EP Perspectives

Digital Health: The Revolution That Will Change Everything

The Skirball Center for Innovation (SCI) at the Cardiovascular Research Foundation (CRF) Interventional Innovation Corner is headed by section editor Juan F. Granada, MD, Executive Director and Chief Innovation Officer; Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York.

The Skirball Center for Innovation (SCI) at the Cardiovascular Research Foundation (CRF) Interventional Innovation Corner is headed by section editor Juan F. Granada, MD, Executive Director and Chief Innovation Officer; Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York.

This month, interventional cardiologist Peter J. Fitzgerald, MD, PhD, Professor, Medicine - Cardiovascular Medicine; Professor (by courtesy), Electrical Engineering; Director, Center for Cardiovascular Technology and Innovation and Director, Core Cardiovascular Analysis Laboratory (CCAL), Stanford University Medical School, Stanford, California, talks about big data, digital tech, and its impact on healthcare.

Introduction

Juan F. Granada, MD 

As with other modern industries, the introduction of digital-based technologies within the medical field is rapidly occurring. Over the last decade, we have observed the natural confluence of digital technologies and healthcare, and this trend will only continue to expand over time. The most exciting aspect of this new technological revolution is how patients are becoming empowered to take control over their own healthcare, and these patient-healthcare interfaces will continue to improve and disrupt the system in the near future. Despite its undeniable potential for disruption, the broad clinical adoption of digital healthcare solutions will face significant technological, reimbursement, and regulatory challenges. We are honored to talk with a leader in the field, Peter J. Fitzgerald, MD, PhD, Professor, Medicine - Cardiovascular Medicine; Professor (by courtesy), Electrical Engineering; Director, Center for Cardiovascular Technology and Innovation and Director, Core Cardiovascular Analysis Laboratory (CCAL), Stanford University Medical School, Stanford, California. 

What is the digital revolution?

Right now, “digital revolution” is a buzzword and it doesn’t mean a lot, to be honest with you. I am seeing it both on the academic and industry side, and for certain on the venture side. I probably see 10-15 of these companies a week and most are smoke. 

The notion of digital integration into health care has a pretty low bar associated with it. If you have a cell phone and can spell the word “health”, you’re in. As a result, there is quite a bit of clutter. There are all these different things we can do with these devices we can hold in our hand or look at in our lap. Yet the phenomenal ability to provide and obtain information, as well as serve patients and health care systems with that information, is enormous. In the next few years, the “revolution” will subside, the smoke will clear, and all of a sudden, we will see some real, impactful issues arise, from accurate triage of patients as outpatients to decision support systems for inpatients, to cybersecurity that protects those in/out of healthcare facilities.

You have talked about the notion of “disruptive forces”. What do you mean by that?

Conduits for information are now at everyone’s fingertips. Our kids are able to move through information with their own filter in an amazing way, and they adapt at a very young age. People in my generation didn’t grow up with haptics and gaming, and the ability to move information so quickly. The ability to potentially harness technology from enterprises or the consumer industry, and apply maturing and matured technologies into healthcare, is where the curves cross. Younger people are becoming more engaged in their healthcare, and come to it with the ability to receive and move information. This includes the ability of young doctors to embrace things like haptics in robotics. Some of the gaming industries have transformed how we deal with robotics and tactile movements in healthcare, all the way from imaging to intervention.

There is a lot of IT money pouring into healthcare. 

Yes. Consider AR and VR (augmented reality and virtual reality). The front page of the Lifestyle section of The New York Times a few months ago featured a group of people sitting in an old 1960’s theater wearing virtual reality goggles. The entertainment business has always driven applications that can be utilized in healthcare. The software and hardware behind virtual reality can be applied to robotics and fine surgical techniques, and the analytics are harnessed because we can capture what doctors and patients are interacting with. Using virtual reality software is going to be amazing. That’s where the revolution is, but the problem is that ultimately it has to be a business. It has to be a business in order to take it from these fancy words that I am using into something that scales and truly integrates into this very confusing and fragmented healthcare system in which we live in the United States. But that fragmented space is where the opportunities lie, and that’s where we are going to be able to provide better care, at much more efficient healthcare costs. That’s what I get excited about.

