Friday, October 10, 2014

Why solving healthcare problems is so hard

In my mHealth discussions I often meet budding entrepreneurs who are frustrated that finding solutions to healthcare problems just isn't as easy as it is out in the broader tech world.  They're right.

The reasons for this are many.  I won't get into the complicated reimbursement models or ACOs or proper alignment of incentives.  For the purpose of this discussion I'll focus on just one thing - arguably the most important - the human body.

Leonardo da Vinci's famous Vitrivian Man.  Studying the outside is the easy part ... (no disrespect to da Vinci, of course)

But first, let's discuss physics.  The laws of Newtonian physics (i.e., classical mechanics) have been well understood for hundreds of years.  The understanding and application of Newton's three, simple laws eventually gave rise to the industrial revolution, and, by extension, modern society as we know it.  In just a blink of cosmic time, humanity progressed from horse-drawn carriages to landing a man on the moon, 238,900 miles away.

Even more impressive is that we have successfully sent something the size of a small dog from our dear planet Earth to another planet hundreds of millions of miles away, causing it to land (without damage!) in a very specific location on that planet.  Of course I'm talking about the Mars Pathfinder mission and Sojourner rover (and other successful missions to Mars).  For a little perspective, this would be very roughly equivalent to hitting a golf ball from earth and getting a hole-in-one on the moon.  On the first try.  And don't forget that the moon is moving, so by the time the ball arrives, the moon will be in a totally different place than when it left the end of your club.*

This is a picture taken from another planet (let that sink in).

So if we understand the basic laws governing our universe so well that we can accomplish incredible feats such as this, why is it so hard in healthcare?

To put it simply, because each living organism might as well be its own universe with its own laws.

The human body is an incredible, complex universe, governed by laws that we still know relatively little about.  Yet unlike classical mechanics, once we learn a new law or association about the human body, it's not guaranteed to hold true for each unique organism.  That's because we're all different owing to our personalized genetic makeup, something we're just beginning to understand.  Although DNA was discovered in 1869 and its double-helix structure identified in 1953, the function of each gene in our intricate genomes is still largely a mystery.

And then, even if we knew the function of each gene, it wouldn't necessarily explain the complex interplay of proteins and carbohydrates and receptors and positive/negative feedback loops ... the list goes on.  There could never be a set of simple laws to govern these unbelievably elaborate interactions.  Despite numerous advances and tremendous knowledge, we still can't eliminate pain without side effects, completely eradicate cancer, or even cure the common cold.

Wanna know a secret?

For those of you outside the field of medicine, this is why we're always speaking in the language of statistics and probability - why we say things like "maybe" and "likely" or "unlikely."  Because we can't precisely define an outcome based on predefined laws (i.e., no Mars landings here ...), we must observe the outcome in lots of human beings so that we can then make an educated guess about what will happen to you.

That's right!  That's our big secret!  As physicians, we're just guessing most of the time when it comes to how we treat you!

Now before you get too excited (or worried), sometimes those are really, really good guesses ... like, we're 99.99% sure.  For example, we know vaccines save lives (and don't cause Autism).

But it's that last 0.01%, or 0.1%, or sometimes 20%, where there remain lingering doubts and inconsistencies.  This is why healthcare innovation is hard, and will ever remain so.

BUT, this is also why it's essential that we take advantage of the latest technology advances - including mobile technology - to solve these problems.  Despite the inherent difficulties in healthcare innovation, the promise has never been greater, and the tools have never been more accessible.  Let's go heal the world together!

*And even this pales in comparison with the Rosetta mission currently underway by the European Space Agency, where they are in the final stages of landing a craft on a comet (named Churyumov-Gerasimenko) just several kilometers long, a process that involved the spacecraft orbiting the sun several times, slingshotting itself around the Earth thrice and Mars once in order to take advantage of those planets' gravity to attain the proper speed and trajectory.  I'm not kidding.  I didn't mention this one because the landing hasn't happened, yet.  That will take place on November 12th, 2014.

Friday, October 3, 2014

Why Facebook will (mostly) fail at healthcare

Simply reading the title of the Reuters article this morning gave me chills: "Facebook plots first steps into healthcare"

Perhaps the authors just shouldn't have used the word 'plot' like it's some sort of underhanded scheme.

Let me just get this out of the way:
Any company who profits off the aggregation of user data has an inherent conflict of interest when it comes to the security of those same users' healthcare information.
I've previously discussed Apple's HealthKit and how it has been positioned as a data broker of sorts.  The data never leaves the device, and thus is inaccessible to Apple for data mining, analytics, etc.  The data belongs to the user, and the user has complete control of it at all times.

This is easy for Apple to do, because Apple is a consumer electronics company first and foremost.  They almost exclusively earn revenue by selling hardware, and provide software simply to allow users to get the most out of the hardware they've purchased.  Apple used to make more money through sale of software, but over the past 7 years, the cost to upgrade Mac OS X has dropped from $129 in 2007 to free in 2013.  Apple's office suite was reduced to free last year.  Upgrades to iOS have always been free.*

Tim Cook said it best last month in an open letter discussing Apple's commitment to privacy:
A few years ago, users of Internet services began to realize that when an online service is free, you're not the customer.  You're the product.
Apple has no interest in monetizing your data - you've already paid them for the products you use.  When was the last time any of you remember handing over your credit card to Facebook?  Anyone?

That said, I'd be remiss if I didn't acknowledge that any innovation in healthcare is a good thing, and if Facebook can bring novel ideas to this space given their unique perspective, I'm all for it.  Facebook is useful for connecting groups with similar interests, and patient support groups have thrived there.  That's a great thing, especially for chronic or rare diseases.  If patients are informed and comfortable sharing their own data with Facebook, we absolutely shouldn't stop them.  It's their data.

Also, applying machine learning to Big Data has become somewhat of a holy grail for healthcare (as evidenced by Google's Baseline Study).  If Facebook has something to contribute here, and is willing to follow applicable IRB protocols and HIPPA guidelines (which wouldn't involve any data obtained via the Facebook site itself), perhaps we could learn something.  However, if Facebook decides to create a solution whereby they mediate data sharing between patients and providers via, I anticipate failure.

Of course, this same argument could be made with Google, and perhaps realizing this, the initial version of Google Fit is far more limited than HealthKit, focusing primarily on fitness and nutrition rather than clinical care.  That will be something to watch carefully.

For Facebook to find success in real healthcare scenarios involving direct patient care, they need to do much more to earn the trust of the medical community.  Right now, they haven't done that, and I don't see that changing any time soon.

Facebook, prove me wrong.

*Technically, Apple charged early iPod touch users $9.95 for OS upgrades due to some internal "bookkeeping" rules, but that didn't last long.