Dissecting Digital Health — with Lyle Berkowitz and George Margelis
Ever feel like you spend too many days hitting your head against a metaphorical brick wall? Lyle Berkowitz and George Margelis have a friendship that begun with their shared passionate determination to dismantle those bricks walls.
This is the full transcript of the podcast Dissecting Digital Health with Dr Louise Schaper, interview with Dr Lyle Berkowitz and Dr George Margelis.
Guests: Dr Lyle Berkowitz & Dr George Margelis
Host: Dr Louise Schaper, HISA
Tweet Louise @louise_schaper Tweet Lyle @drlylemd Tweet George @georgemargelis
Production: This podcast is produced by Ivan Juric
[01:33] Opening remarks by host Dr Louise Schaper
[01:42] Today, there are two guests on Dissecting Digital Health. The first, Lyle Berkowitz, a noteworthy figure in the world of healthcare informatics, introduces himself describing his vast work directly in medicine, in innovation and healthcare technology.
[02:51] The second guest, George Margelis, introduces himself as a retired physician who has been involved in healthcare and technology for 30 years. He is a good friend of Lyle’s, whom he met at a health IT event 15 years prior.
[03:54] Louise asks Lyle and George for their insight on how the future of healthcare technology will look like based on their experiences. Lyle talks about the three different kinds of changes that will take place.
[06:27] Louise picks up on Lyle’s point of rationing of care. Lyle talks about the inevitable move towards being more efficient and equitable in the delivery of care. George adds the reimbursement model discussion into the conversation.
[09:28] Louise asks the two to share their thoughts on incentivising smarter care delivery. Lyle delves into what incentivises efficiency, and how it will affect both the patient and the clinician. The conversation turns to comparing and contrasting the cultural differences evident between Australia and the USA.
[12:24] Louise prods about the cultural differences that might exist in terms of technology. George shares the US’ advantages in clinical informatics, and Lyle shares his own personal journey in the US combining informatics, business and healthcare.
[16:24] Lyle talks about his experience as the constant innovator, and the struggles that come with always being ahead of the curve. The conversation shifts towards what barriers and conflicts must be overcome in order for progress in user centred designed thinking to take place.
[19:12] Louise brings the discussion to potential radical “disruptions” in healthcare, especially in terms of how technology can change how we access care services. Lyle talks about the role consumer choice will have, as we make decisions based around quality, convenience and trusting technology.
[23:37] Considering the potential risks of tech companies capitalising on healthcare, George talks about the need for clinicians to be involved. Both Lyle and George dissect the flaws in the systems, that are the root causes of inefficiency in healthcare and Lyle discusses his SAD and FATT Philosophy to improve healthcare.
[27:46] Louise addresses the inevitable flip in scalable healthcare, and asks when Lyle thinks that greater efficiency in care will be reached. Together, the group weighs in on what investments are necessary to advance, and on ideas of individualised care.
[32:30] Louise asks George and Lyle to share advice for those looking to start their own paths in health informatics. Both George and Lyle share what factors were essential in driving their careers forward.
[40:05] Closing remarks. Louise concludes the discussion thanking George and Lyle for sharing their insights.
Opening remarks by host Dr Louise Schaper
[01:33] Louise: Welcome to this week’s episode of Dissecting Digital Health. I’m your host, Louise Schaper, and today I’m trying something new. I’m sitting with two guests. So, guest number one, would you like to introduce yourself?
Today, there are two guests on Dissecting Digital Health. The first, Lyle Berkowitz, a noteworthy figure in the world of healthcare informatics, introduces himself describing his vast work directly in medicine, in innovation and healthcare technology.
[01:42] Lyle: Sure. My name is Lyle Berkowitz. I’m a primary care physician who’s been involved in informatics and innovation and business for much of the last 20 plus years, and I currently practice primary care medicine. I’m starting a new practice called Future Health, which is taking a small group of patients and exploring all the future technologies and clinical innovations that will be available in a couple of years, perhaps, but aren’t readily available now, from genomics and precision medicine to regenerative medicine to all of the cool digital technologies that we see and talk about, but we can’t normally use in practice. I’m additionally the director of innovation for Northwestern Medicine, which is a seven-hospital system in Chicago based and affiliated with Northwestern University, and I’m on the board of directors of two healthcare IT companies, one called Health Finch, which develops physician workflow automation software, and another one called One View Health Care which makes interactive patient engagement tools for hospital rooms as well as senior living.
[02:42] Louise: Okay, so I think probably, Lyle, I’m going to have to come back — I think we could have a whole series, actually [Light laughter], where you and I can just pick up topics and pick one at a time.
[02:50] Lyle: [Light laughter] That’s fine.
