In March, President Obama identified "the biggest threat to our nation's balance sheet." Not major banks on the brink of insolvency. Not paralyzed credit markets. Not a bailout tab in the trillions. The biggest threat, he warned, "by a wide margin," is "the skyrocketing price of health care."
Health care accounts for $1 in every $6 spent in the United States — and costs are climbing at twice the rate of inflation. Every year, an estimated 1.5 million families lose their homes because of medical bills. Although we have the world's most expensive health-care system, 24 countries have a longer life expectancy and 34 have a lower infant-mortality rate, according to the latest United Nations report.
But some physicians and surgeons have been quietly rethinking and reinventing medicine for the 21st century. Often collaborating with innovative companies, these pioneers are experimenting with cutting-edge technologies, from software to robots, that have the power to revolutionize the medical landscape — producing better outcomes, lower costs, broader access, and greater convenience. And advances on a far greater scale could emerge from the stimulus package and the $634 billion the Obama administration proposes to invest in health-care reform; the much-discussed expansion of electronic medical records (see Why Electronic Health Records Are Worth the Hype—and the Price) is just the beginning. As these breakthroughs come together, they will change the world for patients, doctors, insurers, regulators — all of us.
The doctor of the future will see you. Now.
<< the doctor is online >>
"This is a $2.4 trillion industry run on handwritten notes," says 33-year-old Dr. Jay Parkinson. "We're using 3,000-year-old tools to deliver health care in the richest country on the planet." His prescription: a Facebook-like platform that uses technology, from IM to video chat, to restore the traditional doctor-patient relationship that has been lost in today's high-pressure, high-volume, eight-minute-appointment practice model, which is often blamed for the shortage of primary-care physicians.
Parkinson, fresh from residencies in pediatrics and preventive medicine and a master's in public health from Johns Hopkins, started a virtual practice in 2007, in Williamsburg, a Brooklyn, New York, neighborhood known for its heavy concentration of artists, bloggers, and bushy beards. He had a Web site and a blog, of course. He made house calls and conducted same-day e-visits. He accepted PayPal, but not insurance. Three hundred patients signed up in the first three months.
And then, he says, sounding more like a perpetually amazed surfer than a medical rebel, "I blew up on Gawker, man." Through some photographer buddies, the gossip site discovered Parkinson and proclaimed, "Williamsburg's Hipster Doctor Will Diagnose You Via IM." In the accompanying photo, he wore a stethoscope draped casually across his shoulders like a scarf, white jeans, and a white shirt with one too many buttons unbuttoned, as snarky commentators observed. Gothamist, Yahoo, and The Washington Post jumped on the story.
The publicity caught the attention of Nathaniel Findlay, the CEO of Canadian software company Myca Health. A veteran of six startups as well as $91 billion Cardinal Health, he was leading a team building a secure portal to do what Parkinson had cobbled together using multiple applications like Google Calendar. The Myca project had begun with Don Jones, who runs the health and life-sciences group at Qualcomm. Jones had worked on one of the first electronic-medical-records efforts in the 1990s and was eager to expand the wireless company's mobile activities into telemedicine. After his team developed the technical requirements for such a platform, he contacted Myca to build it. Findlay then persuaded Parkinson to serve as chief concept officer to ensure a doctor-friendly application.
On a recent morning in Williamsburg, Parkinson demonstrates the latest version of the Myca Platform, which launches this summer. It's part electronic medical record, part practice-management system, and part social-networking site, complete with profiles and photos of doctors and patients, all in a secure environment that complies with federal privacy standards.
If you're a patient, your profile shows your medical team — a primary-care physician and any specialists you've chosen, perhaps from the experts listed on your primary-care physician's profile. To make an appointment, you look at a doctor's schedule, select a time slot of at least a half hour and the type of appointment (in-person, video, or IM), and fill out a text box describing your ailment so the doctor can start thinking about treatment. Typically, follow-ups are e-visits. A timeline dotted with icons representing previous appointments lets you review the doctor's comments, read the IM thread, watch the video of an earlier electronic house call, or link to test results.
"You can rate a visit, comment on it, share it," Parkinson says. "Is that innovative? Man, I don't know. It's paying attention to what's awesome about Flickr and then doing it."
For the doctor, the platform is an intuitive tool for managing his time — there are lists of upcoming appointments and prescription-refill requests — and communicating with patients and other physicians more quickly and directly. One feature provides a health snapshot, the top conditions treated that week locally, statewide, or nationally. Another allows doctors to organize patients by condition and email them as a group about new treatments. "I'm a big fan of Craig Newmark [of Craigslist]," says Parkinson. "Create something useful and get out of the way. I have no idea what people are going to come up with."
