Even worse, some regulations contradict other regulations, so that it is not possible to always be in compliance with all regulations...

Regulatory compliance is the fastest-growing sector of healthcare these days, and that’s not good news. The best estimate is that the documentation required of physicians, for instance, has doubled in just the last 10 years. According to a recent study by the federal Institute of Medicine, the average hospital or health system employs 50 to 100 people, at an average cost between $3.5 million and $12 million, just to answer regulatory compliance surveys.

Hospitals and other healthcare institutions are regulated by (among other agencies): 
  • The Centers for Medicare and Medicaid Services (CMS) 
  • State health and insurance departments 
  • The Internal Revenue Service 
  • The National Committee for Quality Assurance (NCQA) 
  • The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) 
  • The federal Justice Department (for anti-trust issues) 
  • State “Certificate of Need” commissions 
There are many more. When the Office of the National Coordinator for Health Information Technology (ONC) wanted to build a new strategic roadmap for healthcare IT, it had to consult with 35 different federal agencies. And that’s just for health IT...

The Institute of Medicine has suggested scrapping almost all regulations at federal and state levels and replacing them with a standard of 15 core measures...

...Those who run healthcare and those who buy it and pay for it complain about the burden of regulation, but much of that burden has arisen out of the efforts over decades of the powerful leaders of the legacy system to protect their interests. The movement to the Next Healthcare is not largely something that can be dictated by government; instead it is largely the result of existing economic forces interacting and competing more strongly toward normal economic goals: producing real value for the end user for a lower price than the competition. The winners in the legacy system will fight hard by lobbying legislators and regulators at the state and federal level to maintain their privileged positions and the bloated revenue streams that go with them, even as the regulations choke their ability to move forward [ibid, Kindle Locations 5274-5317].
"Carlton runs his EKG, and talks to his cardiologist about it — on his cell phone, while sitting on a bench at the park."

Yeah. That leads me to my current read, by a self-described "Medical Futurist" I cited in my prior post.

This book, written by a young, absurdly smart, tech-savvy physician who also holds a Doctorate in clinical genomics, is much "geekier," focused principally on technology.
Trends That Are Shaping the Future of Medicine
“Don’t follow trends, start trends.” –Frank Capra

The hardest part of the job of any futurist, particularly a medical futurist, is picking up the trends, technologies and concepts that seem to play a major role in the future of medicine and healthcare as extrapolations for the next years based on today’s trends. What makes it truly complicated is the fact that many of these technologies and concepts intertwine and mix together from many perspectives. The use of artificial intelligence is imminent in the world of electronic medical records, as well as advanced robotics or portable diagnostics.

I chose the topics that appear in the next chapters because they demonstrate the most potential to illustrate what I see as future trends. The goal of these chapters is to give you a clear picture about the key steps being taken in technology by keeping the future of medicine in mind.

The anatomy of a trend description

Each trend’s sub– chapter contains basic descriptions about the technology, real– life stories, practical examples, the concepts that determine its use in medicine and healthcare; and possible future directions. Regarding the twenty– two trends, we will move from concepts that are currently available to technologies that are way off in the future.

At the end of each section are scores that meant to give a better understanding of a particular technology’s usefulness:

A score of availability between 1 and 10, where 1 is currently too futuristic a concept while 10 means it is already available.

