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19 August 2013

Longevity and the looming financial meltdown

Filed under: aging, books, challenge, converged medicine, Economics, futurist, healthcare, rejuveneering, SENS — David Wood @ 2:12 pm

What kind of transformational infrastructure investment projects should governments prioritise?

In the UK, government seems committed to spending a whopping £42 billion between now and 2032 on a lengthy infrastructure project, namely the “HS2” High Speed rail link which could see trains travelling between London, Birmingham, and six other cities, at up to 250 miles per hour. The scheme has many critics. As Nigel Morris notes in The Independent,

In an analysis published today (Monday), the IEA (Institute for Economic Affairs ) says the scheme’s cost has been vastly underestimated and had failed to take into account changes to routes and extra tunnelling because of local opposition.

Richard Wellings, its author, said: “The evidence is now overwhelming that this will be unbelievably costly to the taxpayer while delivering incredibly poor value for money.”

Supporters of this investment claim that the improved infrastructure will be a boon for business in the UK. Multi-year infrastructure improvement projects are something that the private sector tends not to attempt. Unless there’s coordination from government, this kind of project will not happen.

The BBC news website (here and here) helpfully listed ten alternative infrastructure improvement projects that might be better recipients of portions of the £42B earmarked for HS2. Suggestions include:

  • A new road motorway for the east of Britain
  • A bridge to the Isle of Wight
  • A new Channel tunnel, directly accessible to car drivers
  • Tram systems for Liverpool and Leeds
  • A tunnel between Great Britain and Ireland
  • Aerial cycle highways for London

If it were my decision, I would reallocate a large chunk of this funding to a different kind of multi-year infrastructure improvement project. This is in the area of health rather than the area of transport. The idea is to significantly promote research and deployment of treatments in preventive and regenerative medicine.

Ageless CoverThe argument for this kind of sustained investment is laid out in the book The Ageless Generation: How Advances in Biomedicine Will Transform the Global Economy, by Alex Zhavoronkov, which I’ve just finished reading. It’s a compelling analysis.

Alex will be sharing his views at a forthcoming meeting of the London Futurists, on Saturday 31st July. There are more details of this meeting here. (Note that a number of copies of the speaker’s book will be available free of charge to attendees of this meeting.)

The book contains many eye-opening pointers to peer-reviewed research. This covers the accelerating pace of medical breakthroughs, in areas such as bioartificial organs, stem cell therapies, repairing damaged tissues, fortifying the immune system, and autophagy. The research also covers financial and economic matters.

For example, here’s a snippet from the 2009 report “The Burden of Chronic Disease” (PDF) – which is written from a US point of view, though the implications apply for other countries too:

Our current economic reality reminds us that now more than ever, we need to invest in the backbone of our economy: the American workforce. Without question, the single biggest force threatening U.S. workforce productivity, as well as health care affordability and quality of life, is the rise in chronic conditions…

Further into that report, data is quoted from the Milken Institute report “The Economic Burden of Chronic Disease” (PDF)

By our calculations, the most common chronic diseases are costing the economy more than $1 trillion annually—and that figure threatens to reach $6 trillion by the middle of the century.

The costs include lost of productivity, as well as absenteeism:

The potential savings on treatment represents just the tip of the proverbial iceberg. Chronically ill workers take sick days, reducing the supply of labor—and, in the process, the GDP. When they do show up for work to avoid losing wages, they perform far below par—a circumstance known as “presenteeism,” in contrast to absenteeism. Output loss (indirect impacts) due to presenteeism (lower productivity) is immense—several times greater than losses associated with absenteeism. Last (but hardly a footnote), avoidable illness diverts the productive capacity of caregivers, adding to the reduction in labor supply for other uses. Combined, the indirect impacts of these diseases totaled just over $1 trillion in 2003…

In his book, Alex builds on this analysis, focussing on the looming costs to healthcare systems and pensions systems of ever greater portions of our population being elderly and infirm, and becoming increasingly vulnerable to chronic illnesses. Countries face bankruptcy on account of the increased costs. At the very least, we must expect radical changes in the provision of social welfare. The pensionable age is likely to rocket upwards. Families are likely to discover that the provisions they have made for their old age and retirement are woefully inadequate.

