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What exactly is digital health? How can big data, artificial intelligence (AI) and digital health improve healthcare? Our expert panel gives their final thoughts on the empowerment of these technologies in the health sector:

Leveraging Big Data and AI in the Hospital of Tomorrow

 (David and I) both trained at Duke University and there's a very famous professor there who used to say, “What this patient needs is a doctor, and he needs him right now.”

Well, of course, that was the doctor saying that.

It was a doctor saying that to the junior doctor.

Watch the last PX: What to Consider When Taking on a Big Data Initiative

Because it was basically a doctor insulting junior doctors that this patient, who you just presented to me, needs a real doctor.

We need to get better, we need to improve.

Dr. Eugene A. Stead, a very famous chairman of medicine at Duke University. I think we all know that we need more innovation — this area of digital health. I’ve been asked many times: what is digital health to you? Digital health is nothing more than focusing on the patient, whether it’s patient-sourced data or patient in the home, it is focusing on the patient. Pharmaceutical companies now market to patients, but they’ve traditionally marketed to doctors. Medical device companies still market exclusively to doctors, to hospitals, and the patient, unfortunately, should be the center of those activities. To me, the essence of digital health is that we’re finally bringing the patient into that circle of the stakeholders and putting them in the middle of it, which is where they should be.

 The biggest problem to that concept — so I think we are all completely aligned that the patient needs to be at the center &mdash;

I’m not aligned with that even remotely.

 Transparency, right? Number one, it’s very hard to be a consumer in medicine; you don’t know what you’re buying half the time.

 Two, you don’t know how much it costs.

 And then you don’t know how to interpret it. Even if you have all your data, lab work and x-rays, you have no clue what you’re looking at. That’s one of the challenges for the consumer in today’s model: the idea that there needs to be interpretation and transparency.

 But I also think, and John might agree with me on this, that we have ways to get that data interpreted through reliable searches, websites and other reliable sources, so that I can understand. I can’t tell you how many of my friends say, “Hey, my doctor just did this lab work. I have no idea what it means,” and they’ll text me their lab work and I interpret it for them. But we could find another way to do that, potentially.

I don’t think that digital health is a social science. I think that digital health is the empowerment of technology, whether it be nanoparticles, CRISPR [clustered regularly interspaced short palindromic repeats], or immuno-oncology. That’s the magical convergence of science and technology, which will ultimately serve patients. But if you ladder the endeavor up to the ethereal feature, benefit, value — everything becomes consumer-centric &mdash; cars, restaurants. And it just becomes laddered up into an undifferentiated pablum of: “I’ve got my life back; whether it’s an arthritis advertisement, I’ve got my life back; CHF [congestive heart failure], I’ve got my life back; schizophrenia, I’ve got my life back.” All of them say the same thing. And the pharmaceutical companies all have the tagline: “Innovate for life.” It’s nonsense. I think we should return to the roots of science and the wonder of discovery and recognize that we are here to serve the patient, but we don’t have to ascend to this notion of patient-centricity. I think it’s a big, big mistake. And, finally, for anyone who’s climbed that ladder &mdash;

Why are we doctors? We’re doctors to serve patients. They are at the center of the doctor universe. Why the heck do we even have medicine if all we want to do is play with toys?

Watch PX: Is Regulation the Pitfall of Technology and Innovation?

The practice of medicine may be a little bit closer to that construct, but I believe the initial premise was digital health, and I expanded that into pharmaceutical.

You just said that digital health has nothing to do with the patient.

And you just said that the patient is not at the center. Nothing in medicine, whether it’s digital, whether it’s a stethoscope, whether it’s my hands, my breath, and my voice, is not patient-centric.

The hotel business is the same way; it all matters about the customer. The restaurant business is the same thing. It’s undifferentiated and it becomes laddered up to this top step. If you’ve ever climbed a ladder, it says something up here; it says, “danger,” “warning, do not step here,” and I think that’s where we’re moving into this undifferentiated patient-centricity. The magic of digital health, I believe, lives in the application of technology to patients.

Digital health is a phrase that’s used for a lot of things. Principally, it’s focused in today’s world on things related to that powerful smartphone in your pocket.

