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 Welcome to this Week in Health It where we discuss the news, information and emerging thought with leaders from across the healthcare industry. This is episode number 32. Today we're going to do a deep dive episode. We're going to, we're gonna look into the future of medicine and explore the world of exponential medicine.

This podcast is brought to you by health lyrics. Health systems are moving to the cloud to gain agility, efficiency, and new capabilities. Uh, work with a trusted partner that has been moving health systems to the cloud since 2010. Visit health lyrics.com to schedule your free consultation. My name is Bill Russell.

We're covering healthcare, c i o, writer and advisor with the previously mentioned health lyrics. Before I get to our guests and update on our listener drive, our sponsor has agreed to give $1,000. Uh, for every additional a hundred subscribers to our iTunes, Google Play, and YouTube channels. This last, this is the last week of that, we've raised $3,000 for Hope Builders, an organization that provides disadvantaged youth, the life skills and job training needed to achieve enduring personal and professional success.

I've hired their graduates and their stories really are inspiring. Uh, if we get an additional 80 subscribers this week, we can make it, uh, $4,000, which would be fantastic. You can join us by subscribing today and be a part of giving someone a second chance. Today we are joined by a physician, scientist and entrepreneur among things, chair for medicine at Singularity University and founder.

Of exponential medicine. I first heard Daniel at the Exponential Medicine Conference at the Historic Hotel Del Coronado in San Diego. If you haven't gone to one of these conferences, it really does, uh, just e expand your thinking about what is possible. Uh, the next one is the first week of, uh, November in San Diego.

Today we welcome Dr. Daniel Kraft to the show. Good morning, Daniel, and welcome to the show. Well, so let me, uh, you know, you, you amongst our other guests have such great bio. I'm gonna, I'm gonna run through this real quick, uh, just for our listeners. So Daniel is, uh, Stanford and Harvard trained physician, scientist, entrepreneur, and innovator.

25 years of experience in clinical practice, biomedical research and healthcare innovation. Uh, you've chaired the medicine for Singularity University since its inception in 2008 and founded and is executive director for Exponential Medicine, a program that explores convergent rapidly developing technologies and their potential in biomedicine.

Healthcare Following undergraduate works at Brown and Stanford. Daniel was board certified in both internal medicine and pediatrics after completing a Harvard residency at Mass General and Boston Children's and Fellowships in hematology, oncology and bone marrow transplantation at Stanford. Multiple.

Uh, he has multiple scientific publications and medical device immunology and stem cell related patents through faculty positions at Stanford University School of Medicine. Clinical faculty for the Pediatric Bone Marrow Transplantation service at U C S F. Uh, Daniel is a member of the Coffin Fellow Society, member of the inaugural class of the Aspen Institute Health Innovators Fellowship.

Daniel's done some really cool academic research. I'll just for time purposes, you can check that out, Daniel Kraft md.net. He's also the inventor of the Marrow Miner, an F D A approved device for minimally invasive harvest of bone marrow and founded Regen Med. Systems, a company developing technologies that enable adult stem cell-based regenerative, regenerative therapies.

Daniel is an avid pilot and is served in the Massachusetts and California Air National Guard as an officer and flight surgeon with the F 15 F 16 fighter squadrons. He has conducted research on aerospace medicine that was published with nasa. With whom he was a finalist for astronauts selection. You know, it's, you've done so many amazing things, but I, I really have to start there.

So, um, you missed the fact I'm a Capricorn. My favorite color's blue. I like long walks. I'm still, I know. It's, you know, I, I, the, uh, but the amazing thing to me, I've read all that amazing stuff you've done in medicine, but I'm, I'm, I'm sort of fascinated with the finalist for astronaut selection. Uh, what does one have to do to become an astronaut these days?

And where did you finally get off that path? Well, there's no exact one path. Uh, but I always had the space and flying bug. I grew up in the Washington DC area. I think I went to the Airspace Museum probably a hundred times as a kid actually when I was three or four years old. I was at the very last Apollo launch, Apollo 17.

