Tuesday, July 28, 2015

Uncertain Health in an Insecure World – 50

“Digital House Call”

As early as 1925, “diagnosis by radio” was predicted in Science and Invention magazine. I recall watching the 1959 television series, The Flying Doctor, inspired by the Royal Flying Doctor Service of Australia. Dr. Greg Graham (played by Richard Denning) flew into the remote outback, serving the medical needs of inhabitants and Aboriginal peoples.

Given the option, most patients would rather be seen face-to-face by their physician. But population growth in the developing world and chronic physician shortages in developed countries mean there are tens of millions who simply cannot see a doctor in the flesh. 

That is uncertain health. That is an insecure world.  

The telehealth era began at the Medical College of Georgia in 1993. As the immediate past dean, I am proud that the electronic house call was invented there by Dr. Jay Sanders. The U.S. Institute of Medicine released a definition and made recommendations in 1996. It has since evolved into the standard of care for healthcare access by millions. Governments around the world are actively pursuing efforts to get people onto the telehealth grid (like Inuits, below).

Telehealth (a.k.a. telemedicine, e-health or e-medicine) is the all-inclusive term for virtual care delivery at a distance.  Communications take place between physician and patient or between physician and consultant, either in real-time or asynchronously using “anytime” store & forward capabilities. Only real-time care meets U.S. Medicare’s narrow definition of reimbursable telehealth services.

At the just completed 2015 Global Telehealth Conference in Toronto, the theme was “serving the underserved”. Scientific papers from >25 countries showed that telehealth technology is continuing to make a difference in global healthcare. Telehealth is widely utilized for stroke management in a hub & spoke model, with systems like the Mayo Clinic at the center of the wheel. In novel ways, telehealth is now the basis for virtual tumor boards, diabetes population management and retinal scanning (above), and off-site ICU patient monitoring. Ebola patient Dr. Richard Sacra (below), in quarantine in Nebraska and physically separated from family and doctors for bio-containment purposes, was cared for using the Vidyo telehealth platform! 

The global telehealth market will double in the next five years at a robust CAGR of 18.9% through 2019. This sector is receiving intense VC interest and major vendor investments, including big plays by McKesson, GE, Seimans, and Philips Healthcare. IHS Inc. predicts that the U.S. telehealth market will grow by 50% per year to US$1.9B in 2018.

Much of the impetus for such rapid growth comes from U.S. healthcare reform requirements for universal access and pressure to expand population health management. Increasingly, U.S. states are authorizing payments for telehealth services in public programs and for privately insured patients in 24 states and the District of Columbia. More than 50% of U.S. hospitals now use some form of telehealth platform. Deloitte predicted that in 2014, 75 million of the 600 million G.P. visits in the U.S. and Canada would be e-visits. 
One wonders how this well-aging, fixed platform telehealth tortoise will keep pace with the newer, more nimble digital health, AI, IoT and robotic hares. Increasingly, the tools of telehealth are digital and portable – laptop webcams, video-enabled smartphones and tablets.

Several large employers such as Booz & Co., Home Depot and Westinghouse Electric now offer telehealth consultations to their employees. Walgreens Boots Alliance, Inc. is now collaborating with MDLIVE to expand their digital telehealth offerings in pharmacies located states like Colorado and Washington. In 2015, Walgreens Boots and MDLIVE jointly launched a mobile app for iOS and Android devices to connect customers 24/7 with board-certified doctors. Walgreens just announced that this service will be available in 25 states by the end of 2015.

Is there anything that telehealth cannot do?

Dr. Peter Antall, CEO of Online Care Group, warns that telehealth should not “disintermediate care from one’s medical home, particularly their primary care.” In June, the pro-doctor American Medical Association (AMA) tabled its ethical guideline for telehealth services due to delegates’ concerns about AMA guidelines requiring an initial face-to-face patient-doctor visit. Previously, AMA had required that telehealth doctors be licensed in the patient’s state.

There’s little risk of people living near doctors becoming telehealth shut-ins.

Telehealth brings certainty to an insecure world,

We in The Square don’t want doctor disintermediation, especially when the human touch is part of healing. But technology is progress, and by bringing care everywhere, telehealth is the next best thing.

Monday, July 20, 2015

Uncertain Health in an Insecure World – 49

“The Voice”

Like bigotry, stigmatization is a sign of a society that avoids confronting its realities.

