Snake Oil vs. Innovation

Dr. James L. Madara’s candor can be sincerely appreciated in this current partisan political climate. To see someone care about his own constituency enough to publicly take a stance is a great pleasure. Of course there are nuances but the gist is this:

• People matter
• Can we please focus on the “end-user”?
• Innovation is something everyone can get behind but can you please, “show me the money” / time / value?
• Please separate tactics from strategy

People matter

Even when that wonderful day arrives when we have finally coaxed the machines into doing all the things we want them to do, and none of the things we don’t, we will still be left with one human being seeking help at a time of great need and overwhelming anxiety.

- Dr. Robert Wachter, The Digital Doctor

That quote, from Dr. Madara’s speech, origins form Dr. Wachter’s book, The Digital Doctor. Although we can all go on and on about data, digital health and self-care, guess what?

• The masses don’t care unless it’s relevant.
  Cleveland Clinic spent millions to get people to sign up and use the patient portal with X target. Guess how many signed up? Short answer, nobody. I think the goal was 5% active users each month. Lots of signups. No continued engagement.
• Those who care about their health aren’t the problem.
  We’ve all read about the Quantified Self movement. But the challenge that physicians run into is Quantified Self doesn’t address the actual problem. What perhaps Dr. Madara is also trying to communicate is that, while there are a lot of statistics around how many people have these devices, the 60 year-old male/female with some combination of diabetes, COPD, CHF and other co-morbitidies that he/she tries to see every week, doesn’t have one of those and isn’t going to be helped by having one of those. That’s a tactical problem that physicians face every day
• Raw data isn’t the answer.
  In the innovation interview with Dr. Wachter referenced earlier, he says, “Here’s where I go a little bit berserk. When I hear people say how wonderful it’s going to be; the patient is going to be wearing something on their wrist or something in their underwear that is going to measure their heart rate, their sweat and that data is going to beam to their primary care doctor who is going to be thrilled to get it, then I say, “What planet is that exactly on?” Because every primary care doctor I know, if they get one more piece of data on one of their 2000 patients, will jump out the window.” Can we get to the point of everyone caring about their health to capture their data, uploading it, and someone qualified making sense of it all without expending massive amounts of time? Eventually (hopefully), yes, but that’s not now.

So in the interim what do we need to do? Focus on….

The end user

On the other side of the screen, it all looks so easy.

- Kevin Flynn (Tron)

There’s the physician and the patient. From a patient perspective, low-hanging fruit like appointment scheduling, lab results and quick (secure) emails to physicians were quickly addressable and have had success. There is more work to be done on making the medical record more accessible and work like the ONC competition.

But the physician’s life hasn’t been simplified at all. If anything, it’s become worse. There was a recent study done which claims that an ED physician has to click more than 4000 times in an EHR during a single 10–12 hour shift. To quote Dr. Wachter again, “It should have been obvious that if we built this technology that required doctors to document 47 different check boxes and provide high quality care that, a) they weren’t going to look patients in the eye any more, b) they were going to be incredibly unhappy, and c) it would distract them from what they were really trying to do.” Given that, is it surprising to see a hard push back from physicians on this newest “solution” to healthcare problems?

The frustration on the physician side is two fold:

• Intent vs Reality: The intent behind EHRs and digital health applications is a positive one. Collect data, reduce errors, make data reusable, derive insights across populations, patient enablement, physician productivity etc. But EHRs haven’t lived up to that intent in reality. While it has improved data collection and data quality, it hasn’t made physicians lives easier but shouldn’t that have been an equally important goal? As Dr. Madara says in his speech, “Our current state? American physicians have become the most expensive data entry workforce on the face of the planet.”
• Data matters, insights matter more: No one will argue that data isn’t important. The question is how do we capture that data with a small enough effort and at the same time make it usable by an already constrained individual? Dr. Wachter: “Part of that is asking some central questions about all this data we are collecting. Now we are asking for new data because we can. Which piece of data are really important and which pieces of data are simply busy work and don’t add any value to the patients, and if we can, let’s get rid of some of that.”

Innovation

You can save me time AND money?!

-Me

I really doubt if Dr. Madara was protesting against innovation. Innovation without purpose, yes. Time is the most valuable thing we all have. Collecting data is good but the question to always ask is what is the user going to do with that data? Can we separate the wheat from the chaff? Can we derive insights from the data that can aid a physician in providing better care? Can we do that without asking them to log into five different systems?

There are companies like Omada and Propeller Health that are doing great things by focusing on data and workflows. Providing patients with guidance outside the physician office, passively collecting and correlating data, summarizing that for the patient and the provider and finally providing that summarized data soon within the EHR itself. These things are possible. Dr. Madara talks about the AMA Innovation challenge, their partnership with MATTER and more to foster innovation with a key criteria being that “…new products and services are deeply informed by our actual problems and needs, rather than flying on an entrepreneur’s incomplete views.” Not an unreasonable request, is it?

Summary

We can only see a short distance ahead, but we can see plenty that needs to be done

- Alan Turing

Healthcare is a complex industry. The problems being faced here aren’t new or that different from what other complex industries have faced with the advent of new technologies. But healthcare is interesting again. You can see more money flowing into healthcare from VCs and large organizations like Kaiser, Tenet, UCSF, and HCA, who have app development teams where none existed before. Change is coming and it’s exciting but a focus on the users and a more in depth understanding of the problem is required before touting the benefits of some new thing. There is a reason why Omada, Propeller and Twine are regarded as leaders in this digital health space and that’s because they’ve spent the time and effort to prove the efficacy of their solutions in conjunction with physicians and patients. Healthcare is an industry ripe with potential and what Dr. Madara is asking for is a partnership to address these problems.

I’ll leave you with a final quote from Dr. Wachter:

“…the exciting part is that we are getting toward the middle or end of that foundational stage where the wires are there, the tracks have been laid, and you now have the environment where you can innovate and come up with cool ways of solving tough problems.”

The full interview reveals even further insight.