I was there. I still remember that. Uh, and years later when I was a medical student at Stanford, I did a rotation at Johnson Space Center in medical ops, and I met Gene Serin. Oh, wow. Just in, in space and flying. I knew I couldn't be a, Fighter pilot because I didn't have the 2020 vision. Uh, but I kept that interest up.

And I sort of, actually during um, college, I spent a summer at Kennedy Space Center while a medical student worked on space systems engineering, um, with some Stanford engineers building and designing missions to Mars. Got involved in the International Space University for summer during medical school.

So kind of get that space in flying passion going, um, with, you know, never quite losing that. Desire to wanna be an astronaut for being a little kid. And, uh, eventually applied. And there's no exact criteria. It helps if you might be a test pilot, you know, in the Air Force or Navy, but most of the Medical Corps are often scientists or, or engineers, uh, not necessarily full on aviators.

And they take a whole subset and there's several, um, physician astronauts. Uh, and there's a lot of medical issues, particularly if you wanna go to back to the moon and on long duration admissions to Mars. So, It was an interesting area for me to always sort of blend the interest of, of space flying, aviation, uh, space.

And as mentioned briefly, I, I, uh, didn't get to be a full on fire pilot, but I joined the International Guard as a flight surgeon, which means you're sort of the, the dock for a bunch of pilots and got to be in the squadron and fly a bunch in, in the backseat, but got to fly the f f fifteens X sixteens and get part of that world as well.

So when Elon Musk, uh, decides to go to Mars, he's gonna reach out, tap you on the shoulder, and uh, see if you're still interested in, in. Uh, practicing medicine in Mars. I at Mars, I guess we'll see. Yeah. Yeah. I, I know you on a bit. I've been to SpaceX. It's incredibly half fast. That's moving now. Um, and there are a lot of big issues if we're gonna go to Mars and have sustainable life radiation issues, uh, d d a lot of issues that you can take from space and apply to healthcare on earth, like cardiovascular, deconditioning, bone issues, radiation exposure.

So, uh, it's been a fun area to kind of cross fields. So one of the things we like to do, uh, with each of our guests is just sort of give them the floor and ask a pretty open-ended question of, uh, what are you working on today and what are you excited about? Well, I wear a couple different hats. Um, I sort of interestingly come, it's kind of through these space connections, uh, through going to International Space University, uh, kind of got hooked into the early stages of Singularity University, uh, which is su.org.

And what's interesting about, uh, many folks in health and medicine is we get really good at some specialty. I'm a oncologist, cardiology, biotech, pharma, but it's often rare that you get to bridge fields and. Part of my role sharing medicine at Singularity University and spinning out this exponential medicine program is to help particularly folks outside of and inside health and biomedicine see what's happening and what the convergence is where three D printing might be heading, or ai, which is certainly a hot topic, or healthcare it or mobile or sensors.

Uh, and you know, 10 years ago we did our first programs. You know, I was getting people the very first 23 me kits, um, or the very first Fitbits that was now, now that's sort of normal. Uh, at the time. That was pretty interesting. Um, So one of the things I'm still excited about is kind of getting this cross-fertilization, exposing folks in the healthcare world to some analogous areas.

Sometimes even lessons from aviation like checklists and simulation, uh, are being applied to health and medicine in, in very impactful ways. Um, and to bring people, people out of their silos to look at what are. Small challenges, big challenges, grand challenges across, across health and medicine, and how do we catalyze that?

That's what, what's the theme as you've seen at Exponential Medicine, is to bring people together from different fields, catalyze their thinking, see what's here now, and how do you think about where the puck is going to help, um, reshape whatever issue or realm of health and medicine you're involved in.