Whether it’s using Zocdoc to schedule an appointment, interfacing MyChart into the Epic of your healthcare provider, or using AliveCor’s ECG [electrocardiogram] device — it is around the ability to acquire, analyze and communicate information about you that hopefully will improve your health or the treatment of your disease. To me, again, I come back that that wasn’t medicine. Medicine was focused &mdash; when I trained a long time ago &mdash; medicine was focused on the hospital, first of all, and it was focused on treating diseases. And our thought about the patient was the patient is an example of a disease. And, oh, by the way, when the nurse wheeled that patient out the door, it was over.

Only when the government said, “If that patient comes back within 30 days, it’s your nickel now,” did they become concerned about what happened when that door closed on that car. And, by the way, that’s sad that that was it, but that was true. I think the smartphone is empowering people; it puts Dr. Google in their pocket anywhere, anytime.

I am wholeheartedly for it, even though sometimes Dr. Google is totally wrong. But we’re going to make mistakes, we’re going to stumble, but I think our trajectory is correct. I still see the notion that the patient is the critical factor and that we lift the veil off the cost conundrum, the master price list, and all these things that we do to hide that 19 percent of GDP [gross domestic product] that we’re spending. We want to hide it; it’s not over here, it’s over there, it’s third party. Any other business where you ever heard the term reimbursement? There is no other business where the term is reimbursement. It’s usually price, cost, pay, bill.

Why does a hip replacement cost 10 times in New York what it costs in Oklahoma City? Why? Same procedure, same tools.

I will hope that AI and big data — predictive analytics &mdash; will in some measure allow us to address those real issues, which come down to money.

This is what I’d love to do. We’re running short on time here. I would love to give every panelist one minute for final thoughts on AI, big data and medicine. John, let’s start with you.

Let’s keep it short and sweet: we have to ask ourselves: “Is AI man’s last great invention?” We are going to shift creativity from humanity to a thinking machine. Now, I’m not saying it’s going to happen, and I know you’re going to recoil when you hear that, but I think that is an emerging reality that has to be put in some kind of human context.

 I disagree. I think AI is a tool like any other tool, any number of tools that have come and gone in medicine, whether we talk about the da Vinci robot or invasive procedures that have now become noninvasive. I think AI is an extraordinary tool. It will be a powerful tool in medicine. It will be one of the many tools we use as doctors and continue to use in our practice to make things evolve and that much better for the patient.

I echo what Geeta says. I consider [that] AI, at least today and the promise of the future, will enable us to improve healthcare, access, lower costs and prevent disease. But it’s not going to happen tomorrow: this is a process like driverless cars that will take probably decades, but I’m very optimistic that when my children are my age, that they will have AI-enabled healthcare.

Well, I can’t thank you guys enough for being here today. This has been a fantastic discussion. John, Geeta, David, it’s just been great to have you on the panel. I love the fact that we’ve been able to discuss some really difficult issues and we’re actually trying to be fortune tellers. We’re trying to predict the future. So, on behalf of our panel, we thank all of you for joining us today. We hope you found this 

Peer Exchange® to be helpful, useful and informative. We look forward to seeing you again next time.

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PX: What Does the Hospital of Tomorrow Look Like?

Videos

What is digital health to you? A social science? Patient-centric? Our 4 KOL's have some differing views. 

PX: What Does Digital Health Mean to You?

What should health systems consider before taking on a big data initiative? How can they overcome initial failures to become successful? Our expert panel weighs in:

 Let’s take this another way. Every good project can fall apart if it’s not planned out and done properly. If you make early mistakes, it can doom a project down the road. What do you think healthcare systems must consider if they want to take on a big data initiative?

  I think that’s a great question. How do you fail and how do you fail early so that you can become successful? I don’t think we ever ask ourselves that enough. I’m a big believer in innovation, but the first thing that you have to do when you’re innovating anything, whether it’s big data—related or not, is what is the problem you’re trying to solve. So, I think number one as a health system, what are your top three strategic priorities? How do you then innovate back into that problem to find the solution? You have to create a culture where you are failing early or it is okay to fail, you budget that is kind of an X factor, since we don’t know how this is going to play out. We don’t know what we don’t know, and that’s OK to budget — this could be a revenue maker, it could not. The culture is so key, especially at health systems doing whatever you do with the medical staff, with the patients &mdash; not against them and not to them.

All stakeholders at the table, which is what our government failed to do with the ACA [Patient Protection and Affordable Care Act].

Watch the last episode: PX: Is Regulation the Pitfall of Technology and Innovation?

