Viewing entries in
What If

moores law in healthcare - three predictions for massive disruption

Je n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. —Blaise PascalTranslation: I have made this longer than usual because I have not had time to make it shorter.

As Appley as it gets

A while ago I was challenged to write about what an Apple-like approach to healthcare might look like. That challenge has been weighing on me. For starters, we’re all over Appled aren’t we? Maligned anecdotes about Steve Jobs and the iPhone make their way into almost every presentation remotely related to innovation or technology. Triteness aside, I’ve been stalled because Apple is really a philosophy, not a series of steps or lessons learned. (Although, they are nonetheless methodical.) Instead, what I’ve been kicking around in the ole noggin are three notional predictions, which I’ll assert are inevitabilities which will fundamentally disrupt healthcare delivery as we know it today.

What follows is about as Appley as I’m likely to get. Despite big-bang product launches, Apple actually plays the long game. They introduce small features into products to affect user behavior years before a flagship product takes advantage of those reprogramed behaviors. That’s how they disrupt.

I believe there are three meaningful, unstoppable trends, in our current world which will significantly alter healthcare. The steps taken towards these inevitabilities, along the way, are the what will define the innovators and leaders. They are the ones who see this future and know how to drive towards it. The three trends are:

  • Tools and culture which favor individual empowerment
  • The commoditization and automation of diagnosis
  • Accelerated globalization of treatment options

But wait, there’s Moore

Don’t worry, I’m not going to leave you hanging. I’ll attempt to rationalize each of these points and explain why, particularly when considered as a bundle, they are a powerful force for disruption. And to prime that pump, we have to talk about Gordon Moore.

Moore, the co-founder of computer chip foundry Intel, in 1965 posited computer chips would double in speed every two years. Moore’s Law The speed increase, according to Moore, was inevitable; a fact, it will happen.

Before we put on our propeller hats, and geek out over processor speed, suffice it to consider a few examples of how this actually plays out. Sure, computers have gotten faster. Remember that first home PC you had, with its external disk drive and green-screen monitor? What? You aren’t old enough to remember that? Get off my lawn! We also see Moore’s Law in effect in the general progression of technology. Consider how cell phones have advanced, exponentially, since the 1990s.

Cell Phones

What Moore’s Law describes is a general absoluteness about the advancement of technologies and processes. It might be thought of as Newton’s First Law applied to manufacturing and society, rather than mass. In other words, some things continue to advance, and that’s the fact, jack.

The three prognostications I’ve laid out are examples of trends which I believe will follow Moore’s law. They will continue, they will evolve and they’ll be an increasingly powerful force on healthcare.

Just ask a travel agent

The internet is a wily enabler. Its vast interconnectedness, often terminating at the tips of end user fingers, works like a stream of water slowly eroding mountains of rock. When we step back and observe with some time or distance, we call that erosion disruption. Nearly every industry has been affected by the rapid increase in our technological interconnectedness over the past 20 years. Although, how we view the effects depends entirely on if you are the stream or the mountain.

Consumers are the streams. Customers, end users, call them whatever you like, they are the ones seeking the path of least resistance. In healthcare we call them patients. They want what is most effective, simple, desirable and affordable to them.

Mountains, on the other hand, prefer not to be moved. It takes a long time to build up a granite wall. And, according to Newton, an object at rest tends to want to stay put. Companies and industries —intentions and altruism aside —are often large, resting forces.

There was a time when, if one wanted to travel, particularly on a complicated international trip, one used a travel agent. Sure, they still exist and can provide a great deal of value, but according to a 2010 survey Travel, nearly 78% of airline tickets were purchased online. 40% were sold directly through the airlines and 38% were sold through online channel partners (think Expeida and the like).

Anyone who remembers the days of travel agents remembers the travel industry didn’t love this trend at first. But consumers did. Travelers showed what they desired was affordable, simple, direct access to shop for travel and make their own choices in the comfort of their own homes.

