Sunday, June 1, 2014

It is Time to Stifle Some Innovation

Stifling innovation is a very bad thing. As a society it is incumbent upon us to let innovation breath free, prosper and multiply, because innovation is good for us. All innovation is good for us, even if it doesn’t look that way initially, because you never know when a seemingly useless innovation will spawn that one innovation that will save the world. Hence, we should not try to look innovation in the mouth and we should not attempt to discriminate between innovations that seem worthy and those that look and sound like snake oil of days gone by, or much worse. We should just lay back and let ourselves be immersed in the fragrant, colorful and relaxing innovation bubble bath.

Health care innovation comes in three basic flavors, scientific discovery, technology utilization and operational model. What distinguishes enlightened societies from those left behind is the ability to harmonize all three domains of innovation to benefit individuals and as a result society as a whole. Health care in America is in trouble because this paradigm is broken now. Jonas Salk with his scientific discovery financed by the dimes of regular people and placed back into the public domain, could not happen today for two reasons. First, no activities can be undertaken in our time without the potential for massive profit to somebody. Second, few if any individuals are in a position to have and exercise the courage of their convictions, unless of course they happen to be billionaires. The upheaval engulfing health care today is not driven by a desire to alleviate the suffering of small children. Our health care is being transformed in a bipolar process whose diametrically opposed goals are to reduce the costs of care while maximizing the profits extracted from caring for sick people. This is an accounting exercise where the services and passions (and, yes, ambitions) of great scientists and great humanitarians are not welcome anymore.

Technology Innovation

Accounting of dollars and cents, which is what our lives are being boiled down to, is by definition based on what we used to call data, or numbers, and what we now call Big Data, or surveillance. The primary innovation of our times is the stunning realization that for the first time in history, we will be able to collect literally everything – every word, every step, every thought, every breath and every heartbeat, of every person on planet Earth – and we can do it all from afar, without spooking the observed. When the technology juggernaut was unleashed in the health care sector, it came with an audacious philosophy stating that, once we are able to collect every bit of information about every single person at every moment in time and “mash” it all together, the world will be a better place. What was once basically a criminal endeavor, perpetrated by individuals in bits and pieces under the cover of darkness, has been elevated to the #1 aspirational goal of humanity, when administered in bulk by the State and its corporate partners. Bestowing renewed legitimacy on the age old debate about tradeoffs between individual rights to privacy and self-determination, versus tangible material benefits, such as safety, sustenance and medical attention, is the most significant contribution American health care is making to a changing world order.

In a recent JAMA opinion piece, physicians from Harvard University are attempting to drive home this innovative idea. First we are reminded of the spectacular benefits to humanity made possible when we go “beyond aggregate data and link information to individual people” as evidenced by the achievements of the NSA, Google and the Obama 2012 cybercampaign. Then in a beautiful graphic, the authors are illustrating how we would combine clinical data diligently collected by doctors, with Facebook, Google, Twitter, tracking devices, police records, grocery store purchases, employment records, genetic information and whatever else we can get our hands on (I would throw in the NSA data too), to “assemble a holistic view of a patient”.  To overcome the trifle technical and social barriers to progress, Drs. Weber, Mandl and Kohane are advising that it is time “to convene a public forum whereby the relevant stakeholders, including citizens, the health care community, and commercial data vendors could meet to frame the policy from which legislation and ultimately technical protections for big biomedical data linkage will devolve” [emphasis added]. This in and of itself is a rather innovative idea, seeing how in one fell swoop it dispenses with all the arcane complexities of the democratic process, while elegantly redefining the will of the people to be just another special interest on the same footing with data vendors.

Systems Innovation

In response to the emergence of new technology philosophies, the operational model of health care is now shifting to better position itself to take advantage of these innovations. A stethoscope wielding doctor is as poorly prepared to leverage the potential benefits of big datasets to humanity, as any individual patient focused on his or her own small and, let’s face it, inconsequential existence. The leadership role will fall to others. Three years ago, the President’s Council of Advisors on Science and Technology (PCAST) issued a landmark report advising the government on how to best facilitate the generation of Big Data in health care. Last week, the PCAST issued another report, supported by evidence from manufacturing and commercial aviation, recommending the application of Systems Engineering principles to health care to help big organizations and “communities” (i.e. bunches of poor people living in close proximity to each other) leverage their Big Data. Considering that American manufacturing is dead, and that flying coach on commercial airlines makes you wish you were dead too, one could be tempted to question this second round of massive taxpayer expenditures recommended by the PCAST. In all fairness though, the PCAST does place strong boundaries on government intervention which “should in no way, however, be a substitute for what the market can and should develop, i.e., for-profit organizations that provide training and skills to health-care systems”.