 You’re right. I’m concerned that fail fast is being confused with fail smart; I see this on the life science side, not in clinical medicine, but in pharmaceutical development that that’s sort of big idea — fail fast, fail fast. And I think being agile is part of that construct, recognizing where the errors are and making smart decisions about failing. The other thing is I want to echo the notion of culture, and I wrote about this several times: culture crushes innovation without a doubt.

 This is the single biggest inhibitor of transformational change in Corporate America today. I would argue it’s probably like that in the hospital — regimented rounds, right? It’s a pecking order; it’s military, and I think that unless people recognize the value of certain changes, unless a nursing staff recognizes the value of data and technology to varying degrees, you’re not going to drive those changes. We often look for the inspired leader, but it’s really not the inspired leader, it’s inculcating the nature of innovation into the rank and file that helps drive innovation; if you don’t do that, you’re doomed.

Dave, you and I have talked about fail fast and tech companies many times; I’d love to get your take. I like being agile. I like embracing risk. I have a bracelet that says, “Embrace risk,” but I say, “Embrace calculated risk.” Talk to me about fail fast.

 The issue is, the Silicon Valley culture of fail fast has with medicine is that a failure in medicine has a human cost. It’s not just this screen — people didn’t like this screen; they didn’t like this GUI [graphical user interface]; they didn’t like this form factor &mdash; it’s that patient didn’t do well. We have the added burden of, as I said before, human beings involved, handle with care. And so, the notion that we can change a process and fail fast and innovate, in medicine we have another thing to consider: that there is a human being who is hurting or is sick that’s involved in that process; we need to be sensitive to that. I’m not saying that should inhibit completely the notion of failing quickly, but it should help you put into your calculus &mdash; the fact that we have human beings and their lives at stake. And that’s a unique challenge and charge that we are given.

What do you think health systems must consider if they want to take on a big data initiative?

PX: What to Consider When Taking on a Big Data Initiative

How do regulations hinder the innovation and potential use of technologies such as big data, artificial intelligence (AI), virtual reality (VR) and telemedicine? How are we building hospitals around big data and AI? Our expert panel weighs in:

A Healthcare Analytics News™ Peer Exchange®

 When we talk about the hospitals of tomorrow, are you guys aware of specific examples of where technology is at the forefront of a hospital? I know [John] has some clients overseas that are looking. If you could, share with us some specific examples of how we are building hospitals around big data and AI.

 What I find is that the value of technology in many developing countries and places around the world is not so much to find that nano-mediated early detection— nanoparticle mediated detection of cancer&mdash; but to use existing technology to leapfrog problems. For example, in Mexico, there’s a problem with physicians, so let’s implement telemedicine as a solution. Technology allows you to leapfrog and solve solutions, and I’m seeing that around the world. I’m seeing that in the Soviet Union. One of the biggest questions is: how can we build a hospital integrated into an existing infrastructure? In Bahrain, they’re looking at taking a hospital and building it around cardiovascular disease. In Bolivia, they’re looking at how we can leverage technology to not be a bastion of innovation, but leapfrog to a point where we can take care of our citizens. So I think it’s a hot button now around the world; people want to build new hospitals because they see it as an extraordinarily high capital expense. What’s it cost to build a hospital today?

Watch the last episode: PX: What Does the Hospital of Tomorrow Look Like?

 It’s probably one of the most expensive things that you can build in a community. It’s essential, it’s necessary, but it’s really expensive. So the solution here is: how can we leverage VR and train my house staff by using guys over at Johns Hopkins or Duke University, and have them walk us through it. Those are really interesting options.

 And at the same time, rural hospitals are closing at an incredible rate.

 Those are easy access points for poorer people.

 And so we have had a migration to urban areas in our country, but we still have tens of millions of people living in rural areas that are basically unserved— you don’t have to go to the South Pacific to find people to serve.

 Absolutely, there’s plenty here at home.

 As I said, we could go to the South Pacific or South Jersey, both have a shore, right? I just think that technology will be critical. The technology we’ve discussed today — whether it’s big data, AI, telemedicine, virtual reality, these are all going to be critically important because it comes down to money and access. We’re not going to train more doctors, and doctors can’t come out of medical school with $350,000 of debt and then think they can go into rheumatology. There won’t be any rheumatologists because you can’t go into rheumatology and pay that back; my wife was there.

WATCH: PX: Will AI Affect Medicine's Evolution?

 That brings up an important point, because I don’t think the question is: is the technology there? The technology is there; the innovation is there. What always hinders innovation is regulation; it’s the reimbursement and regulatory bodies that are saying what do we do with global medicine.