  • Focus of attention that describes which stakeholder can best take advantage of the trend.
  • Websites & other online resources that keep you in the information loop by following them.
  • Companies or start– ups working on the particular trend and being in the forefront.
  • Books and Movies describing the advantages and disadvantages of the trend or technology.
Trend 1. Empowered Patients
Trend 2. Gamifying Health
Trend 3. Eating in the future
Trend 4. Augmented Reality and Virtual Reality
Trend 5. Telemedicine and Remote Care
Trend 6. Re– thinking the Medical Curriculum
Trend 7. Surgical and Humanoid Robots
Trend 8. Genomics and Truly Personalized Medicine
Trend 9. Body Sensors Inside and Out
Trend 10. The Medical Tricorder and Portable Diagnostics
Trend 11. Growing Organs in a Dish
Trend 12. Do– It– Yourself Biotechnology
Trend 13. The 3D Printing Revolution
Trend 14. Iron Man: Powered exoskeletons and prosthetics
Trend 15. The End of Human Experimentation
Trend 16. Medical Decisions via Artificial Intelligence
Trend 17. Nanorobots Living In Our Blood
Trend 18. Hospitals of the Future
Trend 19. Virtual– Digital Brains
Trend 20. The Rise of Recreational Cyborgs
Trend 21. Cryonics and Longevity
Trend 22. What Will a Brand New Society Look Like?
Bertalan Meskó (2014-08-27). The Guide to the Future of Medicine: Technology AND The Human Touch. Dr. Bertalan Meskó (Webicina Kft.). Kindle Edition.
Love the "AND The Human Touch" in the title. We'll see about that. 
We are facing major changes as medicine and healthcare now produce more developments than in any other era. Key announcements in technology happen several times a year, showcasing gadgets that can revolutionize our lives and our work. Only five or six years ago it would have been hard to imagine today’s ever increasing billions of social media users; smartphone and tablet medical applications; the augmented world visible through Google Glass; IBM’s supercomputer Watson used in medical decision making; exoskeletons that allow paralyzed people to walk again; or printing out medical equipment and biomaterials in three dimensions. It would have sounded like science fiction. Sooner or later such announcements will go from multiple times a year to several times a month, making it hard to stay informed about the most recent developments. This is the challenge facing all of us. 
At the same time, ever– improving technologies threaten to obscure the human touch, the doctor– patient relationship, and the very delivery of healthcare. Traditional structures of medicine are about to change dramatically with the appearance of telemedicine, the Internet full of misleading information and quacks offering hypnosis consultation through Skype; surgical robots; nanotechnology; and home diagnostic devices that measure almost anything from blood pressure to blood glucose levels and genetic data...

My background as a medical doctor, researcher, and geek gives me a unique perspective about medicine’s future. My doctor self thinks that the rapidly advancing changes to healthcare pose a serious threat to the human touch, the so– called art of medicine. This we cannot let happen. People have an innate propensity to interact with one another; therefore we need empathy and intimate words from our caregivers when we’re ill and vulnerable. 

The medical futurist in me cannot wait to see how the traditional model of medicine can be improved upon by innovative and disruptive technologies. People usually think that technology and the human touch are incompatible. My mission is to prove them wrong. The examples and stories in this book attempt to show that the relationship is mutual. While we can successfully keep the doctor– patient personal relationship based on trust, it is also possible to employ increasingly safe technologies in medicine, and accept that their use is crucial to provide a good care for patients. This mutual relationship and well– designed balance between the art of medicine and the use of innovations will shape the future of medicine [ibid, Kindle Locations 73-104].
I remain conflicted about this "art of medicine" stuff. I've thought about it, read about it, and written about it at some length. See, e.g., my December post The art of medicine consists of amusing the patient while nature cures the disease -
I have long been conflicted over the phrase "art of medicine." Is it a dodge proffered as a disavowal of responsibility in the wake adverse outcomes (particularly in light of the relatively loose coupling of cause and effect in clinical science)? Is it legitimately invoked in pushback over what clinicians decry as top-down mandated EBM / "cookbook medicine"? Are the imaginative ("creative?") heuristic leaps of the adroit physician an inescapably necessary and net value-adding component of the diagnostic and healing method? Is that what we mean by "The Art of Medicine?"

On the tx side of things, matters can be a bit more straightforward. One surgeon may have a rep and a record of being a hack and a butcher while another performs sensitive and precise work that can only be described as "exquisite," "artful."

Diagnostics are inescapably far murkier. Symptoms map overlappingly to myriad disorders, and the lexical narrative fluency of patients to describe them and clinicians to subsequently interpret them varies widely.