The situation is bleak, but solutions are at hand, through a wave of biomedical innovation which could make our recent wave of IT innovation look paltry in comparison. However, despite their promise, these biomedical solutions are arriving too slowly. The healthcare and pharmaceutical industries are bringing us some progress, but they are constrained by their own existing dynamics.

Alex_cover_2_smallAs Alex writes,

The revolution in information technology has irreversibly changed our lives over the past two decades. However, advances in biomedicine stand poised to eclipse the social and economic effects of IT in the near future.

Biomedical innovations typically reach the mass market in much slower fashion than those from information technology. They follow a paradigm where neither demand, in the form of the consumer, nor supply, in the form of the innovator, can significantly accelerate the process. Nevertheless, many of the advances made over the past three decades are already propagating into mainstream clinical practice and converging with other technologies extending our life spans.

However, in the near-term, unless the governments of the debt-laden developed countries make proactive policy changes, there is a possibility of lengthy economic decline and even collapse.

Biomedical advances are not all the same. The current paradigm in biomedical research, clinical regulation and healthcare has created a spur of costly procedures that provide marginal increases late in life extending the “last mile”, with the vast percentage of the lifetime healthcare costs being spent in the last few years of patient’s life, increasing the burden on the economy and society.

There is an urgent need to proactively adjust healthcare, social security, research and regulatory policies:

  • To ameliorate the negative near-term effects
  • To accelerate the mass adoption of technologies contributing positively to the economy.

Now that’s a project well worth spending billions on. It’s a vision of expanded healthspans rather than just of expanded lifespans. It’s a vision of people continuing to be happily productive members of society well into their 80s and 90s and beyond, learning new skills, continuing to expand their horizons, whilst sharing their wisdom and experience with younger generations.

It’s a great vision for the individuals involved (and their families), but also a great vision for the well-being of society as a whole. However, without concerted action, it’s unlikely to become reality.

Footnote 1: To connect the end of this line of reasoning back to its start: If the whole workforce remains healthy, in body, mind, and spirit, for many years more than before, there will be plenty of extra resources and skills available to address problems in other fields, such as inadequate traffic vehicle infrastructure. My own preferred approach to that particular problem is improved teleconferencing, virtual presence, avatar representation, and other solutions based on transporting bits rather than transporting atoms, though there’s surely scope for improved physical transport too. Driverless vehicles have a lot of promise.

Footnote 2: The Lifestar Institute produced a well-paced 5 minute video, “Can we afford not to try?” covering many of the topics I’ve mentioned above. View it at the Lifestar Institute site, or, for convenience, embedded below.

Footnote 3: The Lifestar Institute video was shown publicly for the first time at the SENS4 conference in Cambridge in September 2009. I was in the audience that day and vividly remember the impact the video made on me. The SENS Foundation is running the next in their series of biennial conferences (“SENS 6”) this September, from the 3rd to the 7th. The theme is “Reimagine aging”. I’m greatly looking forward to it!

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25 March 2012

Smartphone technology, super-convergence, and the great inflection of medicine

Filed under: books, Connected Health, converged medicine, healthcare, Internet of Things, medicine — David Wood @ 10:07 pm

You are positioned to reboot the future of medicine…”

That’s the rallying cry that rings out from Eric Topol’s marvellous recent book “The Creative Destruction of Medicine”.  The word “Destruction” is meant in the sense elaborated by Austrian-Hungarian economist Joseph Schumpeter.  To quote from Investopedia:

Creative destruction occurs when something new kills something older. A great example of this is personal computers. The industry, led by Microsoft and Intel, destroyed many mainframe computer companies, but in doing so, entrepreneurs created one of the most important inventions of the century.