So that's one area I stay excited about. Um, Some of your listeners might wanna come to Exponential Medicine this November four through seven. Exponential medicine.com has a ton of links to prior talks and and content. Another fun thing I'm interested in, I'm launching, uh, in the next month or so, is there's the field of digital health, connected, mobile health, whatever you want to call it, that is sort of, uh, becoming more and more part of healthcare.

You know, it started off . Kind of as a, as a side element. But now I would argue we don't need to call it digital health. It'll be health. But I'm often asked, you know, what technologies should I use for managing a patient's hypertension or diabetes or what apps are there in VR for therapy? And, and so, um, uh, I'm launching in the next month or so, a website, digital.health, as a new.health domain to try and help bring together the sort of best of breed apps, devices, platforms.

Inform folks mostly on the clinician side, what's already out there that you could be using if you're trying to manage hypertension or, um, what diagnostic tools out there that, you know, connected, uh, stethoscopes or apps that might be already proven to be valuable. So that's another element I'm working on.

A bunch of other things we can talk about. Uh, those are a couple of things that are, I think, uh, top of mind. Yeah. So, um, that's fantastic. So let, let's, let's just dive in. So this is deep dive episode in deep dive episodes. What we do is we, uh, generally explore a single topic. Uh, we've done one on AI with Dr.

Anthony Chang. We've done one on cloud computing with Robert Rice. Uh, today looking at exponential medicine, it is actually not a single technology. It's a confluence in advancements in a lot of different technologies that's, that's changing the landscape. So let's just start at the beginning. Uh, give us an idea of what exponential medicine is.

Well, the, the term exponential is sort of, as many of you know, the idea that things progress in some fields very quickly. You know, instead of linearly 1, 2, 3, 4, 5, it goes 1, 2, 4, 8, 16, 3, 2, 6, 4, with by 30 exponential steps. You're at a billion. And the usual example we all get is, uh, you know, our, our smartphones, you know, Moore's Law impacteding, these, how, how much computer power, you know, in my iPhone.

10, uh, you know, is, is probably multifold over my iPhone one. My iPhone one would feel antique today. I still actually have it in my drawer. Uh, and that was only a decade ago. So things, especially if you look back a decade, there's that famous quote from Bill Gates. We overestimate what happens in a year and underestimate what happens in a decade.

You, it was only 10 years ago this week that Airbnb launched. It was 11 years ago that that, uh, Twitter launched South by Southwest. Um, Only 10 years ago since the app store, and now obviously the fortunes of Apple are looked like they're writing partly on, on healthcare. Uh, and we've got other big players from Amazon to, to Facebook to to, to, uh, to many others moving in that space.

So the idea is to get people thinking about the exponential or technologies that move relatively quickly and think about where are we in 2018, what will likely be available in, in 2020 or 2028. You know, one area that's gone past exponential is personal genomics. Uh, 10 years ago to get your full genome done wasn't available really commercially.

Now it's less than a thousand dollars probably in a. Arguably available for a hundred dollars or yes, and, and maybe hopefully integrated into many of the E M R and personal health records that the clinician listening and patients who might be listening will have available to them, not just with the data, but applying, as you've talked about on prior episodes, machine learning and AI to make sense of that data and turn it into actual clinical information.

So there are many things moving quickly. I think exponential can be overused as a. Kind of to encapsulate where we might wanna catalyze the future of health and medicine and bring fields together from VR to synthetic biology, to, to robotics, to, to drones that are, are moving pretty, uh, pretty quickly.

Yeah. And we're gonna look at a bunch of examples, but it really is that hockey stick. It's, you know, it's incremental, incremental, incremental. And then all of a sudden it goes up and, and you gave the example of, uh, you know, mapping the genome. And that has gone from, you know, taking a massive team and millions of dollars down to, um, I mean, 23 and me, it's, you know, send it off and here you go, here's, or at least a, you know, a portion of it.