There was a time when we had to go to a shopping mall for things like books, wrapping paper, and new jeans. Enter Amazon.com. There was a time when buying music meant buying a physical object. Enter Limewire and Gnutella. And you thought I was going to say iTunes didn’t you? The online music sales industry grew out of a consumer hack. People wanted to download music because it was easy! It was the path of least resistance. The desire path as designers say. Figuring out how to sell it online only came after the stream eroded a path through the mountains.

This is happening in healthcare too

Tools and culture which favor individual empowerment

The internet provides us the tools for increased consumer empowerment. If we look to Amazon, iTunes and Expedia, we affirm our culture already favors consumer empowerment. Today, we see this in healthcare selectively, although it is more evident on the fringes.

In the main stream delivery system, providers are implementing patient portals to view notes, lab results, and share some limited communication with their providers. Avant-garde and large provider organizations with sophisticated resources are starting to crack that most desired nut: online appointment scheduling (see above re travel trends).

As consumers of healthcare observe what they can do in other industries, they begin to seek those same experiences in healthcare. These desires include online scheduling, easy asynchronous communication (think emailing your doctor), one click prescription refills, etc. Put it this way, if you are given the choice between shopping on Amazon or driving across town, waiting for an hour, disrobing, waiting some more, and walking out with a piece of paper you now have to physically deliver to another building and wait some more…. well, you get the point. The stream is starting to eat away at the mountains.

On the fringes of healthcare, we see some examples of consumerism empowerment in action. Several companies are experimenting with online, Skype-style doctors appointments. We also see empowerment taking off among quantified selfers, those of us who casually (or…cough…obsessively) track data about our steps, diet, sleep, etc. The companies who provide those services are inherently customer-focused and provide easy to use tools and direct services to customers.

For a last example, consider the genetic testing company 23AndMe.com. I’ve called 23AndMe.com the Netflix of spit. You go to their website and purchase a kit. They mail you the kit, you spit into the test tube and return it in the provided mailer. A few weeks later, you get a rich genetic profile. Setting aside concerns about their process and the presentation of the data, it doesn’t get much easier than the 23AndMe.com process. You never leave you house.

It is simply inevitable. As a matter of culture, we will continue to seek out paths of least resistance to enable consumer-centered solutions.

Patient experience, the movement around re-centering processes and healthcare deliver around patients, is an example of this trend towards true empowerment. And, while it is an early bellwether, many who are deeply involved on the front lines of patient experience will attest, it’s still about getting a proverbial seat at the table.

Real empowerment comes when consumers of a service are able to get what they need or desire in different ways; ways which short circuit the people who didn’t let them sit at the table in the first place.

Your destination is ahead, on the left

The commoditization and automation of diagnosis

A friend recently remarked: “the real economic product of the healthcare system is a diagnosis.” In many ways, that is in effect what is being purchased. Without a diagnosis, or a working hypothesis, doctors cannot order labs, or tests or write prescriptions. A diagnosis is the widget which the factor produces.

Clinician readers may take rightful umbrage at the following oversimplification. A diagnosis is the logical conclusion of a series of data inputs. Blood pressure + lab results + family history + observational data = diagnosis. Are there other, extremely important, more nuanced points to consider when making a diagnosis? Of that, I’m 100% positive. Nonetheless, a diagnosis essentially a distillate of data points.

Take, for example, strep throat. The generally accepted way to determine strep is through a rapid strep test. The rapid strep test can be done in a doctor’s office and provides results which are definitive enough to conclude a diagnosis. The data point is the test result + your sore throat and fever. Your doctor then writes a prescription for whatever is generally regarded as the best antibiotic for step these days.

What happens when a version of that rapid strep test is made available to home users? If the test has the same degree of accuracy, isn’t the home diagnosis just as valid? What if the testing device could electronically transmit its diagnosis to a pharmacy? Couldn’t then the pharmacist -if our regulations allowed it- dispense the appropriate medicine?