The first practice that will employ the portal is Hello Health, a more polished, three-doctor version of Parkinson's early practice. "Think of Hello Health as a Mac and the Myca Platform as Intel, the stuff running inside," says Parkinson, who is never at a loss for a tech analogy. There's no receptionist, so doctors greet patients as they arrive. The clientele skews young. Half have insurance, and it's their responsibility to file for reimbursement. So far, very few insurers cover a wide range of e-visits, but the number is growing.
Insurance is, in fact, both a challenge for Parkinson's vision — and, perhaps, an industry that could be transformed by the kind of medicine made possible by the Myca Platform. Doctors using the platform set their own fees, and Myca takes a cut of each transaction. At Hello Health, patients pay a $35 monthly subscription fee and $100 to $200 an hour for online or office visits. Brief email queries are free. Doctors at other practices who adopt the Myca Platform may charge less than their usual rates, since online appointments slash overhead. The sweet spot for this business model right now, Parkinson says, is the "invincibles," as health-care types call young, healthy people who forgo high monthly insurance premiums; instead, they pay doctors directly and buy relatively inexpensive high-deductible policies for emergencies.
About 2,000 doctors have inquired about joining, says Myca's Findlay. He maintains there's no shortage of companies looking for health-care options for employees that could eliminate lost productivity through absenteeism or waiting in a doctor's office. "The genie is out of the bottle," he says. "People want it. We just have to figure out how to do it properly."
<< half man, half machine >>
One of the paradoxes of modern medicine is that it demands continual innovation yet often resists change. This is particularly true for highly complex surgeries, such as open-heart operations. After all, the traditional procedure works. Why change it? But Dr. Douglas Murphy, 59, a cardiac surgeon at St. Joseph's Hospital in Atlanta, has led the way in repairing the heart's mitral valve robotically, using Intuitive Surgical's da Vinci Surgical System. The procedure has proven more effective, quicker to do, and dramatically less invasive. Now he's on a mission to make it more widely adopted, providing a model for both high-tech surgery and remote medical education.
Murphy's achievements in the operating room are nothing short of miraculous to the rest of us. Instead of cutting the sternum and splitting open the chest, one of the more violent operations performed on the body, he inserts long, slender instruments, including a robotic camera, through a few fingertip-size incisions. Slipping the tremor-free instruments between the ribs, he's able to slice and enter the heart. "It's like building a ship in a bottle," he says. The camera gives him a three-dimensional, high-definition view (and magnification up to 10 times stronger than the human eye). The small size of the incisions nearly eliminates the risk of infection; there hasn't been one in 750 surgeries.
"Traditional heart surgery has always been a mixed blessing," Murphy says. "Sure, it's life-saving, but it takes you two or three months to recover. The heart recovers in a couple of hours. But the body takes much longer. With robotic surgery, the patient is out of the hospital in less than half the time and recovered in three weeks. I'm talking back to playing golf or tennis."
Why isn't robotic cardiac surgery already the treatment of choice? Murphy estimates that it takes 100 cases to learn to perform it efficiently, and there's no immediate financial incentive to do that since the reimbursement is the same. That means few surgeons — let alone other members of the surgical team — can afford to travel and observe an expert in action. What's necessary, Murphy realized, is robot college.
So earlier this year, his hospital launched the International College of Robotic Surgery, the first such remote facility with a cardiac focus. Murphy and his colleagues teach via a secure Internet site. Tuition runs as high as $100,000 for a comprehensive package that includes more than 30 presentations, live video feeds of operations, proctoring, and sessions tailored to each role on the surgical team — surgeon, surgical assistant, nurse, anesthesiologist, and so on. "There are review sections, checklists, a section I call 'Things I wish I hadn't done,'" Murphy says. "We've documented 750 cases on video, so I can show it all — the great examples, what's routine, what's not routine. They get the know-how of the first 100 cases before they do their first."
Murphy, who performed heart transplants before moving into less-invasive surgeries, teaches repair of the mitral valve — a flap in the heart's upper chamber that can become leaky, leading to congestive heart failure. The optimal treatment is repairing the existing valve, but in nearly half of all nonrobotic procedures, surgeons install an artificial replacement, a considerably more expensive process. With robotics' 3-D magnification, Murphy is able to repair more than 90%. Dr. Sudhir Srivastava, who joined St. Joseph's from the University of Chicago Medical Center this year, teaches an even rarer robotic procedure: coronary bypass surgery on a beating heart.
Currently, hospitals around the world have more than 1,100 da Vinci systems, at a cost of $1 million to $1.7 million apiece. Using them more for cardiac procedures makes sense both medically and economically. The demand is there: Murphy has a two-month waiting list, with patients from all over. St. Joseph's, which has five da Vincis, has grown its total annual robotics-surgery revenue to $25.5 million from scratch in six years. And the need for less-invasive measures is expected to increase as the population ages, because traditional surgery is too traumatic for the elderly.
