My thoughts on the MIT Solve Talks at Google Hosted by Kara Miller on Healthcare

MIT Solve Talks at Google Hosted by Kara Miller
Video: https://youtu.be/MpMrK2nm3pU

Streamed live on 28 Oct 2015

Guests:

  • Rushika Ferdandopulle, CEO of Iora Health
  • Denny Ausiello, Chairman Emeritus at Mass General Hospital
  • Heidi Williams, MIT

About Solve: “Learn about MIT’s initiative that asks extraordinary people to work together to find solutions to the extraordinarily hard problems facing our global community.” http://solve.mit.edu

My take home message was that Healthcare needs to consider building these Healthcare Operating Systems Platforms that leverages Big Data and other new technology of this digital era to integrate between sources of data, the practise and the patients. It will allow collaboration between clinicians and patients both in the provision of care and in research.

My Observations about the speakers

  1. Heidi has a very typical data scientist and epidemiologist perspective, cautious and tempered by date
  2. Denny has a very typical experienced practitioner perspective, interested in reform but cautious about hype around revolutions.
  3. Rushika has a next generation medical conceirge or patient advocate kind of perspective.
  4. The host Kara does not have deep enough knowledge of the domain to truly leverage on the panels knowledge, but she does a good job. The panel however don’t always take her queues, as evidenced in the Watson comments.
  5. The overal theme and consensus is the need for leveraging new IT capabilities to provided more wholistic lifetime medical records to clinicians at the point of care so that evidence based medicine can become the norm of practise.

My Observations about the issues

  1. Issue raised in 5:35, US using biggest % of GDP in healthcare but not getting as good quality measures as some other nations who spend less.
  2. In 7:50 its established that the driver of inflated healthcare cost in the US is waste. One driver of waste is fee for service, which skews incentives to provision unecessary procedures and therapies.
  3. The story from 17:54 by Rushika demonstrates the issue of fee for service procedure pushing and upselling that needs a better and stronger primary care doctor to prevent. At the heart of the issue is a lack of a patient advocate and the information assymetry
  4. Comments from Denny in 23:06 onwards show the need for good data science and epidemiology to avoid inaccurate misconceptions and generalisations
  5. Comments from Denny in 26:42 bring up the culture of the US, and how it rejects ‘benign neglect’, where accepting less is acceptable, but it the US, patients are vigilant and expect more. He goes on to say that medicine today is probably only operating on a 50% ratio on evidence based, the other 50% of blindness is caused by lack of information.
  6. Key point from Denny in 28:00 “The quality and quantity we get from our patients at the point of care is quite random and episodic”, its in this absence of information that a physician may resort to basing their decisions on their personal expereince rather then the nature of evidence that is available.
  7. 3:35 Kara: “how do we get from 50% to 80%?” Denny: “The quality of that information has to be guarded under more continous and presymtomatic ways” – He goes on to say that we need to use the digital tools of today to capture all phenotype information to provide clinicians with the information needed to make informed decisions. “We need a complete retake on how we garner these information, how do we partner with our patients not only in clinical care but in discovery, and then how we annotate that information to give a much more evidence based and scientific base to medicine.”
  8. 34:35 Rushika: “The right way to do this obviously is to get a tonne of data in from when people are living their normal life, we have to figure out how we interpret that data, how do we pick signals out of the noise, and turn that into action”
  9. When Kara talks about IBM’s Watson in 36:20, Denny responds to say Watson is good for dealing with structured data but not unstructured data. I know IBM’ers who will jump at this statement, but I think Denny’s point here is that until Watson can be part of ingesting and consuming data from the points of care and make sense of it depsite its lack of structure and ontology, it will be relegated to studdying journals and already structured medical knowlegde and correlating that to post structured content created by clinicians.
  10. Denny paints a picture from 37:20 of a scenario where we are able to process the data glut and turn it into a data resource that includes journaling and participation from patients, then then turned to knowledge and actions. The market now is full of apps that are comodities, that are not prioritized for goals of precision and not intergrated into the overall patient record. “We need a fully integrated and wholistic system”
  11. 39:49 Heidi points out that IT has failed to be the magic bullet to solve issues as promised
  12. 40:52 Rushika explains that the reason for this failure of IT to deliver has been rooted in the fact that much of the systems built were pivoted on billing and with that focus, the ROI and gains were focused on billing optimisation, and therefore they seeked to make Doctors structure on input, turning their documentation from a simple note in plain english to 50 clicks of forms and severely driving down productivity.
  13. 42:40 Denny: “we were all trained to diagnose disease and treat disease and its progression to ultimately death, we are the only profession in the world that doesn’t know its gold standard, we can’t diagnose wellness”. To drive wellness and engage patients, we need to work on defining what wellness looks like.
  14. Comments till 48:00 on the theme of whoslistic planning for policy makers and factoring the social aspect for health, to be able to meet the public policy goals they typically have.
  15. 49:00 Denny: “Partnerships with patients, not just in care, but also in discovery”. Behaviour science is a science, and its something to master to modify behaviour. Read Social Physics http://goo.gl/IGPaJw
  16. 57:29 Rushika describes Iora as building an operating system for healthcare instead of an EHR, a link between technology and people. Not billing but collaborative care. “Technology in the context of realtionship”
  17. 58:56 Denny: “Integrated Healthcare Systems” – “Intergration depends on people not machines, BUT machines, toolkits and skillsets can ehance much of that, and we would be foolish living in such a technologically advanced era in not taking advantage of that”

