Rock Health, Enterpreneurs, Doctors and Witchcraft?

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker,

“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.

Khosla believed that patients would be better off getting diagnosed by a machine than by doctors. Creating such a system was a simple problem to solve. Google’s development of a driverless smart car was “two orders of magnitude more complex” than providing the right diagnosis. A good machine learning system not only would be cheaper, more accurate and objective, but also effectively replace 80 percent of doctors simply by being better than the average doctor. To do so, the level of machine expertise would need to be in the 80th percentile of doctors' expertise.

Is it possible technology entrepreneurs can disrupt health care? He challenged any doctor in the room to counter his points.

Silence.

Was it because everyone agreed? Were the doctors in the room simply stunned? Was there a doctor in the house? And where did he get that 80 percent statistic?

Was Kholsa serious that technology could make health care better by utilizing large data sets and computational power to clinch better and more precise diagnoses?  Was he simply being provocative to hear other points of view to learn even more? Like many others in the conference, he believes that giving consumers more opportunities, access, and choice to information about themselves and their bodies would empower them to do the right thing. He held up an EKG attachment to the iPhone which was just one of many consumer directed products in the pipeline his company has invested in.

Kholsa is a very smart and successful entrepreneur. Does innovation mean the two guys in a garage who come up with a radical idea or is it possible that innovation is having people with different experiences and point of view looking at the same problem as best selling author Malcolm Gladwell noted in his New Yorker piece Creation Myth -  Xerox PARC, Apple, and the Truth About Innovation? Surely to make health care better, technology entrepreneurs must engage with doctors. All the speakers before and after Kholsa spoke about the incredible value and insight different stakeholders to bring to the table.  The most vocal? The doctor entrepreneurs and those who worked with doctors to bring their ideas to market.

Kholsa's criticism of the health care system is completely valid. Can we do better in being more reliable, consistent, and creating a system process and design that is comparable to highly reliable organizations and industries? Of course. Can we be more systematic and doing the right things every patient every time on areas where the science is known to level of the molecule? Yes. Care must be incredibly simple to access, extremely convenient and intensely personal.

It isn't that we don't have smart people. Compared to a century ago more illness are understood, specific medications and treatment protocols can be designed. But we haven't solved it all. When we thought we knew it all, we were shown how little we truly knew. Thirty years ago, doctors predicted the demise of infectious diseases as a specialty, another footnote in medical texts as more powerful antibiotics and vaccines were available. Enter AIDS, the swine flu, and many super-bugs which have humbled our profession. Ask accomplished physician and writer Dr. Abraham Verghese about his experiences.  Dr. Verghese is rightly worried, as many others are, that even doctors are being too focused on the iPatient and not on the real patient as he writes in his New York Times op-ed Treat the Patient, Not the CT Scan. Is this what we want our health care system to look like?

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort. As conference speaker Dr. Aenor Sawyer, an orthopedic surgeon from UCSF noted, we need to figure out how to have our different cultures of doctors, gamers, designers, and technologists interact. Fixing health care is more than simply "we know the problem and we know the solution". She reflected that the level of dedication, perseverance, and a willingness to make impact among the different groups demonstrates more similarities than differences.

I know health care can't simply be solved by smart people in Silicon Valley alone.  To solve health care we need everyone to collaborate. As Harvard Business School professor Amy Edmondson noted in her book Teaming - 

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."

Perhaps Kholsa's call to action was simply an entrepreneurial mindset, but simply ignoring those who have chosen a field to improve and safe lives and who meet humanity everyday on the front-lines is problematic and dangerous. There are some things that may never be codified or driven into algorthims. Call it a doctor's experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

Abraham Verghese - The Top Gun of American Medicine

The first year medical students I precept were too young to see Tom Cruise's alter ego Lieutenant Pete "Maverick" Mitchell grace the big screen in the 1986 blockbuster film Top Gun.  Yet, the story has a relevant analogy to medicine. 

According to the film, during the Vietnam war American pilots were relying too much on technology to bring enemy fighters down.  They weren't as skilled in taking out the opposition.  They fired their technologically advanced missiles to try and get the job done.  They didn't think.  It didn't work.  They forgot the art of dogfighting.

The military discovered that technology alone wasn't going to get the job done. The best fighter pilots needed the skills, insight, and wisdom on when to use technology and when not to. As a result, the Navy Fighter Weapons School, known simply as Top Gun, was created to retrain the military pilots on this vital lost skill. 

The goal of the program was specifically to make the best of the best even better.

Like the military, the country is discovering that the healthcare system enabled with dazzling technology isn't getting the job done either.  One study suggests that Americans don't live as long as citizens from other industrialized countries not due to our obesity or smoking habits but because of the failings of the healthcare system even though we pay more per capita on healthcare.  Since the recent and current generation of doctors, residents, and medical students are trained to rely heavily on technology, the situation is only going to get worse.  These doctors do not know how to do a thoughtful history or thorough physical examination.  Individual patients as well as the nation will pay a price for more unnecessary testing as well as wasted time and money which could have been avoided if doctors focused on the art of medicine. 

To slow healthcare costs, the next generation of doctors will need the skills, insight, and wisdom on how to take an accurate history, perform a thoughtful clinical examination, and use technology judiciously.  They must be experts in the art of medicine.  Like the art of dogfighting, the art of medicine was a skill that should have been embraced as technology proliferated instead of being marginalized in training.


So who are medicine's Top Guns?  Who are the best of the best?  Where is medicine's Navy Fighter Weapons School?

If medical students want to be the best of the best, then they should look no further than Dr. Abraham Verghese of Stanford Medical School.  Dr. Verghese, already an accomplished author who is also board certified in internal medicine and infectious disease, engages them with the virtuoso performances on the fine art of medicine.  For doctors to become expert diagnosticians, he and his colleagues outlined 25 skills doctors should know simply as a beginning to more learning.

If students want to be in the specialty where the best and brightest work, then they should look no further than primary care, family medicine or internal medicine.  Besides dermatology, primary care is a specialty where doctors often start evaluating patients by talking, observing and examining.  Primary care doctors often see patients for the first time without any test results as these visits are usually the first time someone has sought medical care.  As a result, they need to skills to figure out which patient needs more extensive work-up and which one can safely care for the problem at home.  Though primary care isn't as attractive to medical students and proposals are underway to make the field more appealing, there is no question that it is the most cognitive specialty - a doctor's doctor specialty.

If the US healthcare system is to provide Americans better care it will need a generation of Top Guns in primary care to lead the change.  What Dr. Verghese offers his medical students and residents in his training is what all of us want in our doctor - someone who listens, observes, and examines thoughtfully to get the right diagnosis.

In other words, a doctor who is the best of the best.  As a practicing doctor, I would jump at the opportunity to learn from him.