Addiction and mental health disorders are chronic illnesses that nobody expects to claim them. Both take an incredible toll on the lives of those affected, and their families. They often co-exist, among patients whose physical addiction and emotional affliction are too entwined to be teased apart – so-called ‘dual diagnosis’ patients.

Half of Finns seeking addiction care report a mental illness. Both can be fatal.

Public policy and healthcare economics complexities in the 60’s and 70’s triggered these deadly epidemics. In that era, many large inpatient psychiatric hospitals were closed, squeezing care into outpatient mode. Pop psychedelic dope culture blossomed like a weed, while tens of thousands of soldiers returned from Southeast Asia with a nasty heroin habit to kick. We’ve touched on some of the pertinent global forces that still propagate these dangerous health and social trends (see posts #8 & #9).

Long overdue change is in the wind!

One big reason for the chronic lack of societal awareness and medical attention to these illnesses has to do with their long-standing stigmatization. The number of people affected has exploded, and such high prevalence has made them unavoidable to the press and public healthcare funders.

As reported by The New York Times’ Katharine Seelye (July 12, 2015), some of the grieving relatives of thousands of people dying from heroin overdoses are talking more openly about the ravages of the disease in obituaries and on social media. She notes that the celebrity obituaries after heroin OD’s of people like Amy Winehouse (July 23, 2011) and Philip Seymour Hoffman (February 2, 2014) usually perseverate on the cause of death.

But the less celebrated die quietly “at home” in an “unexpected” manner. They are often a “Son, Daddy, Brother and Friend”, as well as being an addict. The growing openness about drug fatalities in these families is now joined by law enforcement agencies and policy makers pushing addiction treatment as a public health crisis, instead of a crime or moral failing.

As the U.S. Centers for Disease Control reports, the epidemic is shifting to the old, women (doubling between 2003-2013), and the affluent (up 60% among those making >US$50,000). Some 22 million Americans are now addicted to drugs or alcohol. Heroin-related deaths have quadrupled to >8,200 per year. Change.org and other advocacy groups have forced many U.S. states to adopt naloxone (Narcan™) opioid antagonist kits as lifesaving antidotes in overdoses. 

A good start, but not good enough.

The promise of a better future requires that we put an end to guilt, silence and embarrassment. Only this will save others from the pain and heartache of a heroin death in the family.

Some families that struggle with “this Hell that is Addiction” choose to keep their feelings private. Part of this has to do with the great divide between those that live for years with the weight (i.e., anger, enabling, helplessness), and “people who have NO clue about addiction”. Neither side should judge the other harshly for being outspoken or private in the dealing with a death.

It is highly complex, to say the least.

The Economist (“Out of the Shadows”, April 25, 2015) reports that while the stigma of mental illness is gradually fading, persistent societal prejudices cause many to conceal their diseases and to not seek medical care. We discussed this in the context of the tragic crash of Lufthansa flight 9525 (see post #30).  In all but the most severe cases, mental illnesses can be successfully treated, and those in treatment do not usually pose a threat to their families or co-workers. And when 1 in 5 working age people in developed countries report having a mental illness, it is no surprise that economic impact estimates are 3-4% of annual GDP. 

Given these numbers, any public resistance to real engagement on the issue seems futile, and frankly misguided. 
Talk therapy – openly discussing one’s mental illness – is now becoming acceptable. This could prove cathartic for patients and the broader society. The mental health advocacy group, MIND, has been actively campaigning with the U.K. government and charities to reduce the stigma that perpetuates public ignorance. As a result of this and other initiatives, in 2013 only 13% of Britons felt that a mental illness history should bar a person from public office (down from 21% in 2008).

Half of adults with chronic mental conditions experienced their first symptoms before age 14. The anxiety provoked in teenagers by this condition, fueled by social media pressures and bullying, increases substance abuse and suicide deaths.

Under-treatment of chronic mental illness remains a serious problem. It contributes to the excess suffering and mortality in developed countries, where mental illness outstrips heavily treated chronic conditions like heart disease and stroke. U.K. men with mental illness die 20 years earlier, primarily from non-suicide events.

Who speaks up against all these premature deaths?

Some 200 countries signed on to the 2013 WHO Mental Health Action Plan.

In the 2015 U.S. Presidential Campaign primaries, more questions to the candidates revolve around addiction. In 44 states, the largest mental health facility is a prison.