By the way, this isn’t pie-in-the-sky stuff. This year, the Scanadu device will come to market. Scanadu is an in-home diagnostic device which includes a small, hockey puck-like sensor and an in-home urinalysis machine. Scanadu have also announced ScanaFlu, an in-home rapid strep test. How long do you imagine it will take before Scanadu enables patients to transmit those in-home results directly to providers and pharmacies?

Dr. Petrov: [Ramius has taken the Political officers Missile key and kept it] Sir! The reason for having two keys is so that no one man may… Captain Ramius: May what, Doctor? Dr. Petrov: Arm the missiles Captain. Captain Ramius: Mmm, thank you for your concern Doctor Red October

I get it. There are laws and stuff about this today. Yawn. #SorryNotSorry. They will change. It’s inevitable. Our laws, regulations and processes often evolve to match the current state of the art. See also the power of consumerism. When the traditional players don’t keep up, the stream finds a way to erode the mountain. Maybe the local mega pharmacy won’t accept the Scanadu diagnosis, but I’m sure an enterprising mail order pharmacy will.

We see further support for the automation and commoditization of diagnosis in IBM’s Watson. From IBM:

Physicians can use Watson to assist in diagnosing and treating patients by having it analyze large amounts of unstructured text and develop hypotheses based on that analysis. Watson can then identify the key pieces of information and mine the patient’s data to find relevant facts about family history, current medications and other existing conditions. It combines this information with current findings from tests, and then forms and tests hypotheses by examining a variety of data sources—treatment guidelines, electronic medical record data and doctors’ and nurses’ notes, as well as peer-reviewed research and clinical studies. From here, Watson can provide potential treatment options and its confidence rating for each suggestion.

Hummm….that sounds an awful lot like automated diagnosis to me. But it will never take the place of a physician’s expertise, right? There was a time when pilots didn’t have GPS instrumentation. Today, I don’t know a single pilot who would consider going up without a GPS. Can you still fly a plane without GPS? Absolutely. But GPS allows you to focus on actually flying, rather than navigating.

If Watson can make an accurate diagnosis, what does that change? It means patients can know their diagnosis without leaving home. They can research treatment options, if they so desire. They can research which providers are the best at treating their condition. Providers, in the mean time, can start treatment plans, rather than spending time on the diagnosis. Pretty soon, both patients and providers are copiloting the plane, rather than looking at the map.

When we apply Moore’s law to something like 23AndMe.com, Scanadu and Watson, its not far fetched to imagine a small bluetooth gizmo into which one feeds a single hair. In a few seconds, you get genetic data on your phone. A few seconds later, a cloud service renders a diagnosis. Within five minutes, an evidence-based, personalized treatment plan is emailed to you. But Nick…DNA sequencers are huge and expensive and the tests take forever to run… To which I offer the cell phone picture above.

At this point, there is also an obvious connection between these first two themes. If consumers of healthcare desire more empowerment and autonomy, and we short-circuit the traditional process by putting reliable, accurate tools in their hands, then they also become more responsible for the end result. Isn’t that what we in the empowerment movement so desire? Isn’t that also what providers who speak about patient activation also want?

Bingo jet had a light on

Accelerated globalization of treatment options

Just as technology has enabled connections which make our world feel smaller, so too have advancements in travel. From the US, we can be in Europe in less than a day. We can fly from coast to coast in less than six hours. And, increasingly, people are considering if a few hours by car or plane is worth it for better, newer, or more cost-effective treatment options.

Consider the following:

In 2012 Lowes hardware stores inked a deal with Cleveland Clinic. Cleveland Clinic became the sole provider for Lowes employees with specific heart conditions. The value proposition goes something like this: Cleveland offers a recognized name in quality —we’ll set aside an analysis or discussion regarding the validity of that assumption —and Lowes offers a statistically predictable amount of business. A special price is agreed to. Lowes, even when covering the travel cost for employees and a family member, saves money and gets better quality results.