Get it right and you're a hero. Get it wrong and you may have a MedMal problem. In a world of reduced reimbursements, the relentless creep of encroaching daily time constraints, and ever-more complex technology and medical research findings (not to mention increasingly onerous regulations), simply navigating the numeric digits and the alphanumeric codes easily fills the clinicians' days."
Is "the art of medicine" really all about adept, ongoing deployment of clinical heuristics (skilled inductive leaps of intuition) amid the churning seas of frequently inconclusive "data" and incumbent processes, buttressed by an equally adroit and abiding sense of "empathy"? (Y'know, the "care" part of "health care"?)

Leads me to another book I recently finished.

Cited this book in an earlier post. I have now finished it.

We cannot begin to understand the changing nature of high-value skills without appreciating the hardwired power and importance of human interaction in our lives. “Natural selection mandated us to be in groups in order to survive,” the eminent neuroscientist and psychologist Michael S. Gazzaniga has written. “Once there, we construct our . . . social relationships, with our interpretive minds ever busy dealing with the stuff around us, most of which involves our fellow humans. . . . Those human social relationships become central to our mental life, indeed become the raison d’être of our lives. . . . We now think about others all the time because that is how we are built. Without all those others, without our alliances and coalitions, we die. It was true . . . for early humans. It is still true for us.” 

That is, we are hardwired to connect social interaction with survival. No connection can be more powerful. We can easily forget— living and working in highly developed economies, doing linear, logical, rational thinking all the livelong day— that such activity is not in our deep nature. But whether we recognize our true nature or overlook it, it’s there inside us, driving us. “We are social to the core,” says Gazzaniga. “There is no way around the fact. Our big brains are there primarily to deal with social matters, not to . . . cogitate about the second law of thermodynamics.”

Colvin, Geoff (2015-08-04). Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will (pp. 36-37). Penguin Publishing Group. Kindle Edition. 
The elevator speech on this book? "Social/group skills, 'empathy' at the forefront, will be principal criteria for employability in the coming world of AI, IA, and job-displacing robotics."

Not sure yet to what extent I buy this sanguine notion. Seasoned "futurists" estimates indicate that nearly half of service sector jobs -- including those in the degree'd "knowledge worker" strata -- are vulnerable to automation in the coming decades. It's useful to recall that the unemployment rate during last century's protracted, enervating "great depression" of the 1930's was 25%.

See my post "The Robot will see you now -- assuming you can pay."

apropos of "Futurism," this might be a good time to consider again the arguments proffered in the intriguing essay "Four Futures."
Much of the literature on post-capitalist economies is preoccupied with the problem of managing labor in the absence of capitalist bosses. However, I will begin by assuming that problem away, in order to better illuminate other aspects of the issue. This can be done simply by extrapolating capitalism’s tendency toward ever-increasing automation, which makes production ever-more efficient while simultaneously challenging the system’s ability to create jobs, and therefore to sustain demand for what is produced. This theme has been resurgent of late in bourgeois thought: in September 2011, Slate’s Farhad Manjoo wrote a long series on “The Robot Invasion,” and shortly thereafter two MIT economists published Race Against the Machine, an e-book in which they argued that automation was rapidly overtaking many of the areas that until recently served as the capitalist economy’s biggest motors of job creation. From fully automatic car factories to computers that can diagnose medical conditions, robotization is overtaking not only manufacturing, but much of the service sector as well.

Taken to its logical extreme, this dynamic brings us to the point where the economy does not require human labor at all. This does not automatically bring about the end of work or of wage labor, as has been falsely predicted over and over in response to new technological developments. But it does mean that human societies will increasingly face the possibility of freeing people from involuntary labor. Whether we take that opportunity, and how we do so, will depend on two major factors, one material and one social. The first question is resource scarcity: the ability to find cheap sources of energy, to extract or recycle raw materials, and generally to depend on the Earth’s capacity to provide a high material standard of living to all. A society that has both labor-replacing technology and abundant resources can overcome scarcity in a thoroughgoing way that a society with only the first element cannot. The second question is political: what kind of society will we be? One in which all people are treated as free and equal beings, with an equal right to share in society’s wealth? Or a hierarchical order in which an elite dominates and controls the masses and their access to social resources?