 It’s the money, right? So my doctors — we have 500 doctors &mdash; we can offer telemedicine. My doctors are not going out of business.

 They’re not going out of business. Their brick and mortar practice is not going out of business. Why would they do telemedicine? Why would they make $50 less or $100 less doing a virtual visit when the same advice can be given in person for more? That, you have to ask the regulators.

 We have to change that in Congress. I can’t tell you how many times I’ve been to Capitol Hill and I’ll talk to leading legislators in both the House and the Senate and say “Remote monitoring. For every 1,000 patients we remotely monitor that have a pacemaker defibrillator, we can save 53 lives, and we can save this many hundreds of thousands of dollars to CMS [Centers for Medicare & Medicaid Services] and Medicare.” They look at me and say, “Well, why aren’t we doing that?” And I respond, “Because you guys don’t reimburse remote monitoring or you penalize remote monitoring indirectly.” Their lights go off and then the next step is you’re in a room with some intern who has no power, no idea, and nothing ever happens. That’s what’s wrong.

WATCH: PX: Can AI Be Smarter Than Humans?

 I know that health spends are capitated, the days of the DRG [diagnosis-related group]. And people think that it’s a zero sum game— that there is $100 on the table and if I start using telemedicine, they’ll get $20 and I’m going to lose that $5 that I got. That’s a real concern. It’s interesting, the days when radial keratotomy and LASIK surgery came en vogue. There was a real problem because eye doctors, even optometrists at that level, were afraid they were going to lose their business &mdash; people will not need glasses anymore and there was a real fear. What happened is the market expanded. It became more robust, and they ended up selling more reading glasses and sunglasses, and the market went in a different place than they thought. So I recognize that medicine is capitated. I’m not saying that we grow, but I think the market will change and physicians will find different revenue streams to accommodate some of those financial needs.

 I think they’re going to have to, and we’re also going to have to decide if it is okay for medical schools to charge $100,000 a year. Is it okay for pharmaceutical companies to charge what they charge? Is it okay that we allow these types of huge punitive damages in a malpractice suit, so that physicians have to carry incredibly high-deductible policies?

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How are regulations hindering innovation in healthcare?

PX: Is Regulation the Pitfall of Technology and Innovation?

How do we build the hospital of tomorrow and what does it look like? How do technology and data play in a role in the hospital of the future? Our expert panel weighs in:

In our next segment, we’re going to talk all about building the hospital of tomorrow. It’s essential that we in healthcare leverage the power of big data and AI to improve care to our patients. One of the ways in which we can best implement these technologies will be through using them in direct patient care. One of the costliest aspects of healthcare today is inpatient care in hospitals — we see these rising costs in both academic and private-practice settings. To that end, let’s now explore how we can utilize these novel technologies to build the hospital of the future. Dr. Albert, I want to start with you: you’ve got all of these technologies, all these innovations; how do we build the hospital of tomorrow? Where is the hospital of tomorrow?

Kevin, my view has always been that instead of building more and more tertiary care temples of medicine, that the hospital of tomorrow will be, in many ways, the home — that we will care for patients utilizing technology and AI &mdash; building on knowledge from big data. We will enable those patients to be diagnosed and treated outside of those ivory tower institutions. I think we have to do it if for no other reason than cost.

Watch the last episode: PX: Will AI Affect Medicine's Evolution?

I think that’s a great point. How do we preserve the doctor-patient relationship in a setting like that, Geeta?

I think Dave is spot on. The hospital of tomorrow is in the home, and so is the doctor, nurse and patient, whether it’s remote patient monitoring, virtual visits, or the doc actually coming to the household, assessing the home environment and socioeconomic status along with diagnosis and treatment. There’s no doubt that to make the shift to value-based care that more prevention will be needed. Keeping people happy and healthier in the home will be key, and meeting the patients where they’re at, right? When we see the retail-ization of medicine — CVS, Walmart, Costco and Amazon &mdash; patients are going where they are going and living in their neighborhood.

You can have drones delivering your beta blocker from Amazon before this is over.

It’s not just the home, but the workplace as well: you have Apple building clinics and staffing them, as do many large companies, and people love that because it improves their productivity, it decreases their time. It’s just like having daycare centers.

