Theodore Parker, and later the Rev. Dr. Martin Luther King Jr. believed that “the arc of the moral universe is long, but it bends towards justice”. That would be a very comforting thought if we could be certain that ours is the “moral” universe. Either way, it probably takes some doing to bend that arc because it certainly will not bend on its own accord. Every generation gets an equal opportunity to contribute to the bending of the arc with whatever tools they possess in their lifetime. Some have done more than others to bend the arc, although not always in the same direction. The current generation seems poised to become one of the most prolific arc-bending generations ever, because the tools at our disposal are more powerful than most of us probably realize.
Whereas life used to be a random mess in the past, the upper echelons of our society are thoroughly convinced that we can control each and single aspect of our existence now, because we finally have the machines necessary to quantify pretty much everything happening under the sun, and many things happening elsewhere as well. If we can quantify ourselves, we can control our destiny. If we can quantify others, we can control their destiny.
Planned perfection is our new destiny, where perfection is defined by our existing mediocre leaders and their mediocre machines, as productive and uneventful industrial uniformity at the lowest per capita cost—or as we commonly refer to perfection in health care: the triple aim.
The retail industry defines perfection as continuous shopping. The financial industry prefers perfect indebtedness. And now the health care industry is throwing its hat into the ring in search of perfect health. Vigorous shopping, faithful debt servicing, and fitness for labor, are and always have been the most profitable and hence most sought after traits of consumers. Businesses large and small have always wrestled with finding the best ways to locate and engage the largest numbers of such consumers, and to reform lesser consumers along the same lines to be more profitable to the enterprise. Since retail and banking have been in business for centuries before health care became an industry in our times, both sectors are way ahead in consumer profiling and all sorts of market segmentation schemes.
To be fair, health insurance companies have been profiling the bejeebers out of consumers for years, but physicians and hospitals had no particular need for this gibberish, until now. Why now? Because hospitals and even the tiniest doctor practices are supposed to pitch in and help the too-big-to-function insurance companies shoulder some of the risks inherent in selling insurance. The esteemed Commonwealth Fund is providing us with a glimpse into how these novel arrangements are supposed to work:
“Amazon and other vendors deliver just about everything but health care — yet probably know more about your habits and behaviors than your doctor does. That may be changing as health care providers begin using the consumer profiling tools that shape advertisements to get to know their patients beyond the examining room.”
As heartwarming as it may be to know that your doctor cares enough to pay for software and terabytes of consumer data describing your financial class and buying preferences, consumer profiling tools are not nearly enough for truly patient-centered health. Drawing conclusions about your body weight from the fact that you subscribe to lots of cable channels, or from your minivan driving preferences is not just potentially inaccurate, but also seems rather offensive, according to a concerned Dr. Joseph Kvedar. In an ideal world, your “provider” would have just-in-time, individualized and accurate data precisely quantifying your fatness, and Dr. Kvedar, the vice president of Connected Health at Partners HealthCare, is optimistic that although “we haven’t put the jigsaw puzzle together yet”, all the pieces are there.
If you are raising your eyebrows involuntarily right now, it means that you do still have eyes (and possibly a head on your shoulders), but this is not about you. Dr. Kvedar is concerned about future generations of “providers” who may not be so fortunate, because “in just a few years, we might all have little automated health coaches in our smartphones, operating similarly to Siri, Cortana, or Google Now.” Those little guys can’t just glance at a consumer and assess obesity in a fraction of a millisecond, and this is where “the things in the Internet of Things” will come in to help us “get it down to the individual level.”
A good example of how these “things on the Internet of Things” can unleash the precision medicine era upon us is a disruptive innovation from Beam Technologies. Beam’s “secret weapon” is an electric toothbrush that informs the Internet of Things (IoT) when you brush your teeth, for how long and presumably how well you do the job (not sure though if it can tell whether it’s your teeth or the grout between the tiles in your shower, but I digress).