The second guest, George Margelis, introduces himself as a retired physician who has been involved in healthcare and technology for 30 years. He is a good friend of Lyle’s, whom he met at a health IT event 15 years prior.
[02:51] Louise: Thank you for the intro. And, guest number two, who are you?
[02:55] George: Well, I think Lyle forgot a couple of things that he’s involved with, as there’s loads of innovations, and there’s other things, so you probably have like a month of podcasts with Lyle. My name is George Margelis. I’m currently a retired physician, is how I like to describe myself. I’ve been involved in healthcare and technology for 30 years, and have the scars to prove it, and met Lyle probably 15 years ago at a health IT event in the United States. We built up a friendship, because like minds think…blend well together.
[03:23] Louise: Fantastic. And, what brought you here together today?
[03:26] Lyle: You know, I was in town for the board meeting for One View, and exploring touring some of the hospitals using it, and of course, I pinged George, because it’s Australia and I’m in town, and he said, “I’m going to be in Melbourne also, and there’s going to be this discussion and telehealth conference. Would you like to speak?” And so I said, “Of course, I’d be happy to talk about, particularly I love the topic of the future — what things are going to look like, not in one year, but in five, 10, 15 years.”
Louise asks Lyle and George for their insight on how the future of healthcare technology will look like based on their experiences. Lyle talks about the three different kinds of changes that will take place.
[03:54] Louise: Alright. Well, that’s a topic for conversation, then. So, what are your thoughts? What comes to mind when you think…because also, five years’ time is just a blink of an eye. Often when people outside of our field think of future technology think, “Well, future means I’ll see it when I’m old,” or that sort of stuff, but we’re talking about things that are happening right now, and how in five years’ time, things will be really different. So, how do you see that future looking Lyle?
[04:21] Lyle: So, I was saying earlier, there’s an old phrasing that says we overestimate the near-term and under-estimate the long-term, so in the next year to couple of years, I think we’ll see gradual shifts, but in five, 10, 15 years, we have to see some type of significant change both in reimbursement, which is that volume-to-value based care, where we’re paying for value and not simply for the volume of care that we do. I think — I call it the three R’s. There’s reimbursement changes. I think we’re going to need to see regulatory changes, particularly around scope of practice. That means everything from can we let a physician assistant and a nurse, a medical assistant, a community healthcare worker do more of the care that has traditionally focused on allowing only the physician to do at the point of service and face-to-face? Can we allow more care to be done via virtual medicine? And then, the next step is can we allow for more automation, whether that’s rule-based automation or AI, similar to how we let cars drive without a driver. How are we having so much trouble in healthcare automating and delegating a fair amount of care? I think it’s regulatory issues are holding us back in some ways, and I think that will have to change. Then, the third R is some rationing of care. We have to come to a sensible understanding that we only have so much care that can be delivered to everybody, and I think in the future, we need to see a fair distribution, that everyone has a baseline level of care, and I think we will see, in the U.S. in particular, some type of standard care that everybody gets, a Medicaid or Medicare for all, as they say, and then, for folks who are able to buy up, they may buy more care, which may mean more convenient care, more intensive care, whether or not it’s better care is to be seen, but at the very least, I think we need that baseline for everybody that allows us to, as a nation, feel good about how we take care of our people.
Louise picks up on Lyle’s point of rationing of care. Lyle talks about the inevitable move towards being more efficient and equitable in the delivery of care. George adds the reimbursement model discussion into the conversation.
[06:27] Louise: I’m going to pick up one of your points there — rationing of care. So, I have a slide in my deck that I talk about, healthcare being unsustainable, and I show all these news headlines, that everyone knows and agrees with, but then I put up a quote by Don Berwick which says, maybe,
we could have all the care we want and need if we just organised it properly,
and in a very similar mode, your talk earlier today, Lyle, you had a quote about physicians. Did you want to quote yourself?
[06:56] Lyle: Yeah. So, I had often said that
we don’t really have a shortage of physicians, just a shortage of using them efficiently.
We have physicians do things that are really below the level of care that they should be doing. We should be able to use, as I said, an IT-enabled team-based care approach so that everyone should be able to get this baseline level of care, and that means not everyone gets to see a face-to-face with a doctor. So, rationing does not necessarily mean worse care, but it does mean that it’s going to be a little different, and it may not be what is traditional care delivery like somebody coming into your house or you going to see the doctor, it may be an AI bot who’s able to manage the level of care you have.
[07:35] Louise: Perhaps reorganisation rather than rationing, because I’m just thinking as a marketing point, people will get scared. I mean, is that what happens?