Topol believes that a similar transformation is underway in medicine.  His book describes at some length what he calls a “super-convergence” of different technological transformations:

  • Genomics, which increasingly indicates connections between individuals’ DNA sequences and their physiological responses to specific drugs and environmental conditions
  • Numerous small sensors – wearable (within clothing) or embeddable (within the body) – that can continuously gather key physiological data, such as blood glucose level, heart rhythm, and blood pressure, and transmit that data wirelessly
  • Improvements to imaging and scanning, that provide clearer information as to what is happening throughout the body (including the brain)
  • Enormous computing power that can manipulate vast amounts of data and spot patterns in it
  • Near ubiquitous smartphones, which can aggregate data from sensors, host all kinds of applications related to health and wellness, and provide early warnings on the need for closer attention
  • 3D manufacturing and synthetic biology, that can create compounds of growing use in medical investigation and bodily repair
  • The adoption of electronic medical records, that allow healthcare professionals to be much more aware of medical history of their patients, reducing the number of problems arising from unexpected interactions between different treatments
  • The emergence of next generation social networks binding together patients with shared interest in particular diseases, allowing crowd-sourcing of new insight about medical conditions
  • Enhanced communications facilities, that enable medical professionals to provide advice and even conduct operations from far-distant locations
  • Improved, free medical training facilities, such as the short videos provided by the Khan Academy.

Topol has an impressive track record as a leading medical practitioner, and gives every sign that he knows what he is talking about.  Importantly, he maintains a critical, skeptical perspective.  He gives plenty of examples of where technology has gone wrong in medicine, as well as when it has done well.  His observation of the application of accelerating technology to medicine is far from a utopia.  There are two sorts of problematic factors: technology factors (including the complexity of the underlying science), and non-technology factors.

First, the technology factors.  The ways that individuals react to different medical treatment vary considerably: a drug that saves one life can have terrible side effects in other patients.  What’s more, diseases that were formerly conceived as single entities now appear to be multiple in nature.  However, the move from “population medicine” to “individual medicine”, enabled by advances in genomics and by powerful data analysis, offers a great deal of hope.  For one example of note, see the Wall Street Journal article, “Major Shift in War on Cancer: Drug Studies Focus on Genes of Individual Patients“.  The core principle is that of ever improving digital analysis of data describing individual people – something that Topol calls “digital high definition of humans” leading to “hyperpersonalisation of healthcare… fulfilling the dream of true prevention of diseases”.

But the non-technology factors are just as significant.  Instead of the complexity of the underlying science, this refers to the structure of the medical industry.  Topol has harsh words here, describing the medical establishment as “ultra-conservative”, “ossified”, and “sclerotic” – existing in a “cocoon” which has tended to isolate it from the advances in information technology that have transformed so many other industries.  Topol calls for “an end of the medical priesthood… the end of an era of ‘doctor knows best'”.  Associations of medical professionals who seek to block patients from seeing their own medical data (e.g. a detailed analysis of their personal DNA) are akin, Topol says, to the medieval priests who fought against the introduction of printing and who tried to prevent church congregations from reading the bible in their own hands.

Given such criticisms, it’s perhaps surprising to read the wide range of positive endorsements at the start of the book, from eminent leaders of the medical industry.  This includes:

  • The global president of R&D for Sanofi
  • The professor of genetics from Harvard Business School
  • The chairman and CEO of Medtronic
  • The professor and vice-chair of surgery from NY Presbyterian/Columbia University
  • The chief medical officer from Philips Healthcare
  • The executive vice president and chief of medical affairs from United Health Group
  • The president of the Salk Institute for Biological Studies

and many others.  And for a growing list of reviews of the book, including from many people deeply embedded in the medical industry, see this compendium on the 33 Charts blog.  What’s happening here is that Topol is drawing attention to structural issues inside the medical profession, which many other people recognise too.  This includes risk aversion, long training cycles that place little emphasis on information technology, funding models that emphasise treatment rather than prevention, tests that are unnecessary and dangerous, and lengthy regulatory processes.

If the problem is structural, within the medical industry, the fix is within the hands of patients.  As per the quote I started with,

You are positioned to reboot the future of medicine…”

Here’s the longer version of that quote:

With the personal montage of your DNA, your cell phone, your social network – aggregated with your lifelong health information and physiological and anatomic data – you are positioned to reboot the future of medicine.

Topol advocates patients take advantage of the tremendous computational power that is put into their hands by smartphones, running healthcare applications, connected to wireless sensors, and plumbed into increasingly knowledgeable social networks that have a focus on medical matters – sites such as PatientsLikeMe, CureTogether, and many others.