Aravind Eye Hospital in India does more eye surgeries than any other place in the world. It treats nearly 2 million patients a year, for remarkably less than most hospitals in the United States, and it treats nearly two-thirds of those patients for free. It is generally regarded as one of the best facilities for eye care quality in the world.

Rochester Minnesota is a town of roughly 150,000 people. Most towns that size which are fortunate enough to have a towered airport, have runways averaging 6,000 feet. The main runway at RST is over 9,000 feet long and capable of landing medium sized international jets. RST also has immigration services for international flights. What’s in Rochester that warrants a such a sophisticated airport? The Mayo Clinic.

Meanwhile, where I live in Richmond, Virginia, we have 11 licensed hospitals. Eight of which are large, traditional community hospitals and one is a large academic medical center. Of those eight, seven offer most of the same services: OB, general surgery, diagnostic imaging, orthopedics, emergency care, etc. At the risk of sounding anti-capitalistic, does it make sense for seven hospitals to all do the same thing, with different processes, standards, outcomes and costs? Or might I be better off flying to India for my eye surgery?

My point in these vignettes is to consider the globalization of treatment options. As our world gets smaller, our ability to specialize treatment options and concentrate them into true centers of excellence becomes not only a reality, but an important consideration.

In fact, the VA has had this model for many years. The VA recognizes it is better for quality and costs to concentrate expert providers in key centers, and move patients and families to those centers for treatment. We also see this today in cancer care. May patients, albeit most often those with resources, consider traveling to the Kennedy Center, Sloan-Kettering, MD Anderson or Stanford. Steve Jobs famously traveled to Tennessee for his liver replacement.

See! I told you every discussion of disruption had a mention of Steve Jobs.

As an inevitability, these high-volume, high-quality centers will increasingly emerge. Insurance companies will recognize the bang for their buck and deals will be stuck where airfare, hotel and treatment are bundled into one payment. Need a knee replacement? Your options may be Denver, Bar Harbor and Juno. Or something like that…what do I know, I’m no cartographer.

There will, of course, be intermediate steps along the way. You might travel 2,000 miles for a knee surgery. But you probably aren’t going to get on that flight 3 times a week for physical therapy. Some things, like politics, are local. But, as our national discussion of quality and cost evolves, we’ll be forced to ask when volume, specialization and concentration matters. Maybe all hospitals don’t need to offer the same services.

Sushi, in the mountains?

These three inevitabilities play off each other, don’t they? We desire consumer empowerment, we’re building the tools to circumvent the system and enable that empowerment and we’re seeking out the best options for acting on that empowerment. These things will happen, because they always happen. The technology will come to enable them, because Moore’s Law shows that it always does. And we’ll broaden our geographic view of our options. After all, the best sushi restaurant I’ve ever been to is in the middle of Colorado. If my Yelp app on my iPhone tells me FedEx can get raw fish to Aspen, we can surely get the blind to India.

what if corporate personality tools were used in medicine?

Treat me how I want to be treated at that moment without knowing me or how I feel. Seems like a reasonable request, right? Maybe not so much. And still, it’s what our modern —indeed overdue —conversation about patient-centered care demands. Patients and providers are clamoring for better partnerships; they desire to communicate effectively, to understand one another. But we don’t really have great tools and processes in place to support fast, low-effort assessments of learning styles and communication preferences.

Are you visual or aural? Do you need control or want to be directed? Does the nature of a situation affect how you might answer that question? Do you want reenforcement, an opportunity to teach back, an opportunity to question? Do you need time to reflect, or do you make quick decisions? And how many of even clearly know these things about ourselves in our daily lives, let alone when we are dealing with our health and wellbeing.

Imagine this scene: you arrive at your annual physical. Except for the occasional cold, you really only see your physician once a year. How well do you really know each other? You are highly visual and prefer diagrams to lengthy documents. You also like to have all the facts and tend to worry when you feel under informed. You are ok to let someone else plan things, so long as you know the plan. Your physician, in her spare time, is an amature writer. She would much prefer writing to talking, and is often reserved during your interactions. She is of a generation where her training reinforced a paternalistic, I know best style of practice.