[07:43] Lyle: Yeah, I do think we have to think about rationing at some point, in the sense we just…we spend a lot of money on the last few months of care that doesn’t necessarily…is not the best use of the money that we have available. So, I do think there’s absolutely a re-organisation to provide efficiencies of care, but I do also think eventually, we’ll have some level of rationing, just to say not everyone should be in the ICU for six months, just because we can do it. I don’t think that’s going to substantially change the quality of care that we deliver, the expected life expectancy, but I do think that it’s one of the things we culturally do right now — we ration care right now, but we don’t do it necessarily sensibly. We have some people who get too much care, and we have some people who get too little care, and so we have to equalise that out to some level of baseline. And, maybe using artificial intelligence and computer algorithms to sort of figure out what is the right amount of care for folks, and again, this is just trying to balance the sustainability of our system, but I’m much more interested and enthralled by the concept of how do we make care much more efficient and democratic for everybody.
[08:52] Louise: Yeah, well, I’m a big fan of that. George, what do you think?
[08:54] George: Well, when you actually look at the rationing of care. I mean, we’ve often seen that some of the overexposure to care we have now is driven by the reimbursement model. So, procedure pays 3X what a non-procedure does, so therefore, we become proceduralists. So, therefore, we have a rise in procedures. So, can we use technology to shallow that gap and automate the stuff that…physicians still need to be paid well.
You still need to incentivise physicians to do their job, but you don’t need to incentivise them by paying them to do repeat prescriptions that their brain is being turned off to do.
Louise asks the two to share their thoughts on incentivising smarter care delivery. Lyle delves into what incentivises efficiency, and how it will affect both the patient and the clinician. The conversation turns to comparing and contrasting the cultural differences evident between Australia and the USA.
[09:28] Louise: Does that model work well if we incentivise them to play smarter and be smarter, from your experiences, both as clinicians yourselves, but then also in the work that you do in advocating for other people to get on the bandwagon?
[09:45] Lyle: Yeah, and that is true, what you were saying —
the volume-based system drives volume, a value-based system will drive value. The system always gets what it’s designed to get,
and so right now, we will do more procedures and more tests, because we get paid to do it, and as we’ve seen via bundled care payments (which is a common thing in America, where you get paid a set amount to manage a patient through let’s say a pregnancy or a knee surgery), once you are able to bundle that into one payment, it becomes a lot easier to say hey, we can do more telecare, we can do more virtual care, we can use computers to automate and delegate certain amounts of care, and the result, usually, is a win-win. It’s more efficient for the patient, and it’s less costly for the system, and we’ve incentivised this idea of value and efficiency rather than incentivise seeing someone face-to-face.
[10:39] Louise: George, what do you think in terms of…because both of you travel extensively, and I’ve known you, for a very long time … for someone who might be listening to this and not as familiar with this work, do you see that there are any significant cultural differences between the U.S. and Australia and how our experience in Australia is different, could be different, or do you see it that we’re on a similar trajectory?
[11:03] George: Look, if you take a final year new medical student out of an American university and an Australian university, they all come out with exactly the same idealistic goals of helping people and providing high quality care and making a difference. Whilst our reimbursement systems differ to some degree, and that impacts some of their career paths, at the end of the day, a clinician’s engagement with their individual patient is a core part of what they do, so be it an American physician or an Australian physician or a Chinese physician, the interaction with their patients is the raison d’etre to what they do. So,
I think the cultural differences are driven by reimbursement models, but the actual quality of care, safety of care, access to care are all very deeply ingrained in us through our training and through our desire to become physicians.
But, we’re all facing exactly the same problem, we talk about under-supply, and yet, whenever I catch up with GPs, they complain how boring their job is because all they’ve been doing is filling out sick notes and repeat prescriptions all day, and that’s not what they’d gone into medicine for, and a whole bunch of them have left the industry as a result. So, we need to make it exciting for the provider, and also valuable for the patient, and that’s a challenge, but it’s a goal we need to really aim for.
Louise prods about the cultural differences that might exist in terms of technology. George shares the US’ advantages in clinical informatics, and Lyle shares his own personal journey in the US combining informatics, business and healthcare.
[12:24] Louise: And, what about in terms of using technology for clinicians on this journey? Any cultural differences there, or do you think it’s very similar as well?
[12:32] George: No. I mean, we…20 years ago, we had less access to gadgets, but any gadget that comes out in the US is probably getting built in a factory in China, so we’re probably getting it a week before you because the shipping routes are shorter. I think the access to technology is no longer an issue.