There are therefore four logical combinations of the two oppositions, resource abundance vs. scarcity and egalitarianism vs. hierarchy. To put things in somewhat vulgar-Marxist terms, the first axis dictates the economic base of the post-capitalist future, while the second pertains to the socio-political superstructure. Two possible futures are socialisms (only one of which I will actually call by that name) while the other two are contrasting flavors of barbarism...
This will soon be a book release.

I first cited it back on June 29th. The "abundance vs scarcity" by "egalitarianism vs hierarchy" matrix.

Also of relevance, my August post "Medical Progress: Looking back, looking ahead." And my July 20th post "AI vs IA: At the cutting edge of IT R&D."

I'm no "futurist." Just an analyst. My quantitative predictive acumen is limited to the deployment of low-multicollinearity multiple regression model suites (pdf) that can profitably forecast which credit applicants will still be around in five years and paying on time.

I Googled "Healthcare Futurist," and "Medical Futurist," etc. (Not sure of the connotative difference between "healthcare" and "medical" futurists). There are a number of them out there. I don't have time to do a "meta-analysis" of their respective and aggregate prognostications. I'm sure I'd find a lot of Venn Diagram overlap.

In politics they'd simply be called "pundits." 

Dr. Michael Burry was a "futurist," I guess (central figure in Michael Lewis' acclaimed book "The Big Short"). He accurately "saw" the calamitous late-2000's future of of securitized subprime mortgages and made huge Bank "shorting" them (I had a foot in that world for a time. See my old posts "Tranche Warfare," and "The Dukes of Moral Hazard").

Back in the healthcare space, at a more down-to-earth operational level, as it pertains to health IT specifically, Dr. Jerome Carter has some nice new "futurist" thoughts up at EHR Science:
The Future of HIT Innovation is Ambulatory

Well, it’s time to start designing new clinical care systems.  MU is winding down, so the yearly certification requirements churn will be ending soon, or at least slowing greatly, which is a good thing for someone jumping into the market. Current vendors have to support users who do continue in MU because, no matter how few users continue, no vendor wants to have a product decertified. In for a penny, in for a pound… Let’s not forget ICD-10. That transition should cause headaches for at least a few months. Every current vendor is bound to MU and ICD-10, and those with mature products have systems that originated when LAN-based client/server was king. As a group, EHR vendors are protected among themselves by a common set of circumstances. However, they are vulnerable to products that play by different rules—those currently in the design stage.

Here a is list of what we have learned in the six years since HITECH took effect:

  • Interoperability still doesn’t work quite right.
  • Care coordination is a real thing, and EHR systems don’t do it well.
  • Disease registries and chronic disease management are important for care quality.
  • Small practices need good products that are inexpensive, easy to implement, learn, and update.
  • HIT with safety issues can lead to poor care and malpractice suits.
  • Clinician productivity should go up, not down, when HIT is introduced.
  • Workflow is important for EVERYTHING.
  • 64-bit mobile systems are powerful enough to run real software.
  • The cloud is a reliable infrastructure component.
How many items in this list would have been considered important when designing an EHR in 10 years ago? Market leaders, both inpatient and outpatient, had products on the market when HITECH went into effect in 2009. If we assume it takes a minimum of three to four years from concept to product to create a viable EHR, then many current EHR systems date back to at least 2005. A lot has happened since then, so these systems have to play technological “catch-up.” But MU and ICD-10 are putting the serious kibosh on that…
Compelling stuff, as always. See also my August post citing Dr. Carter "Are EHRs Obsolete?"


Steve Brill's amazing "Docuserial" expose of the J&J Risperdol Rx scandal continues apace.

People need to go to jail over this.

More to come...

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