There’s an important precedent.  This is the way business professionals are taking their own favourite smartphones and/or tablet computers into their workplaces, and are demanding that they can access enterprise systems with these devices.  This trend – “bring your own device” (“BYOD”) – is itself a subset of something known as “the consumerisation of enterprise technology”.  People buy particular smartphones and tablets on account of their compelling ease of use, stunning graphics, accessible multimedia, and rich suite of value-add applications covering all sorts of functionality.  They enjoy using these devices – and expect to be able to be use them for work purposes too, instead of what they perceive as clunky and sluggish devices provided via official business channels.  IT departments in businesses all around the globe are having to scramble to respond.  Once upon a time, they would have laid down the law, “the only devices allowed to be used for business are ones we approve and we provide”.  But since the people bringing in their own personal devices are often among the most senior officials in the company, this response is no longer acceptable.

Just as people are bringing their favourite smartphones from their home life into their business life, they should increasingly be willing to bring them into the context of their medical treatment – especially when these devices can be coupled to data sensors, wellness applications, and healthcare social networks.  Just as we use our mobile devices to check our email, or the sports news, we’ll be using these devices to check our latest physiological data and health status.  This behaviour, in turn, will be driven by increasing awareness of what’s available.  And Topol is on a mission to increase that awareness.  Hence his frequent speaking engagements, including his keynote session at the December 2011 mHealth Summit in Washington DC, when I first became aware of him.  (You can find a video of this presentation here.)  And hence his authorship of this book, to boost public understanding of the impending inflection point in medicine.  The more we all understand what’s available and what’s possible, the more we’ll all get involved in this seismic patient-led transformation.

Footnote: Topol’s book is generally easy to read, but contains quite a lot of medical detail in places.  Another book which covers similar ground, in a way that may be more accessible to people whose background is in mobile technology rather than medicine, is “The Decision Tree: How to make better choices and take control of your health”, by executive editor of Wired magazine, Thomas Goetz.  Both Topol and Goetz write well, but Goetz has a particular fluency, and tells lots of fascinating stories.  To give you a flavour of the style, you can read chapter one free online.  Both books emphasise the importance of allowing patients access to their own healthcare data, the emergence of smart online networks that generate new insight about medical issues, and the tremendous potential for smartphone technology to transform healthcare.  I say “Amen” to all that.

29 December 2011

From hospital care to home care – the promise of Connected Health

Filed under: challenge, Connected Health, converged medicine, healthcare, mHealth, usability — David Wood @ 12:01 pm
  • At least one in four hospital patients would be better off being treated by NHS staff at home

That claim is reported on today’s BBC news website.  The article addresses an issue that is important from several viewpoints: social, financial, and personal:

NHS Confederation: Hospital-based care ‘must change’

The NHS in England must end the “hospital-or-bust” attitude to medical care, says the body representing health service trusts.

At least one in four patients would be better off being treated by NHS staff at home, figures suggest.

2012 will be a key year for the NHS as it tries to make £20bn in efficiency savings by 2015, according to the head of the NHS Confederation, Mike Farrar.

Ministers say modernising the NHS will safeguard its future.

Mr Farrar said: “Hospitals play a vital role but we do rely on them for some services which could be provided elsewhere.

“We should be concentrating on reducing hospital stays where this is right for patients, shifting resources into community services, raising standards of general practice, and promoting early intervention and self-care.

“There is a value-for-money argument for doing this, but it is not just about money and the public need to be told that – this is about building an NHS for the future.”

Mr Farrar said the required changes included treating frail people in their homes, and minimising hospital stays wherever possible.

Politicians and NHS leaders must show the public how these changes could improve care, rather than focusing on fears over the closure of hospital services, he added.

“Many of our hospitals know that the patients that they are treating in their beds on any given day could be treated better – with better outcomes for them and their families – if they were treated outside of hospitals in community or primary care,” he told BBC Radio 4’s Today programme.

Mr Farrar told Today that people had become used to “the hospital being a place of default” and that primary and community healthcare services had sometimes been under-funded.