The big difference in America, you can actually now get sub-board certified in clinical informatics, so you have a career path. The biggest challenge we had here is that clinical informaticians, myself and a couple of my colleagues, had to leave the healthcare system and work for industry
because there were no paid jobs… there’s lots of things for us to do in the healthcare system, but someone’s got to pay us to do them. So, at the end of the day, you need to pay the school fees and feed the family, and that’s a big part of the challenge. In the U.S., we now have clinical informaticians ingrained in the system, and that’s driving change. We’re starting to see that here, but it’s very spotty. We have a chief clinical informatician officer at a state level, but in the hospital, there’s no one who’s actually following their lead, and that’s part of the challenge. We need a career path which involves education, because doctors generally like to be continuously educated. It’s one of those obsessions we’ve all developed, but without a career path, it’s really easy to sort of say, “I want to do this,” but the reality of the world comes into play, and you end up not doing it.
[13:54] Louise: Thanks, George. And, Lyle, what about your own personal journey? You’ve crafted a very busy, long CV doing this, really crafting a career path out. The general workforce issues I know are similar in the States, but you do have certain advantages like the board certification. How have you chosen, and did you choose a path that you navigated, or are you just making it up as you go along?
I would say I’ve always had this dream of, “I want to change the healthcare system. I want to make the healthcare system better,”
and I usually have five-year plans. So, like George, I got into what is called clinical informatics because of my interest and passion. I was an engineer undergrad and I spent some time at the Harvard Informatics Group when I was a senior med student to learn about academic informatics. I actually recognised, even then, I did not want to be an academic informatician, I wanted to be an applied informatician, which really means I’m not studying, doing research, as much as applying information technology, computers, etcetera, into healthcare, and as a result, I ended up partly going into industry early on. In ’95, my group let me be Director of IT, but that literally just meant getting everyone email. So, I went into industry pretty early, and became Chief Medical Officer of a publicly traded EMR company. There I learned about project management, product management and combined with my informatics background, clinical background with business skills and stayed in industry for a couple of years while I still practised medicine, and then when my group, in the early 2000s, was ready to implement an EMR, electronic medical record, they came and said, “Hey, would you do this? Would you come back and help us do this?” and I was ready to do it then, so I had my street MBA, some skills, etcetera, and then spent time doing that within the group and implementing our EMR and optimising it, and eventually recognising that that was a good base platform, but I wanted to innovate more. So, I was able to, with some funding from some of my patients and donors, start the Szollosi Healthcare Innovation Program, back in about 2007, which allowed me to start exploring much more than just the standard informatics, but how might we use innovative thinking, design process, human-centered design, etcetera, to really think how we would use this baseline technology we have for care coordination and efficiencies of care and telehealth, and we started doing some things much earlier in the curve because I had some time to explore them.
Lyle talks about his experience as the constant innovator, and the struggles that come with always being ahead of the curve. The conversation shifts towards what barriers and conflicts must be overcome in order for progress in user centred-designed thinking to take place.
[16:24] Louise: I was going to say, very early in the curve, because now, even at today’s conference, we’ve got a presentation by a human-centred user design expert who gave a great talk, but that’s still so new for us, even to include that stuff, and if you go to a normal medical conference, you don’t hear about #UX or what it means. So, ten years ago you were doing that?
[16:47] Lyle: Yeah, so, for good or bad, I’m usually ahead of the curve. It’s not necessarily the best professional advice to give to someone, because I’m constantly the ‘innovator’, meaning my head bangs against the wall a lot trying to explain things to people. It took me years to explain to our process improvement people that process innovation was different, but now they get it and now we’re moving forward. We’ve gone from a one-man band to creating the innovation department at Northwestern, where we have six, and hopefully more people over time to bring in some of these concepts. I joined, very early on, a group called the Innovation Learning Network, a non-profit consortium of now 25 plus healthcare organisations focused on how do we use human-centered design thinking to improve the healthcare experience for both patients and the providers of care, So I’ve just been learning along the way. George said it right, particularly people like him and I are constantly looking to learn, learn, learn and then apply it into healthcare, and it’s a constant thing.
In innovation, I’ve sort of found the ultimate there’s always something new going on. Informatics, in a way — gosh, I hate to say it, bored me, but eventually, I got it, I knew what to do. I actually didn’t go for the degree, which is a really recent option as it’s not going to do anything for me. I’ve been there, done that, so I’m moving onto this next stage of my career, but I do love the fact that it’s available. It’s a little weird, because it’s not like a pulmonary or renal fellowship, but it does speak to people who understand and are trained a bit more in informatics. By no means is it perfect in the U.S. — we still have a lot of issues with academic informatician researchers who don’t really understand operations. The few who are in operations are always butting up against others who aren’t necessarily looking to radically change what’s going on.
Healthcare, is a very slow-moving business. People who like technology are used to moving faster, and there’s a conflict there right now.