Laissez faire capitalism is but a pipe dream.

Apologies for this Non HIT post, but these issues affect us all an post economic turmoil, its worth thinking about this. Economist who are usually champions of capitalism are also quick to point out some common weaknesses that have to be addressed.

Hirchman’s Exit vs Voice

This wonderful obituary to Albert Hirschman in the economist, summarizes his voting theory from his most famous book, “Exit, Voice and Loyalty: Responses to Decline in Firms, Organisations and States”. According to the theory, Mr Hirschman argued that people have two different ways of responding to disappointment. They can vote with their feet (exit) or stay put and complain (voice). Mr Hirschman raised some problems with the cult of exit. Sometimes, it entrenches the status quo. Dictators may rule longer if their bravest critics flee abroad (indeed, Cuba uses emigration as a safety valve). Monopolies may have an easier life if their stroppiest customers find an alternative.

So in disappointment, many give up ownership and no longer have influence to change the factors that brought about the disappointment.

Hardin’s Tragedy of the commons

In this well documented phenomenon first postulated by Garret Hardin in the journal science in 1968. Wikipedia summarizes the theory well;

“The metaphor illustrates the argument that free access and unrestricted demand for a finite resource ultimately reduces the resource through over-exploitation, temporarily or permanently. This occurs because the benefits of exploitation accrue to individuals or groups, each of whom is motivated to maximize use of the resource to the point in which they become reliant on it, while the costs of the exploitation are borne by all those to whom the resource is available (which may be a wider class of individuals than those who are exploiting it). This, in turn, causes demand for the resource to increase, which causes the problem to snowball to the point that the resource is depleted (even if it retains a capacity to recover). The rate at which depletion of the resource is realized depends primarily on three factors: the number of users wanting to consume the common in question, the consumptiveness of their uses, and the relative robustness of the common.[18]

In a nutshell, when a common resource has no ownership, there is little or no incentive to manage it.

Externalities

Externality as defined by Professor Jan Horst Keppler of the University Paris-Dauphine; “Externalities or external effects are goods that have an impact on welfare (positive or negative) that is not taken into account by the agent producing them” – I would have that this impact to cost or benefits are often left out in the transaction of buying and selling.

Often in a negative externality scenario, the market is unable to recognize the true cost of the good sold due to the lack of a feedback mechanism. Examples of this abound in environmental concerns – where the cost of the good does not factor in the cost of pollution or socio economic ills incurred to other anonymous stakeholders affected by this transaction.

So I’ve been thinking that the 3 issues mentioned above we see in capitalism have a common theme of a perversion of ownership. Sometimes what matters is not the same as what is valued in our selfish quest for utility and around incentives. In some parts of the world, culture plays a strong role to mitigate this. If there exist a culture of common ownership, then there will be a non monetary motivation to own and manage that which is subject to the perversion of our selfishness, apathy or greed. Another mitigating factor is information – when we truly understand true cost, or have constructs for collective ownership or a collaborative deep motivation to retain ownership despite disappointment, we can mitigate this natural inclination of the perversion of ownership. In any case, these issues inform me that there will always be a need for government and laissez faire capitalism is but a pipe dream.