"We're toward the end of our careers, and we decided that rather than grind out more cases, we wanted to teach this worldwide," says Murphy. "Every major metropolitan area should have one or two teams that are proficient in this."
Last year, robotic surgery using the da Vinci system, the only one with FDA approval for soft-tissue surgery, reached a milestone: More than half of the 80,000 prostate removals in the United States were performed by surgeons manipulating robotic metallic arms instead of wielding scalpels in their own hands. A total of 136,000 operations involved da Vinci robots, a 60% increase from 2007. This revolution in the OR is likely to pick up speed as surgeons like Murphy and Srivastava perfect new robotic procedures — and exploit telemedicine technology to share that knowledge efficiently.
<< a diagnostic search engine >>
In theory, the more doctors learn about the body, the better basis they have for figuring out what's wrong with you. In reality, they can't keep up with the flood of new information. In neurology alone, the number of identified disorders has more than doubled in 10 years, to more than 1,800, the majority extremely rare. True, doctors as a community know more, but what any individual knows constitutes a smaller portion of medical information overall. What if physicians could use technology to tap their peers' expertise to make quicker, more accurate diagnoses?
Dr. Michael Segal, 54, a renowned pediatric neurologist in Chestnut Hill, Massachusetts, has been working on this problem off and on for 20 years. The result: SimulConsult, a sophisticated online crowd-sourcing tool for identifying neurological disorders that demonstrates the potential of the Web to transform the way all kinds of diseases are diagnosed. Doctors enter a patient's symptoms and test results, and the software produces likely diagnoses and the probability for each.
"It's like having a group of more- experienced physicians helping with every diagnosis," says Dr. Viveck Baluja, a resident in pediatric neurology and developmental medicine and a fellow at Baltimore's Kennedy Krieger Institute. "The people inputting data about the diseases are experts in this field."
Segal recognized the need for such a tool as a resident in the 1980s, when he spent hours poring through books and looking at every possible unusual disease for one particularly perplexing patient. "The problem is that textbooks are arranged so if you know the disease, they tell you the symptoms or lab results," he says. "But patients come to us in the opposite way, with findings that we need to put together in a story to reach a diagnosis."
SimulConsult works the way a physician does. It produces an initial diagnosis based on information from experts with a wealth of experience, then prompts the doctor to consider other pertinent tests and findings. For example, if a physician enters information about a teenager with a history of attention-deficit-hyperactivity disorder, an abnormal electrocardiogram, and bouts of weakness, SimulConsult asks about recent salt intake. "Most clinicians would not flag such information as relevant," says Segal, but sodium has been known to trigger those symptoms in patients with a neurological syndrome known as hypokalemic periodic paralysis. Says Baluja: "There are thousands of outliers. The problem isn't in the disease itself. It's in the subtle variations of disease. The details matter."
In 1997, Segal went part-time at Harvard Medical School, where he had been an award-winning researcher, to found SimulConsult. The firm didn't begin generating revenue until this year; the tool was more of a puzzle he wanted to solve than a way to make money. Last year, in hopes of expanding, he hired a CEO, got his first ads, and secured an initial round of funding from an angel investor; eventually, he plans to charge a subscription fee for access to more detailed information. "This is typical of a lot of medical innovations," says David Williams, a health-care consultant in Boston and informal adviser to Segal. "There's a long incubation from basic R&D to commercialized product."
Segal began by offering the database free to pediatric neurologists. Now primary-care physicians make up 20% of users, a development that should increase its impact. If SimulConsult helps generalists make correct diagnoses early on, that means fewer visits to the wrong specialists and unnecessary tests, greatly reducing costs and accelerating appropriate treatment.
Most significantly, more users would lead to more findings and a richer, more valuable diagnostic tool. "I think we will discover that many diseases that we thought were rare," says Segal, "will turn out to have been just rarely recognized."
It's this ability to expand and harness knowledge that makes cutting-edge information technology such a powerful driver of the emerging health-care revolution. Professional tools like SimulConsult, Isabel, and Diagnosaurus can improve care and control costs. Sites such as PatientsLikeMe, which connects people with similar conditions, help them understand their health and may promote compliance with treatment. Physicians, not surprisingly, complain about patients who try to diagnose themselves after logging onto the symptom search engine Medgle. But the end result is to deepen communication, both among doctors and between physicians and their patients. Everyone will be smarter for it.
<< in two places at once >>
The call came after hours. A 36-year-old woman had arrived at the ER in Big Rapids, Michigan, with an apparent stroke. Omar Qahwash, a neurosurgeon at St. Joseph Mercy Oakland in Pontiac, outside Detroit, rushed to have a look. In the quiet of his bedroom, he flipped open his laptop and transported himself 197 miles away.