You have 25–30 minutes together for your visit. Most of that time is spent doing a physical exam and updating your history. But your physician finds something unexpected, a lump. “Get an MRI and I’ll call you soon when we know more…”

Do things break down?

Do you leave feeling informed or terrified or somewhere in between? Could you describe to your spouse what happened, where the lump is and what it might be?

The challenge with treat me how I want to be treated at that moment without knowing me or how I feel is the unfair burden it places on both parties. How, in a time-restricted environment are two parties supposed to quickly get to know one another’s styles and preferences in a way some spouses even spend years working towards? And, for patients and physicians who have a long-standing relationship, wouldn’t an aid at least help remind you of the other person’s prefernces, so you don’t have to rely on memory or assumptions?

When I worked for a large multi-state health system, we used a commercial tool called Personalsys. Everyone in a management role took an online personality preference test. The computer spit out a brief narrative and color-coded chart. As will not be a surprise to those who have worked with me, I tend to be highly energized by ideas and creative brainstorming and am less driven by deadlines than others (something I’ve had to build systems to help support). Many of my healthcare finance coworkers, at the risk of generalizing, were, conversely, highly structured. They like plans and deadlines and clear objectives. If we had a meeting, someone would see my chart and the spikes in my green creative areas, where they might have spikes in their red structure areas. “Ohhh you’re one of those aren’t you? All creative and loosey-goosey…” And we’d laugh and poke fun at each other’s personality traits and preferences. “yeah, well I bet you’re all tightly wound and obsessed with numbers…”

Personalysis

In reality, the framed charts behind everyone’s desks became a bit of an inside gag. The insecure among the lot would cast their doubts on the efficacy of the hippie tools and new age management practices. But even the doubters knew there was some benefit to understanding how their colleagues work and think. You could walk into someone’s office, and know within seconds how they like to interact and work with other people, and in turn what you might expect from them.

There are other examples of these types of tools which are being deployed increasingly in large corporate settings. The DISC assessment, for instance, looks at how a person feels about control using the vernacular of dominance, inducement, submission and compliance. And what discussion of personality inventories would be complete without a mention of my personal favorite, the Myers-Briggs Type Indicator (I’m an ENFP for the inquiring minds out there)?

DISC

Visual and narrative aids like Personalysis or the DISC assessment, are not commonly a part of patient-provider interactions. But why shouldn’t they be used? Imagine if every patient had a card with a visual indicator on one side, in a short narrative about their preferences and styles on the other. What if every doctor had a similar tool framed on the wall of their exam room and office? Patient styles and preferences would be stored in medical records and patients could learn about their physicians’ styles online before visits.

Now imagine this scene: you arrive at the emergency room with chest pains and shortness of breath. You are scared, but not in dire straits. You are taken back, immediately, into an exam bay. A physician comes in, sees your chart and knows right away that you like to be in control of situations. You are aural and work better with big pictures than minutia. How might their communication style change to meet your needs, where you are, at that exact moment? Perhaps, in stead of patting you on the shoulder and saying “you are going to be fine dear…” they might instead offer “Ok, we’re going to move quickly, my concern is a blockage, so we’re going to get you to the cath lab, you’ll remain conscious, this is a great team who has done more of these than anyone else in town, after the cath, we’ll know more. Is that plan ok with you?”

To be fair, I suspect the later example is more typical of modern physician communication styles than my patronizing former example. But there is still room for a tool to help aid the process.

We need something quick, easy to understand and effective. It should be a two-way tool, allowing both patients and providers to quickly understand each other and meet in the middle. If this idea of participatory shared decision making is to work, it’s going to need some aids. The good news is some examples already exist. The folks at Diagram Office, a New York-based design firm have created some fantastic conversation aids around shared decision making.

Diagrams OpenIDEO submission

I’m still looking for a solution which fits upstream of decision making. I’m suggesting something which exists as the very first step between a patient and provider, before a word is ever spoken.

Anyone have a prototype?