You’ve talked about the “Uberization” of healthcare. What does that mean?

I grew up through my career working very closely with Johnson & Johnson, Boston Scientific, and Medtronic, and I still do today. These kinds of companies provided the cornerstones of what we have enjoyed in our field. They bring in new ways to service patients through their healthcare and life science technologies, from drugs to devices. What’s changing today is that we are now working with companies like Google, Apple, Microsoft, and Qualcomm, along with CVS, Rite Aid, Walgreens, and Wal-Mart. These are the lifestyle nodes everyone deals with. Only a fraction of the population deals with hospitals, the big nodes. But when you need the big nodes, you have no idea where you are going. I’m sure you have seen or dealt with a common ear infection in a kid. It sucks up your whole day. It shouldn’t suck up your whole day. It should suck up an hour. How does it only take an hour? While you are at Walgreens picking up milk and diapers, you go into a kiosk and your child is examined. There may be a little fingerprick blood test and antibiotics are given to you, or ultimately, delivered to you. But the care you need is at your corner. It is not quite “Uberized” so it doesn’t come directly to you, but it comes much closer. We are going to see the decentralization of hospitals. Clinics will be outsourced and places like CVS, Walgreens, Rite Aid, and Wal-Mart will provide care in three categories: preventative care, urgent care, and chronic care. These types of care are also what cause the turbulence and incredible inefficiency in hospitals today. Hospitals are going to return to ICUs. You have a bone problem? You’ll get it fixed. You have a blood problem? You’ll get your myeloma or your AML treated. You have a brain problem? You’ll have surgery. That is all going to happen in the hospitals. All the other things will be Uberized — or, at the very least, coming closer to patients at their local street corner. 

What do you think about technologies that offer remote monitoring of hemodynamics for heart failure patients? Studies have shown increased quality of life, but no decrease in readmissions.

Part of the problem is that the people involved with this technology aren’t used to doing the scientific studies that we expect in clinical cardiology. I have seen studies saying readmissions decrease just by having a nurse on call and a wireless digital scale, as well as studies showing that the mobile apps that help you take your medicine, or apps associated with a patch that help monitor your blood pressure and/or heart rate, respiratory rate, and PO2, don’t decrease rehospitalization. There is a smattering of data, but most of it has not been collected through true scientific studies. Interestingly, not too long ago, we were bruised on our clinical trial expectations regarding the ability of renal denervation to treat high blood pressure. We thought that we could put a catheter in the renal artery, inactivate some of the plexis of nerves that surround the renal artery, and lo and behold, lower blood pressure. We saw patients enrolled in a single-arm trial lower their blood pressure and be sustaining. What we didn’t realize is that there is a significant behavioral change when you are in a trial. You take your medications when someone is calling you and when you have to go to clinic. As a result, we saw that, at least for blood pressure, the sham arm did just as well as the treated arm. It is exactly that behavior that we can harness with these information conduits that rest in your hand and/or lap. Now, a 75-year-old with heart failure is going to have trouble because they don’t have a Galaxy 7. However, an increasing percentage of people buying iPads today are folks over 60. You’re going to see digital integration even into that group. I don’t want to drift too far from cardiology, but take HIV, for example. It is a curable disease today, so you would expect the compliance for HIV medications to be at 90%. Surprisingly, it is closer to 50%. For the 25- to 45-year-olds, social media and peer-to-peer communication are all going to make a big impact on how people take their medication, and thus complications of HIV therapy as well as the bogging down of ERs is going to decrease. We may not be able to show in a randomized study that mobile health apps (and there are so many of them) can decrease readmission for heart failure. The main reason is because we are going to encounter the “fog of IT” that is going to decrease readmissions by itself. Whether you can prove a specific app or app along with a monitoring patch decreases readmissions is academic. Over the next 10 years, we will see that readmission has significantly decreased and it has been done because of the huge amount of IT working in the middle, from education all the way to device instrumentation. Simply implementing activity tracers to get people motivated after they have had knee surgery, or abdominal or heart surgery, helps get them on a regimen. We can track that regimen with watches and monitoring patches. Several studies are showing that over the next 6 months, these patients take less medication, go to the clinic less often, and are more compliant with their medications. There will be a resulting impact on decrease in hospitalization, ranging from surgical knee issues to getting a stent placed, or post myocardial infarction or heart failure care. It will happen, but it may not be able to be proven, because the sham arm in the trials will be changed by the same behavioral properties.