[18:50] George: And, you brought up a good point in your talk earlier today. The future of healthcare using technology will make the solution to some of the hospitals, which is a real challenge to someone who’s just built a one-billion-dollar hospital building. So, we are challenging the financial models that they currently work with, and when we talk about disruption, well, we’re talking big disruption when we talk about the healthcare system.
Louise brings the discussion to potential radical disruptions in healthcare, especially in terms of how technology can change how we access care services. Lyle talks about the role consumer choice will have, as we make decisions based around quality, convenience and trusting technology.
I think we’re going to see someone coming into healthcare, whether it be an Amazon or someone else eventually, who may create a radical disruption of how we take care and manage, and using logistics and AI and other technologies.
When that happens, just like Blockbuster got taken by surprise, and Barnes and Noble, etcetera, the hospitals are going to wake up and go, “I never saw that coming”. The hospitals who are ready to innovate and ready to think outside that box will be more prepared, and we’re starting to see more of them doing that, but usually in very small baby steps, and it’ll be interesting to see if the same disruptions that happen in so many other institutions can happen as quickly in healthcare. Most of us think, “Oh god, that could never happen that quickly,” and yet, it might.
[20:01] Louise: Okay. I love that topic. So let’s talk about that for a while. All three of us, I think, are often in front of audiences doing the head-against-the-brick-wall thing, but with huge smiles. So, one of the examples I’ll give to audiences is, okay, so you know you can go to Google and you can type in ‘diabetes’ and it’ll give you diabetes information, and soon, with Google’s AI, you’ll be able to type in all sorts of things, and it’ll know that you’ve already got diabetes but instead of just giving you information, that hopefully is better curated than they do now, Google will say, “Oh, you might have diabetes,” or “We think you might have diabetes,” or “We know you have diabetes, would you like to talk to one of our diabetes educators?” and just like Google AdWords, there’ll be a pop-up prompt you can choose, and you will think, “Actually, that would be great. I’m not feeling well today,” or “I have some questions,” and with a click of a button, straight away, you’re in a video consult with a diabetes educator who is a clinician, but is paid and works for Google. Because, if that was available tomorrow, the amount of consumers who would take advantage of that service, I think could be a radical change from how we access health services now. So, what kinds of examples do you guys have in your kit bag of how things could get radically disrupted relatively quickly?
[21:19] Lyle: Well, you brought up two big things. One is sort of the ubiquitous sensing, and the second is the delegation of care to a lower level team. So, in the sensing thing, take it even further, right? What if your phone could start having sensors that could tell what your glucose level was? So, every time you touched your phone, it would start measuring your glucose, it has bluetooth connectivity with your scale, it knows if you’re gaining weight, maybe the camera is always sort of watching what you’re eating, and of course as you’re using social media and email and searching, it takes all of that into account. I think we will see — and we are starting to see, even now, companies who are looking at everything from your search terms to how you’re using social media, to what your FICA score is, which is, in America, that’s a credit score, to whether your car payments are behind, where you live, where you shop, what you’re shopping for, and they’re already taking that and using that as a way to identify patients who are at higher risk, whether that’s because of their diet or where they live and they don’t have transportation, and in ACOs in America (Accountable Care Organisations), where we are paid to manage folks, identifying the high-risk people are critical, and what we’ll do as an organisation, we’ll start calling those folks, and go, “It looks like you’re at high-risk for transportation issues, and we also know you’re at high-risk for disease burden. What can we do to make sure you come into your appointments?” And so, we’re starting to see that now. If and when, it will get distributed to the Googles of the world, if they can find a business model out of it, sure.
And, I think people are — especially younger people — are more and more willing to give up information for any sense of convenience or quality.
I think there’s always going to be that struggle with feeling like someone’s watching you, but as soon as we use Gmail, you’ve given up a fair amount of your life, but it makes your life easier, and so people are willing to do that. The tricky part will always be how do we…who pays for all of it, and if there’s a business model to be had, maybe Google figures out how to sell diabetic devices and books and monitoring, and makes their money off of that. It’s unclear, but that future is a definite possibility.
Considering the potential risks of tech companies capitalising on healthcare, George talks about the need for clinicians to be involved. Both Lyle and George dissect the flaws in the systems, that are the root causes of inefficiency in healthcare and Lyle discusses his SAD and FATT Philosophy to improve healthcare.
[23:37] Louise: Thanks, Lyle. George?