This information is important in many ways. First, if you have small children, you can save yourself the annoyance of standing in the bathroom doorway watching little Suzy climb on her stepstool and brush her teeth every night. A more efficient use of your time would be to stay in the living room, binge watching House of Cards, or answering urgent work emails. The IoT will let your iPhone know when the deed is done, so you can check later and run some trending analytics comparing Suzy’s performance to her brother Tommy, and the 3 year old population benchmarks.
But wait, there is much more… When the IoT branches into your mouth, it can save the world, or at least have “meaningful impacts on the uninsured population.” Yes, you guessed it; the technology company is building a dental insurance plan around a toothbrush. The possibilities are of course endless, as Alex Howard of the Huffington Post notes, because a toothbrush that “can do tracking and monitoring and drive some behavioral changes,” is not just a toothbrush anymore. But this is not nearly enough either. Wouldn’t it be better if the toothbrush became aware of your opening the fridge right after brushing your teeth? Wouldn’t it be super cool if the fridge knew that you just brushed your teeth and hence locked itself for the night? Shouldn’t your dentist and your primary care “provider” be apprised of your nocturnal feeding habits? Something is still missing here.
When technologists from other industries, on a quest to find El Dorado, finally make their way to health care where $3 trillion are known to be growing on disruptive innovation trees, they are almost invariably disillusioned. Writing for TechCrunch, John Sung Kim the founder of DoctorBase (acquired by Kareo) makes a startling confession: “I thought making a play in the healthcare industry would be a cakewalk. I was wrong. Stupidly, ignorantly wrong.”
Mr. Kim’s “play in healthcare” consists of a software application that allows physician practices to improve their social media ratings and market their services. It also allows their patients to ask questions and make appointments online. Kareo, a vendor of EHR, practice management and billing services is currently selling Mr. Kim’s app for up to $300 per physician per month, which is two thirds of what eClinicalWorks (for example) is charging for a full blown EHR plus patient portal, with a host of “engagement” bells and whistles.
Mr. Kim attributes his failure to hit a health care home run (although he seems to have hit a nice clean double) to the “the difficulty in integrating to legacy systems” or lack of a Federal mandate forcing EHR vendors to open their software and data repositories through public application programming interfaces (APIs) that can be freely exploited by those looking for a “cakewalk” through health care. It seems that existing EHR vendors (legacy is a matter of opinion), found no compelling reason to integrate DoctorBase with their software for various reasons, including the obvious one: most EHRs already offer the features DoctorBase is selling (with the possible exception of social media ratings), and/or have similar features in development.
As Mr. Kim’s “courageous, innovative tech entrepreneurs” of fortune, who “come into healthcare at significant risk to their finances and careers,” should very well know, APIs are indeed gaining popularity in other industries. Retailers expose APIs to coupons, specials and catalogs to increase their profits from Internet commerce, and even financial institutions are beginning to nurture tech startups helping to boost bank profitability through limited sets of simple APIs. What all these APIs have in common is that they make money for the corporation that exposes the APIs, and that the Federal government had nothing to do with their creation. APIs did not come about because “walled gardens in other sectors of business annoy consumers” and they will not magically appear in health care because said walled garden’s “business practices hurt patients.”
Patients are not hurt by lack of APIs. Patients are not suffering because their EHR refuses to talk to their toothbrush. Patients are not harmed by a shortage of doctor ratings or by the inability of pharmaceutical companies to identify fat people. Patients are hurt by lack of access to doctors, by lack of medicine, by lack of food, shelter, work, education, fair wages and opportunity for a better life.
With a few notable and despicable exceptions, health care is not now, never has been and hopefully will never become a cakewalk for people looking to get rich quickly. There is no doubt in my mind that technology can help us all take better care of the sick among us, and science can help more people live healthier and longer lives. Unfortunately, there is also no doubt in my mind that the proliferation of exploitative digital health trinkets is actively and measurably bending Dr. King’s long arc of the moral universe towards anything but justice.
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