Dave, remember Karl Malden and American Express? What did he say? “Don’t leave home without it.” Remember, you always carry your American Express card. Well, for me, here it is; this is my card, I carry it with me everywhere because it becomes part and parcel of care. It goes with the patient. But I want to pose another interesting perspective: let’s destroy the hospital. Instead of trying to say, “Well, the hospital is going to move from a brick and mortar to your house,” let’s look at things like stage-zero disease, restorative and regenerative medicine, stem cells. Think about the opportunity of stopping disease from happening at earlier and earlier and earlier stages.

So, for me, we look at a hospital now; a hospital is — wait for it &mdash; it’s where you go to die. I mean ultimately that’s sad, but in many instances that end-of-life care is defined by a hospital. Walk through the wards and you see a lot of sick, old patients there. So that I think is intrinsically a problem in healthcare; for me, I think that we can change that dynamic. We can address disease at again that proverbial stage-zero: how can we find cancer at the earliest stage? How can we find an MI [myocardial infarction] at the point where maybe we’re looking at thromboxane, free-circulating thromboxane prior to the actual platelet plug? Who knows what the mechanism is, but I think that’s going to be interesting because technology will change the need for the hospital in the first place.

I certainly agree with those points because I think we have to shift the focus on healthcare in the United States from treatment to prevention. If we can use predictive analytics and tools like this with AI in our pocket and AI leading the charge, I think that we will be able to prevent a lot of disease. We certainly can prevent the complication of diabetes; we can prevent multiple strokes; we can prevent multiple MIs; we can prevent a lot of this just by knowing early, and that’s, again, the dichotomy of big data. We use all these big data sets and the analytics and then we personalize that care based on your DNA.

I will say one thing. We’re all optimists here. And you know when you’re a kid and you say, “Mommy, can I go out to play,” and your mommy goes, “No honey, it’s may I go out to play.” The problem is we’re back to the patient. I don’t have to be compliant. In fact, many times I don’t want to eat those vegetables and I can be an adult and say that I’m not just a kid. I happen to like vegetables, but the point is, we are going to have to have something that today we don’t have much of — personalized coaching and motivation. We sit there and I write a prescription &mdash; now an e-prescription &mdash; for you for atenolol, or for Entresto, but if you don’t take it, it’s not doing any good.

And if you can’t afford it, and if you can’t get it, you can’t have access to it.

Exactly. And so best intentions do not always equal best results.

Our healthcare system does not have any individual accountability placed on the patient; the patient is part of the team. There’s doctors, patients, nurses and healthcare systems, but the patient needs to be held accountable in some way, otherwise we don’t get anywhere.

Sure, no doubt about it, but with the rise of high deductible plans, patients are now accountable because it’s affecting their pocket, right? I completely agree with you, Dave. It’s about lifestyle choices; coaching and lifestyle choices. It’s also about embracing technology, particularly in the youth of today when we look at childhood obesity. For the first time, we have a generation that may not outlive their parents — that is a travesty, right? People are not going outside to play, whereas we did. Now you’re doing something on the computer. Do we need to start looking at gamification and AI, and ways to keep a different generation engaged and physical and prevent?

Think about the suicide rates in our youth today because they’re sitting in a room engaged —

On a game: they’re lonely, they have no human interaction, they’re overweight, and it just spirals.

Watch: PX: Can AI Be Smarter Than Humans?

There’s got to be a way that we can intervene there.

I think two points: one is that I’m not convinced that the solution is in nudge psychology and making people eat their green leafy vegetables; I don’t think that the pivotal change in care will come that way. I think it will be technology mediated through extraordinarily sophisticated diagnostic modalities that see things happening earlier and earlier and earlier.

You may see it happening, but then you have to do something about it.

The patient still has to do something about it.

 Let me get to my second point: the interesting thing — and when we talk about just traditional technology today &mdash; we live in the world of the activity tracker, of the proverbial 10,000 steps. Now, the only person who really is interested in that is the guy at the gym who’s looking to woo a mate, right? That’s an athletic option. We need to move it from an athletic option to a clinical imperative, mediated by data, clinical trials and validation, exactly what you’re doing with AliveCor. But the point is, if I can tell a 38-year-old woman whose status is post-mastectomy for cancer, that if she wears this tracker and it’s going to tell me if the cancer comes back really, really soon, will she wear it, or will it become a dust collector like so many of these other trackers? We’re changing it from an option to an imperative, and I think that’s a data dynamic, and we’re going to see that sooner than later.

PX: Is AI a Physician's Tool or Future Physician?

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