Last week, Barack Obama became the first U.S. President to visit a federal prison, after he commuted the sentences of 46 drug offenders who were slapped with harsh mandatory minimums. In 2015, 40-70% of prison inmates in E.U. countries have a mental illness.

Society is slowly succeeding at changing systems of care and legal judgment.

Transition to community-based home care by social workers & mental health nurses has been successful in Australia, U.K., Italy and Nordic countries. U.S. mental health courts are making a resurgence, attempting to preemptively divert the mentally ill from prisons to community care.

We in the Square know that putting addicts in jail and mental health sufferers in asylums is ignorance.

When people are ill, not “crazy” and “immoral”, humanity demands that they have a voice. Morality demands that we all listen.

Monday, July 13, 2015

Uncertain Health in an Insecure World – 48

Illigitimi Non Carborundum

When both Nature and the Harvard Business Review run cover stories on artificial intelligence (AI) and robotic smart machines in the same week, those of us who are keenly interested in the future of medicine and the life sciences should pay close attention.

HBR (June 2015) highlighted the burgeoning business opportunities around the man-machine interface in articles titled “Beyond Automation” (to augmentation of human capabilities), “The Great Decoupling” (of digital technologies from the workforce), “The Self-Tuning Enterprise” (through algorithmic reinvention), and “When Your Boss Wears Metal Pants” (on thinking machines).  HBR editor Adi Ignatius opined on the inevitability of large-scale worker displacements, confiding that to fear the rise of the machines was reasonable, but essentially futile.

All that emotionality and creativity stuff… Just human failings in need of reverse engineering?

Nature (May 28, 2015), the international weekly journal of science, explained how an injured robot can get “Back on its Feet” by using intelligent trial & error machine learning algorithms to heal itself and get back on task. In another paper about “Robots That Can Adapt Like Animals”, the authors pointed to the fragility of robots in complex environments, especially when they are unable to right themselves by thinking ‘out of the box’. Of course, there’s an injury repair algorithm for fixing robot arm “joints broken in 14 different ways”.  Adaptation to such damage mimics a three-legged dog compensating by avoid painful or ineffective post-amputation behaviors. Balancing these unbridled technological advances, four top researchers shared their ethical concerns on societal risks from humans remotely controlling lethal autonomous weapon systems (LAWS, like drone bombers) and AI-informed robotic units operating on their own recognizance.

In the absence of NASA Mission Control… Just who is in charge of the mission?

While driving in to work, I tuned to the usually erudite albeit all-in National Public Radio show Tech Nation. Pediatric oncologist Dr. Daniel Kraft of Singularity University was breathlessly describing the endless ways that wearables (and yes insideables) will soon change medicine, once and forever. Dr. Kraft is a true believer in the quantified self and the flow of little data (“… digital exhaust coming off ourselves”) driving what he’s dubbed exponential medicine. He used a lot of jargon to explain the potential advantages of leveraging such digital health data to inform clinical trials (“… 90% of adults are not on a clinical trial”), predict-olitics (read analytics), telemedicine (for home otitis media checks), intelligent augmentation (not AI), and X-Prize tricoder devices in the “digital doctor’s bag”.

Such unbridled enthusiasm makes one think… Not just about what’s real, but what isn’t.

Dr. Kraft’s description of a pocket-sized digital ICU sounded scarily powerful, implicating an impending tectonic shift from traditional medicine to a new digital era of critical care.  When the “patient can touch their own data…” and connect it through “feedback loops to their families” and personal caregivers, offshore Nighthawk imaging and second opinion Skype consult services will be rendered obsolete.

I will never think about my pocket contents the same way again!

Silicon (Si) is one of the most common elements in Earth, abundant in sand. Once refined, pure silicon is the seed for ingots cut into wafers that become semiconductor chips. Silicon carbide, or carborundum, is a very hard substance used in granular form since 1893 to grind machinery.

One base element in two different chemical states, with two very different utilities.

Identical information can also be delivered in very different ways, with varied degrees of validity. 

My advice for interested listeners is “Illigitimi Non Carborundum”… Don’t let the bastards grind you down.

The deliberate development, careful field testing and steady adoption of new technologies is the necessary drudgery of global scientific progress.

The facts found in the top peer-reviewed literature and in the hyperbole of trade fair gurus is part of a healthy dialog towards such progress.

But they are not one and the same.

We in the Square remain wary of overt proselytism, especially when the message is delivered by those with the most to gain in the near term.