We have the IT infrastructure: the tablets, the smart phones, the ability to create software. It’s the human interaction with them that we need to learn about.

Every time someone has a device in their hand that is interacting with them, from a behavioral perspective or from a metric healthcare perspective, it has an impact. In physics, they call it the Heisenberg uncertainty principle. The minute you interact with the environment you are trying to study, you have already biased it. The minute we have interacted with a behavior, we have already changed it. Ten years from now, we will see epidemiological studies showing a decrease of, let’s say, 60% of readmissions for heart failure. Everyone will say, “Why? What was it? Which thing was it?” And the answer will be that the decrease resulted from the ensemble of many things that happened. Right now, we are collecting data. Even this conversation and certainly, every time you log on to a device. There is a famous big company out there that I won’t name, looking at billions of pictures per week. They can see if you are a male or a female, they can estimate your age plus or minus 5, and if you interact with this particular application many people interact with daily, they can tell your IQ plus or minus 10%. This company can then sell that information, which is great for retailers. We are going to see the same exact thing with data being analytic and predictive for health care. It will not alienate the decisions of the doctor, but will provide them with a decision support system to increase accuracy in their diagnosis and in the therapies they suggest to patients. The 30-year-old doctor will have as much information at their fingertips as the more experienced 50-year-old. Let’s say you have cancer. You panic, and of course, you want to go to the best. What you are trying to obtain by going to the big academic centers are 58-, 59- and 60-year-old physicians that have seen a great deal in cancer care. Today, with data that is being analyzed by the second in healthcare, the 30-year-old physician will be able to access the same decision support augmented opportunity as an older and more experienced doctor. It will make healthcare better and improve patient access. These are the issues that will ultimately save money. Big data are going to be very helpful. I always get the question, “Then why do you need doctors anymore?” Big data will not replace doctors. You need doctors. They have to complete the loop. But it is going to help them be much more efficient.

What will happen to the data that surrounds the individual patient? Will they own it?

It is going to be a problem. Let me make a point about individual data and young people. Today, a 50-year-old woman might have to wait 5 days for a mammogram to be read. Young people now don’t wait 10 seconds for their Fandango movie tickets to download along with directions to the theater. So they are not going to be willing to wait that long for a response or test result. This need for instant information will part of the revolution, because people aren’t going to care whether the FDA has approved something or not. Today’s young people will say, “I’m going to broker my own care. I have the capability to do it in my own hand.” Revolutions come in different forms, but one of the biggest revolutions is the patient revolution. If I had to recommend a career to an 18-year-old today, I would tell them to go into data science and become a computer scientist, because the encryption that we are going to need in healthcare is going to be at a level even higher than we can imagine now. We need to understand that this information has to be privatized and not utilized for other means, although patients will give up some of their information for efficiency. It is just like what people do on social media; they give up vulnerability for efficiency, and they are used to doing it. The 25-year-old knows, at least partly, how to balance between exposure and efficiency. As a 50-year-old, I don’t even understand it. I just stay away from it. But it is going to change as part of the revolution we talked about in the beginning. Who is going to own that information? Patients will ultimately have control of their data, and they will utilize it, meaning trade it off, depending on what they are going to be able to get. Data transference is a significant issue. Electronic medical records (EMRs) are part of the problem, because EMRs don’t talk to each other. They are like digital toilet seats. They work in one household but they don’t amortize to the next household. There will be information co-owning with the big health care centers that have a great deal of data. People are also developing predictive algorithms that work with certain consolidated healthcare systems like Sigma and Intermountain, and they will share information. You already see it happening today. Data are going to generate a series of innovations for security, but we will also let patients have the responsibility of whether they want to share it or not. Just like you do when you are a consumer. Consider Amazon. It’s so quick. I can get my shampoo. But you don’t know how much information you’ve just shared. People are growing up with that right now and it will be the same in healthcare.

What are we seeing regarding the globalization of ability? How are different countries going to influence healthcare?