But he said even where clinicians knew that better care could be provided outside of hospitals, and politicians accepted this privately, the public debate had not helped individuals understand that…

Some of the replies posted online are sceptical:

As a medical doctor based in hospitals, I believe this will not work logistically. Patients are sent to hospitals as they don’t get the specialist care in the community as the skills/services are inadequate/not in place. Patient attitudes must change as many come to a+e against GP advice as they don’t have confidence in community care…

As long as the selfish British public can’t be bothered looking after their own relatives and see hospitals as convenient granny-dumping centres, there is absolutely no way this would work.

There can not be a perfect solution. Not every family can care for a sick person full time, often due to them working. Hospital care may not be a perfect, yet in some cases it does free relatives to be able to work.  Outsourcing care too has a major downside, my wife has done that for years. 15 mins twice a day, can hardly be called acceptable if you apply some form of dignity to the patient.

I saw too many patients I nursed(often elderly or with pre-existing health conditions) kept in hospital too long because no one to care for them at home/wider community. This wasn’t great for them but also blocked an acute bed for someone else. In recent years the pendulum’s swung too far the other way: too many patients discharged without adequate support…

In summary: care in the community would be better in many, many cases, but it’s demanding and challenging:

  • There are social challenges: relatives struggle to put their own lives and careers on hold, to act as caregivers.
  • There are financial challenges: funding for medicine is often preferentially directed to large, centralised hospitals.
  • There are skills challenges: observation of complicated chronic health conditions is more easily carried out in the proximity of specialists.

However, the movement “from hospital care to home care” continues to gather steam – for good reason.  This was a major theme of the mHealth Summit I attended earlier this month in Washington DC.  I was particularly struck by a vision articulated by Rick Cnossen, director of worldwide health information technology at Intel:

In the next 10 years 50% of health care could be provided through the “brickless clinic,” be it the home, community, workplace or even car

As reported in the summary article by Kate Ackerman, “mHealth: Closing the Gap Between Promise and Adoption“:

Cnossen said the technology — such as mobile tools, telehealth, personal health records and social networking — already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

Fellow speaker Hamadoun Toure, secretary general of the International Telecommunication Union took up the same theme:

Mobile phones will increase personal access to health information, mHealth and broadband technology will improve data collection and disease surveillance, patient monitoring will improve and become more prevalent, and remote consulting and diagnosis will be enhanced, thanks to low-cost devices.

“In the near future, more people will access the Internet through mobile devices than through fixed devices,” Toure said. “We are witnessing the fastest change in human history, and I believe (we have) a great opportunity for social development.”

Connected health technology enables better remote monitoring of personal medical data, earlier warnings of potential relapses, remote diagnostics, quicker access to technical information, better compliance with prescription regimes, and much, much more.

But Kate Ackerman raises the question,

So if the technology already exists and leaders from both the public and private sectors see the need, why has progress in mobile health been slow?

It’s an important question.  Intel’s Rick Cnossen gives his answer, as follows:

“The challenge is not a technology problem, it’s a business and a workflow problem.”

Cnossen said, “At the end of the day, mHealth is not about smartphones, gadgets or even apps. It’s about holistically driving transformation,” adding, “mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors…”

He said health care clinicians can be resistant to change, adding, “We need to introduce technology into the way to do their business, not the other way around.”

Cnossen also said that payment reform is essential for “mHealth to survive and thrive.” He said, “We should not be fighting for reimbursement codes for each health device and app. That is ultimately a losing proposition. Instead, we must fight for payment reform to pay for value over volume, regardless of whether the care was provided in a bricks and mortar facility or was it at the home or virtually through electronic means.”

Personally, I would put the emphasis differently:

The challenge is not just a technology problem, it’s also a business and a workflow problem

Moreover, as the technology keeps on improving, it can often diminish the arguments that are raised against its adoption.  Improvements in quality, reliability, miniaturisation, and performance all make a difference.  Improvements in usability may make the biggest difference of all, as people find the experience in using the new technology to be increasingly reassuring.

I’ll finish by noting an excerpt from the keynote at the same conference by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services:

This is an incredible time to be having this conversation. When we talk about mobile health, we are talking about taking the biggest technology breakthrough of our time and using it to take on one of the greatest … challenges of our time. And while we have a way to go, we can already imagine a remarkable future in which control over your health is always within hand’s reach…

This future is not here yet, but it is within sight. And I look forward to working with you to achieve it.

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