[23:40] George: So, my only concern with it is that we go into healthcare for altruistic means; however, the commercial side of the world can really change the way things are done. So, will we have the homeopath and everyone else trying to flog you stuff using technology? So, I think it’s important to make sure clinicians are actively involved in this discussion going forward, because if it’s purely a commercial transaction, then I can sell you snake oil as well as the next man, so we need to make sure that’s controlled, but at the same time,
the biggest challenge we’ve always had in healthcare is that technology has always promised to cut costs, but because we don’t know what the costs of healthcare are, we don’t capture the costs, so therefore we’ve never been able to deliver on that transaction;
however, once you start having a much more holistic understanding of what a patient’s life involves, you start to understand the soft costs, as well as the hard costs, and we start to change the way we approach this. It’s about continuous healthcare for those who need it, and not everyone needs it.
The problem at the moment is we deliver healthcare to everyone, and the reality is, 5% percent of the population needs it, and 95% of the people are doing just fine without our interaction.
They don’t really need to see Lyle and myself because we’re just there to write their sick notes when they need a day off work. So, working out who needs healthcare, and delivering high quality healthcare to those who need it, and those who don’t need it, let them still enjoy their life. I think it’s part of the challenge we’re going to face going forward.
[25:10] Lyle: Just to add on to that, right now, our healthcare system across the world is basically fundamentally flawed in that we wait until something bad happens and we waste a bunch of time doing rote stuff. If somebody has diabetes, hypertension, high cholesterol, and is relatively stable, they don’t really need to see the doctor — we can automate and delegate a fair amount of that. But, what we don’t really do is true early detection and understanding of what the problems are, and the result is that we wait until they have the heart attack, until they get diagnosed with cancer, and then it’s much more expensive. So, how are we going to flip that model, so to speak, and not wait until someone’s overly complicated? I think it’ll be interesting. I think genomics and the whole idea of personalised and precision medicine are going to become increasingly important. Genomics are getting cheaper and cheaper. They’re able to help identify who’s at high risk for certain diseases: cancer, diabetes, heart disease. From that, we can come up with a more aggressive screening measure for those folks, and perhaps a better prevention method, and by the way, people might listen a little better if they know their genetics make them prone to certain conditions.
At the same time, we have to…I call it the ‘SAD and FATT Philosophy’ to improve the healthcare system. SAD is how do we simplify, automate, and delegate routine, repeatable care? And, I think that’s incredibly important when you look at that big pyramid, and as George said,
90% or so of the people, they don’t need to see a doctor. We can easily automate and delegate that to technology and teams,
and those folks who do need it, the FATT is we need financial incentives that focus on value, we need analytics to understand and identify and sense what’s going on, we need team-based care, and we need telehealth. So, that’s my SAD and FATT philosophy that I think will help transform the healthcare system to one that is much more proactive and less reactive, and much more of delegating the routine stuff away from the doctors, so the doctor may see less patients, but be able to oversee a much larger group of patients by setting some standards and be there for the patients who really need it, and come up with, the early detection algorithms that if we can identify and convince these people to change their lives, to do better screening, and we can avoid the heart attacks and the late stage cancers, then we can ration care in a reasonable way, because we just won’t need to do the significant surgeries and chemotherapy that we currently do. So, that’s a flip that I think needs to happen eventually.
Louise addresses the inevitable flip in scalable healthcare, and asks when Lyle thinks that greater efficiency in care will be reached. Together, the group weighs in on what investments are necessary to advance, and on ideas of individualised care.
[27:46] Louise: I love it. When are we going to get there, Lyle?
[27:49] Lyle: I think it’s like a lot of things. It’s becoming available, it’s just not evenly distributed. My current practice is based on that, and I recognise that it’s not scalable right now and there’s a lot to learn, and so the goal of the practice is how do we get to that particular vision and stage now, recognising it’ll be more expensive and there will be a lot of grey areas? I’ve got to talk to people about the pros and cons of doing genomic testing and full-body MRIs and scans, but if we can figure out a way and see if that works, then we can get to the point where it’s going to be more scalable.
In five to 10 years, I think it’s going to be reasonable for a full-body MRI and a full genome might be $100 or $200. Like Moore’s Law, in every other instance, those technologies are getting better and faster. It’s sort of like that Star Trek scanner, you just scan everybody. So, the pace of change is exponential, and so if we get to that point where it is essentially super cheap to do that level of scanning on everybody for early detection, what does that mean? That’s part of what I want to find out. In a world where it’s not scalable, where it still might be expensive, but I have a small group of folks who are willing to spend that and go on that journey with me, we’ll start discovering, can we save lives, and can we help people live longer and better? I think I’m one of…I’m sure there are others out there who are doing this, and we’re the tip of the spear, we’re going to learn a lot, and it’s not going to be ubiquitous or scalable in a couple of years, but 10 to 15, maybe.
[29:30] Louise: 10 or 15. George, any advances on 10 to 15 years?
