What Congress should really be working on.

From the Wall Street Journal:

The Smart-Medicine Solution to the Health-Care Crisis
Our health-care system won’t be fixed by insurance reform. To contain costs and improve results, we need to move aggressively to adopt the tools of information-age medicine

By Eric Topol

. . . No matter how the debate in Washington plays out in the weeks ahead, we will still be stuck with astronomical and ever-rising health-care costs. The U.S. now spends well over $10,000 per capita on health care each year. . . .

. . . Our health-care system is uniquely inefficient and wasteful. The more than $3 trillion that we spend each year yields relatively poor health outcomes, compared with other developed countries that spend far less. . . .  more than 1 in 4 patients harmed while in the hospital; more than 12 million serious diagnosis errors each year; a positive response rate of just 25% for patients on the top 10 prescription medications in gross sales.

. . . Radical new possibilities in medical care are not some far-off fantasy. Last week in my clinic I saw a 59-year-old man with hypertension, high cholesterol and intermittent atrial fibrillation (a heart rhythm disturbance). Before our visit, he had sent me a screenshot graph of over 100 blood pressure readings that he had taken in recent weeks with his smartphone-connected wristband. He had noticed some spikes in his evening blood pressure, and we had already changed the dose and timing of his medication; the spikes were now nicely controlled. Having lost 15 pounds in the past four months, he had also been pleased to see that he was having far fewer atrial fibrillation episodes—which he knew from the credit-card-size electrocardiogram sensor attached to his smartphone.

In my three decades as a doctor, I have never seen such an acceleration of new technology, both hardware and software, across every dimension of medical practice. . . .

Smart medicine offers a way out, enabling doctors to develop a precise, high-definition understanding of each person in their care. The key tools are cheaper sensors, simpler and more routine imaging, and regular use of now widely available genetic analysis. . . .

One obvious practical effect of these developments will be to replace hospital stays with remote monitoring in the patient’s home. The Food and Drug Administration has already approved wearable sensors that can continuously monitor all vital signs: blood pressure, heart rate and rhythm, body temperature, breathing rate and oxygen concentration in the blood. The cost to do this for weeks would be a tiny fraction of the cost for a day in the hospital. Patients will be able to avoid serious hospital-acquired infections and get to sleep in their own beds, surrounded by family.

We do more than 125 million ultrasound scans a year in the U.S., at an average charge of well over $800 — that’s $100 billion. But we now have ultrasound probes that connect with a smartphone and provide exquisite resolution comparable to hospital lab machines. It is possible to examine any part of the body (except the brain) simply by connecting the probe to the base of a smartphone and putting a little gel on the probe’s tip. When I first got a smartphone ultrasound probe last year, I did a head-to-toe “medical selfie,” imaging everything from my sinuses and thyroid to my heart, lungs, liver, gallbladder, aorta and left foot.

That experience came in handy when I recently developed pain in my flank. Seeing my very dilated kidney on my smartphone screen helped to confirm the diagnosis that I had a kidney stone. The CT scan later ordered by my doctor showed a nearly identical image, but the charge for that was $2,200. If this single tool was used in a typical office visit, a large proportion of expensive and unnecessary formal scans could be avoided.

Smart medicine can also bring some sanity to how we handle medical screening, which today results in an epidemic of misdiagnoses and unnecessary procedures and treatments. The leading culprits are routine tests for breast and prostate cancer for individuals at low risk for these diseases. Because the tests have such extraordinarily high rates of false positives, they result all too often in biopsies, radiation and surgery for people in no medical danger.

It would not be hard to use screening tests in a more discriminating way, for the much smaller population that really should worry about certain serious health problems. Genome sequencing for an individual — identifying all three billion base pairs in a person’s genetic makeup — can now be done for about $1,000, and we know a great deal about which genes predispose someone to conditions such as cancer and heart disease. . . .

Routine use of individual genetic information could also allow us to prescribe drugs more effectively, avoiding the waste, in clinical time and in money, caused by medications that misfire. . . .

Smart medicine can also transform the doctor-patient relationship. Most medical services today are still provided in the traditional outpatient setting of a doctor’s office. It takes an average of 3.4 weeks to get a primary care appointment in the U.S., and there’s little time allotted for each visit. Most doctors provide a minimum of eye-to-eye contact as they busily record the session on a keyboard.

The frustrations and inefficiencies of this system are obvious — and unnecessary. In the era of telemedicine consults, there is no reason to wait weeks for an appointment. For the same copay as an office visit, connection with a doctor can occur instantly or within minutes. With increasing use of patient-generated data from sensors and physical exam hardware that connects with a smartphone, the video chats of today will soon be enriched by extensive data transfer. . . .

. . . In a paper last year in the Journal of the American Medical Association, authors Andrew Beam and Isaac Kohane, specialists in biomedical informatics, calculated that advances in artificial intelligence now make it possible for computers to read as many as 260 million medical scans in a day, at a cost of $1,000. The advances in diagnostic power would be enormous, to say nothing of the cost savings. . . .

Fortunately, serious ventures in smart medicine are well along. . . .

But more could certainly be done to move us toward better health outcomes at lower costs. Perhaps some enterprising member of Congress will propose a Frugal Health Care Innovation Act, providing government incentives for technology, research and implementation. Such public support for electric cars has rapidly changed the face of the whole auto industry. American medicine today is no less antiquated than the Detroit of a generation ago, and it needs to find its way into the present century.


Dr. Topol is a cardiologist and professor of molecular medicine at the Scripps Research Institute in San Diego and the author of The Patient Will See You Now: The Future of Medicine Is in Your Hands. He consults for Illumina and Apple on some of the issues discussed here, sits on the board of directors of Dexcom and is a co-founder of YouBase.

 

 

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