Although Mecosta County Medical Center, an 82-bed facility in Big Rapids (population: 10,849), doesn't have a stroke specialist, it has the next best thing: the RP-7, a 5-foot-tall "remote presence" robot made by InTouch Health of Santa Barbara, California. Using a stubby joystick, Qahwash, 34, zoomed the two-way camera to review the patient's chart and CT scan. Then, parking the robot at the woman's bedside, he asked several questions, carefully studying her responses. To the patient, he was a face on the machine's 15-inch monitor.
She hadn't had a stroke, Qahwash concluded. The immediate and expert assessment avoided a needless helicopter transfer to Detroit, which would have cost several thousand dollars. If it had been a stroke, Qahwash was on hand to direct treatment.
The uneven distribution of specialists is a significant problem for the U.S. health-care system. While some large cities arguably have too many specialists, small cities and rural areas generally have too few. This deficit is especially acute in cases where rapid, expert diagnosis and treatment are the most critical. Some of the most powerful medical advances are those that address this growing manpower crisis. One cost-effective way to extend expertise is leading-edge telemedicine.
Consider stroke, the third leading cause of death in the United States and the No. 1 cause of long-term disability. Only 23% of county hospitals offer neurological services. The shortage is expected to worsen during the next 20 years as aging baby boomers live longer than previous generations. So St. Joseph Mercy, part of Trinity Health, a $6.3 billion nonprofit with 44 hospitals and a few hundred outpatient facilities, has established the Michigan Stroke Network, the largest such network in the country. St. Joseph spends $2 million a year to lease 33 robots that stand at the ready in 31 hospitals across the state.
Time is of the essence with strokes. Most are caused by clots that reduce blood flow to the brain. A clot-busting drug approved by the FDA in 1996 — tissue plasminogen activator (tPA), also known as "brain Drano" — can work wonders, but only with certain strokes and, in most cases, only within three hours of onset. (In other cases, tPA can make things worse.) The remote robot increases the chances of treating a patient effectively. Nationally, about 5% of stroke victims get tPA; in 2007, 80% of eligible patients in the stroke network did. On average, it takes just seven minutes for a network hospital to get a neurologist or neurosurgeon on-site via robot. As the specialist assesses the patient, other members of the team prepare for helicopter transport, just in case.
The RP-7, which some hospitals humanize with a lab coat, ID badge, and name, looks odd — even comical — with the bottom-heavy build of a vacuum cleaner and a flat-screen monitor for a head. (It comes with sounds effects, too, including Arnold Schwarzenegger saying, "I'll be back.") But patients don't seem to mind the machine. "They're relieved that they have a specialist at their bedside," says Connie Parliament, supervisor of the stroke network. "They're used to driving two hours to see someone."
The robot "isn't a panacea," says Jack Weiner, St. Joseph president and CEO, "but it is the kind of technology that significantly reduces health-care costs." With a robot, leased for about $7,000 a month, a community hospital can offer the expertise of a neurologist it couldn't otherwise afford ($500,000 a year and up, says Weiner). That means more stroke victims walk out of the hospital, avoiding bills of $250,000 or more for months of rehab. "We think the insurance companies benefit," says Weiner, "but they are not willing to support the program yet." He wants more departments to use the robots. At St. Joseph, for example, ICU specialists make robot rounds from home before going to bed, which can prevent a late-night call. St. Alphonsus Regional Medical Center, a Trinity hospital in Boise, Idaho, uses eight units to provide neonatal, cardiology, mental health, and other services to rural facilities. And there, the revenue covers leasing costs.
Like the Myca Platform, the robots are just one example of an advanced technology that seems impersonal but actually enables doctors to be more hands-on; in a Twitter and Facebook world, screen-to-screen face time can build relationships with patients. And like SimulConsult and the robotic college's remote learning, they encourage professional connections that dramatically enhance care. Together, innovations like these are beginning to free U.S. medicine from the strictures that have given us the world's costliest health care, but not the best health care.
Think what happens when you put these things together. You can see your doctor immediately without wasting time in a waiting room. A robust database helps your physician make more accurate diagnoses. Advances in robotics cut your recovery time after surgery — and could even lead to operations assisted by remote experts. This is the vision of the medical system of tomorrow. And it's emerging today.
"You get into medicine because you want to take care of people," says a 39-year-old general practitioner in a traditional practice in Philadelphia. "But then you discover it's not a fulfilling profession anymore." Which is why he recently decided to leave the "hamster wheel" of rushing between patients all day without a break. He's following Parkinson's lead and opening a Hello Health practice with the Myca Platform. Just what the health-care system ordered: one more doctor of the future.