[29:34] George: Well, the key thing there, as Lyle emphasises, is we’re learning as we go. We’ve discovered in the past that sometimes, screening tests are good and sometimes, screening tests are bad, and we’ve had to work on perfecting those and work on making them more effective. This concept of using the genome and whole body MRI and 24-hour EEGs, all these sort of data points, we need to then work out do they provide value, and who do they provide value to? Again, you may only provide value to one percent of the population, but
if one percent of the population uses 35% of the healthcare costs, it makes sense to invest in that population.
It’s an ongoing journey for all of us, but the key thing is that we have to evolve a learning healthcare system that takes this into account, and doesn’t just accept, for example, that a study from 1957 said we need to have a blood pressure of 140 over 80, let’s stick with that for the next 50 years, we’ll worry about it in 100 years time when someone else has come up with new research on the topic.
[30:35] Lyle: One of the flaws that we have also is that population health and science is important, so all of these studies that show , for the population this makes sense or doesn’t make sense, we have to take it down to individual level. As we get to genomics and advanced imaging, we can start saying look, in general, statins are good for this type of person — for someone whose at this risk, but for you specifically, statins might be incredibly important, or for you, statins might not work, and the more we get data and information, the easier it’ll be to individualise that level of care.
The reason this is starting very slow — I have less than 50 patients — is this takes a lot of time and energy to understand, a lot of grey area to explain to patients, there’s a risk of false positives, if we do this type of scanning and lab tests, we have to acknowledge that we may find stuff that are a little scary, but we also have to be able to live with the consequences and understand what we’re going to do with that information and not overreact, and I can’t do that with a large population of people. It’s going to start small, but eventually, we’ll be able to make it, I think, more scalable, but there’s still a couple years to learn on that.
[31:46] George: Last year at HISA’s Health Data Analytics Conference, Eric Dishman spoke about the N=1 trial model, and in the past, we’ve been classically trained that N has to equal at least 1,000, if not 10,000 in trials, but as we start to personalise this and have more data, we can actually start looking at what is right for that specific patient. And, Hippocrates, two and a half thousand years ago, focused his medicine on individuals, and we’ve sort of gone full cycle with huge population measures, and now we’re going back to this whole idea of the one-to-one interaction, and what can I do to make your life better, and that’s going to require a different way of delivering medicine. We need to use the technology to remove the chaff and just focus on those that we can actually make a difference to.
Louise asks George and Lyle to share advice for those looking to start their own paths in health informatics. Both George and Lyle share what factors were essential in driving their careers forward.
[32:30] Louise: Alright. Well, I know there are planes to catch, so I’m going to ask you guys one more question, and then we’ll wrap it up. So, back to workforce and your own personal journeys. If someone’s listening to this, and they’ve been hopefully inspired by the things that we’ve touched on, and think, “Oh yeah, we’ll I’m a doctor, or I’m a nurse, and that sounds really interesting,” what advice do you have for them? Where should they start out on their own paths and their own journeys in this space? George, we’ll start with you.
[33:00] George: Look, go into it with a mindset that you’re just looking for answers, and you need to be inquisitive and you need to be willing to poke the bear to make them react. The challenge has always been, for junior clinicians, they’ve been told, “Don’t upset those above you”, and if you don’t upset those above you, you will just learn to do the way they’ve done it, so be interactive. Do it in a nice way, but play an active role, and just keep on learning.
It’s so easy to find information now, read it, digest it, discuss it, be willing to be a little bit controversial if need be, but be involved. If you’re not involved in this change, then you’re not going to drive the change, and you’re going to be the one left behind when the change occurs.
[33:47] Lyle: That is fantastic advice. I imagine George and I were both the medical students and residents who the attending doctors were like, “What are you talking about? Stop talking like that. You can’t challenge what is dogma.” But,
we both probably also found mentors, and that is key. We found people who trusted and believed in us, and let us expand
because otherwise, it’s just brutal. I do get a lot of doctors saying, “Hey, how can I do what you’re doing?” I’m like, it didn’t happen overnight, and I often say first, follow your passion. When I teach to med students, and I tell them, being a doctor has all these responsibilities, but the best thing to do I think in balancing your life, is if you have a passion, if you love ballet or you love baseball or something, be able to combine those passions, and that’s the cool thing about medicine, is we can do that, and you might become the world’s expert on baseball injuries that are very specific, and that’s a really cool passion to follow. I think George and I had a passion on information technology and computers, and then sort of as part of that, I think engineers in general — were you an engineer, George?
[34:52] George: No, but I spent a lot of time…I bought my computer at university and I remember getting in trouble because I handed in a word-processed document back in 1981. They sort of said, “You’ve obviously cheated,” because…[Light laughter] ”Who did this for you?” and I protested “No, I have a word processor.”