You should take a few minutes and read the PCAST report because too many of us are ignoring policy making processes, notices in the Federal Register, and public forums in name only, and even elections, leaving the same handful of very powerful people and their handpicked lackeys to misrepresent the wishes and interests of an entire nation. I will just point to two interesting examples cited by the report where systems engineering principles were applied with great success to health care. One is the VA system, and I find it perplexing that no one at the PCAST saw fit to edit that example out of the final report, after the VA chief was forced to resign in disgrace precisely over a systems engineering fiasco. The other was a truly effective initiative at Virginia Mason, which failed because the hospital saw its revenues tanking when it changed the way it was providing care for back pain. Somehow, the PCAST seems to be of the opinion that cheaper care can be provided without reduction in revenues for those selling care, and the way to achieve this alchemy based innovation is, you guessed it, to switch from fee for service to paying for a yet to be defined concept, called value.

Absent Innovation

The science of medicine is incomplete, yet there are no aspirational goals and no inspirational challenges geared towards pure scientific discovery. There are many initiatives aimed at painstakingly preventing or controlling chronic disease caused by reckless abandon to industrialization and our inability to police the greed of those who are now purporting to solve the health care problems they created, by introducing the same disastrous processes into the last bastion of humanity – caring for our bodies and our minds. And to all the empowered patients (or e-patients) out there, climbing every public barricade, screaming for their “damn data”, and demonizing every old-fashioned physician, while serving as grease for the wheels of our health care revolution, here are the results of your success.

According to Dr. Joseph Kvedar, the founder and director of Partners HealthCare’s Center for Connected Health, this is the future of medicine: “So I fully expect in 10 years your healthcare experience to be very personalized based on you allowing us to capture a lot of data from your device ….. the idea that we can capture your mood based on the number of texts you send and outgoing communications …..We’ll know your GPS tracking, all your mobile purchasing data and we can kind of figure out if you’re eating healthy. We’ll know if you’re drinking too much caffeine or too much alcohol. We’ll know a lot of things about you that we can start to serve up really compelling content to you that should be engaging enough — games, rewards, incentives, what have you in the background — that you will want to stay healthy”. As Forrest Gump would have said, that’s good, one less thing to worry about.

In other words, the “paternalistic” doctor, with his anachronistic stethoscope, strange concerns for privacy and ethics, and a ridiculous urge to lay hands on your body and look into your eyes, is being replaced by the unilateral decrees of a royal “we” of an invisible, machine augmented, superior intellect, presumably systems engineered to perfection, delivered by “smart” phone to a nation of feeble minded people who will be kept healthy by playing Veggie Crush all day.
Either we stifle this innovation now, or it will forever stifle every man, woman and child in this entire country, and perhaps the entire world.


  1. Noting is more exciting to me than creatively using technology to achieve the Triple Aim of healthcare reform. Big Data could eventually play an important role if this happens. The risk we face is that usually well-intended powers could incrementally erode our freedoms. Only transparency of all data and its uses along with fully informed consent will allow health consumers to avoid having one oppressive system simply replaced by another. I certainly hope we are not creating Animal Farm in the process. However, society has largely decided to give up privacy (and freedom?) for convenience. That is the reality that the emerging powers (and some opportunists?) are simply following.
    I wonder how many health professionals are as Boxer right now… faithful and strong workhorses… believing any problem can be solved if we just work harder and follow the new order of things. What happened to him?

    1. I agree that as a people the ball is in our court, and we should not allow this to continue, precisely because I also agree that technology can be used to help individual folks in tremendous ways. We cannot just sit idle and let a handful of "leaders" subvert progress and, yes, innovation this way.

      A couple of years ago I advocated for a universal EHR, a database maintained by the federal government as a public good to be used by all tech vendors in real time, to serve information to clinicians and to update its contents as well. But that assumed that we will be smart enough to not allow a new order of things. Very foolish assumption on my part.

      At this point, I think we need to get our democracy off the couch and put it to work before it dies of inactivity. I am not blaming the tech folks who are trying to make a buck. I am blaming us for not providing them with rules and legislation to channel their natural greed.

      I don't think transparency is enough. Transparency is good if people bother to look, but in a country where everybody is getting poorer and debt ridden, very few of us have the luxury of looking up from the grind, and I think this is the same reason why it appears that we are willing to give up freedoms for convenience (or cheapness really). Most people are not aware of what they are giving up, and with our education system failing as well, perhaps most people don't quite understand what is being done to them.

      In a nutshell, I want laws passed by Congress to make this type of thing a criminal offense. In lieu of that, I want Messrs. Goldstein and Clement to bring this to the Supreme Court (gave up on my own party :-) until someone decides to consider that we have more than two amendments, and the fourth one is being mutilated right now.

  2. You go girl! Hope you succeed. I would like to think we are not yet at an Idiocracy. Would the data reveal it is much more important to know what's Miley Cyrus up to lately?

    1. No doubt about that, Miley Cyrus I mean... As to my success, zero chance there. Now, if you jump in and we do this together, that's a different story altogether.... :-)
      I had another hare-brained idea today.... I'll email you later.....