That is another component of this revolution. Digital technology allows us to communicate in aggregate with different cultures and countries. Let’s say someone is diagnosed with head and neck cancer. Even though it is the same histologically in Mumbai as compared to another guy the same age with head and neck cancer in San Francisco, there is tremendous variance on the impact of that head and neck cancer depending upon ethnicity, environment and social interactions. Everyone thinks cancer is a single, homogeneous collection of cells, but it isn’t. It changes constantly. One tumor can be different depending on where you biopsy it. All of a sudden, with technology we have the ability to gain an aggregate of information in Mumbai for those particular 50-year-olds that have head and neck cancer. We will be able to test what medications may be best for that person in Mumbai and it may not be the same as for the person that lives in California. Aggregating data globally is going to be very important. Our taking advantage of specialties in research worldwide is already happening. For example, Israel has some of the most phenomenal technology that the world has ever seen for many different cultural and situational issues. Cyber security is one example. Gaming technology in Israel is top in the world. We are going to see some of that leverage itself out to healthcare. The handicap in Israel is that while they have phenomenal technology, they don’t have a clear understanding of how it integrates into the largest healthcare system, the United States, because of fragmentation. What does that call for? It calls for old guys like me to go to Israel and help, and only because I have made a lot of mistakes in how you take a concept or technology, and bring it into the clinic. It involves an effort to get other experienced people like payors, regulatory folks, and clinical trialists, to be involved in maturing that technology, and ultimately bring some of it to the United States. I could list 20 things originating from Israel that would blow you away that were crucial to the rise of big U.S. companies. One is voice over IP, which we use all the time when we talk on the phone. The way you auto-park your Cadillac is done with Israeli technology. Some of the ways we maneuver on Google come from Israel. Technologies birthed in other countries can ultimately be realized and brought into other applications for healthcare. That’s what I see as a big advantage and that’s why I go to Israel once a month, because I learn a lot and potentially can help a bit in bringing those concepts to the clinic.

What is the value of interdisciplinary approaches to problems in healthcare and IT? 

I am an Irish Catholic that deeply appreciates how other ethnicities, geographies, and age groups can bring new ideas to how we can help healthcare. One of the most monumental efforts in innovation for life science is at Stanford, under the Biodesign program founded by my mentor, Dr. Paul Yock. This program brings eclectic groups to the same table to look at a common problem. When you have multiple views, ages, ethnicities, all those sort of qualifiers, interesting things happen. We call it the quick moment. You can’t plan it, you can’t teach it, but if you get different people in a room looking at the same problem, it is amazing to see the spectrum and blossoming of ideas. Information technology has allowed for the sharing of common problems to many different people. We are seeing one of the most exciting times in healthcare because of IT and mobile technology. There are many, many different fronts with respect to innovation and integration into healthcare. Sometimes that integration into healthcare is not just the United States. Solving diabetes in Indiana is good, but maybe solving it in remote areas in India is more impactful. We can consider not only the problems, but the regions that have variability associated with them. The smarter the people in the room, the more they come from different backgrounds and hold different understandings of technologies, the more things happen. When IT hits medical and life science technologies, you see many fascinating things. Healthcare is changing at an exponential rate, and it is fun to be an old guy involved in that.

Any final thoughts?

It is an exciting time. One of the biggest issues I see is that people from healthcare or people from IT think they know, within each of their squares, what they are doing. I would issue a call to action that leaders work to get smarter and more experienced people around the table. Always hire up, because it is complex. To make something simple and work well in healthcare is really difficult to do. Like a baseball game, you have to change some elements: change the pitcher, change batting order, and as you take a concept into the clinic, you have to do the same thing. You need to be humble and bring smarter people around the table to make the biggest impact as these two eclectic forces — information technology and medical technology — are colliding.

Disclosure: Dr. Fitzgerald reports relationships with Johnson & Johnson, Samsung, Boston Scientific, Abbott, Medtronic, St Jude Medical, Merrilife, Corindus, Nikon, and Cardinal Health.

Dr. Juan Granada can be contacted at jgranada@crf.org. 

Dr. Peter J. Fitzgerald can be contacted at pfitz@stanford.edu

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