[35:07] Lyle: So, the engineering mindset is always how can we do this better? And, in healthcare, that is not a mindset that is well-regarded, particularly in the non-procedural type of areas. Proceduralists, they were incentivised, if you can do a little better, we can pay you more, etcetera, but for the cerebral physicians, internal medicine, etcetera, there was very little recognition of how might we do this better, but I’m always looking, how can we do this better, faster, quicker, cheaper, and so it does push a lot of buttons, and it challenges a lot of people.
But to me, it was my passion. I loved doing it, and so I’d encourage people to follow their passion
and do it in a little world of your own, have your own little practice where you can do it. If you’re in a larger organisation, you better have a mentor, a protector, someone. I’ve always been fortunate to have someone who respects and understands what I’m doing, because I will always piss off parts of the organisations. In my situation, I have lovers and I have haters. There are people who love what I do and want me to keep pushing, and there are those that are absolutely scared to death of it, and there better be good alignment to allow you to get away with a lot of stuff.
It’s also important to have a balanced portfolio, meaning if I don’t have a good win every year, yeah, I’m going to lose the protection I have. So, as long as I have one or two good wins, it might not be the most phenomenal, coolest things ever, but if there’s some good solid wins in terms of improving the patient experience, efficiency, etcetera, I can get away with playing on the fringes as well. So, that balanced portfolio becomes important. You better have a win every 12 to 18 months so you can play in those other areas that may or may not result in wins down the road.
I worry about young clinicians who want to jump right into industry. I think
to really understand, you’ve got to spend five, 10, 15 years as a clinician, and ideally if you can always work at least part time as a clinician, for a variety of reasons, that keeps your feet in the sand, let’s you eat the food that you’re making for everybody else, and it gives you some level of credibility.
There’s always this big discussion on an online forum George and I are involved in for physicians who are in informatics roles about whether or not you should continue practising as a clinician.
number one, I think you need 10, 15 years of experience, at least part time, to truly be able to do well in this business, and two, I say you should keep practising medicine if you want to.
Don’t do it because anyone else says to. If you love it — I love it, I can’t give up practising. My life would probably be easier if I didn’t in some ways, but I love it way too much, and what I’ve done has evolved and I’ve gone off the primary care treadmill because I couldn’t take it anymore. The idea of seeing patients for 12 hours and doing paperwork for 12 hours, it was crushing me, just like it’s crushed all my colleagues, and now I’m involved with companies who are building software to make that easier, but I personally am trying this new path with a different type of primary care practice because I still need to see patients — it’s in my blood. I’m a doctor in the end, and I always need that, but it is an amazing, amazing job and experience, and allows us to leverage and play, in a way, to reinvent healthcare, that is rare. So, I guess
combining that passion, having that mentor, and always feeling comfortable challenging what is dogma is going to get you to where folks like George and I have been.
[38:39] George: I think one of the key things to come out of that is the advice for clinicians who are — and we have a few of them in Australia — who think, “I finished med school. I’ve learned all I need to know about the healthcare system. I’m going to do a start-up that’s going to revolutionise medicine.” It really is complex, I admit, and sometimes, some of the things that we look at that we think are inherently stupid have evolved over the years because they’ve improved quality, they’ve improved safety. So, it’s not a simple problem, where a simple Uber solution comes in and solves it all. You need to be immersed in it to understand the complexity of it, because otherwise, you’re going to come up with simplistic solutions which we’ve all thought about, and they’ve failed in the past.
One of the vagaries of healthcare is that we don’t publish failures, we only publish successes, so a number of people have come up to me with their ideas, but I’ve seen it about three times before, but hey, maybe the fourth time it won’t fail. So,
you need to be immersed in the industry, you need to spend nights in the hospital ward and realise what are the social interactions that happen in that ward that influence care, and then you can actually go, with those scars on your back, to move forward and fix those issues.
So, there are no overnight success stories here. It’s a journey — it’s a fascinating journey. I mean, if your passion is there, you can really enjoy it. I think that’s really important for junior clinicians to keep in mind as they go forward.
Closing Remarks. Louise concludes the discussion thanking George and Lyle for sharing their insights.
[40:05] Louise: Lyle, George, it’s been an absolute pleasure. Thank you so much for spending a few minutes of your time today chatting with us on Dissecting Digital Health, and I look forward to round two.
[40:14] Lyle: Thanks, Louise. Thanks for what you’re doing. We need people like you to help get the word out. I’ve been going to these types of conferences for many years, and I’ve always learned — all I need is one idea to spark, and so thank you for getting people together and hopefully sparking a bunch of ideas in people throughout the nation.
[40:31] George: Thanks a lot, Louise.
[40:33] Louise: Thanks, you guys.