Or, um, you know, I went down to, uh, human Longevity and, uh, health Nucleus and did that whole thing and, you know, within a week or so, and quite frankly, comparatively speaking, pennies on the dollar, that's, that's exponential. Um, in terms of just having that data, having those capabilities. As well. The most amazing part I found was I was in the full body m r I machine for about an hour.

I came out and almost immediately you probably had this experience. You saw the, the, my full body m r i and with the brain color coded so you could quantify, you know, what percentile your, uh, thalamus was compared to others, for example. Uh, and, and that, you know, really was not available until just about a year or two ago when it's gonna be available with another couple clicks of, of Moore's Law.

Um, and while human longevity, incorporator nucleus is still a bit expensive, it's getting cheaper and cheaper. As you blend those, you know, they do microbiome, genome, full body, M r I, digital health exhaust, combine that with coaching as companies like R. Others are doing, I think is the early stages of hopefully, really catalyzing shift across health and medicine.

Yeah, I, so exponential medicine is advances in imaging, robotics, genomics, uh, nano uh, technology, miniaturization, computing power, ai, all coming together and really creating this, uh, Uh, you know, may, if each one is just moving along at a certain pace, you combine all that across the board, and now you have all sorts of new, uh, capabilities.

So give us an idea of how exponentials, uh, are going to address some of the biggest challenges we have in healthcare. We have, you know, cost access, fragmented care, uh, care variation, uh, even within our communities in the us, but care variation around the world, uh, how, how does, how does exponential start to change that paradigm?

I, I think in a sense, you know, there's lots of challenges and healthcare is kinda like politics. It's a bit local, so you know, so many different healthcare systems, as you know, might have different challenges and needs some which are overlapping. I think where it provides the biggest opportunity is to move from, you know, again, somewhat buzzwordy.

We want personalized and precision medicine, but reality today we're still practicing. Kind one, one size fits all, uh, medicine. Often the same dose of statin. We start with if you're managing a patient with hypertension or diabetes, starting with the same drugs, trial and error, broken feedback loops still communicated by fax machine, uh, in many cases.

Um, and so the opportunity now to take the. Increasingly exponentially more available, accessible data. You know, whether it's our digital exhaust that can be picked up by our wearables or our smartphones or our connected mattresses, and start to connect that into our healthcare system. And, and as you've discussed in prior shows, kind of meld that information.

So understand what it means. What, what does it mean if my, my Fitbit or my mattress sensor tells me that my resting heart rate are only 55, but it's last couple months, it's creeped up to 75. Something might be happening. How do we take that baseline of data, data like barely is doing with the baseline trial or now that all of us trial out at nih and start to understand what are some of these new biomarkers, digital, omics, uh, social metrics start to mean and be then much more proactive and start to shift our sick care system to more of a, of a healthcare one where we can utilize this.

Sometimes overwhelming amount of data and turn it into proactive, useful information that fits into the workflow of the poor of a work clinician. There's some great solutions already here today, but they're not being utilized for reimbursement issues or, or someone moving someone's cheese, you know, uh, turf battles.

Um, there's a lot of other elements beyond the technology itself, the incentives, the user interfaces that need to be put together as well. Yeah, I, I'd really like to get back to that data question, but, but before I do that, I, I do wanna explore a little bit more, um, Of, of the technology. So what I'd like to do is go through a bunch of the technologies, uh, before we get really pragmatic on how does, how integrated.

I'd love to hear you just talk about, you know, some of the things that, that you are seeing, uh, because you visit, you visit a lot of these, uh, startups and, and are talking to some real innovators. So I'm just gonna go, I'm gonna rattle through some, some different areas I'd love to hear you talk about a little bit.

So let's, let's talk about the area of robotics. What are some things you're seeing in robotics? So it's not new now to have, you know, robotic surgery, uh, due to the surgicals, been a leader and those have been out for a while. Still, still debate about whether they really improve outcomes or lower cost.

But remember that's now the surgeon still very intuitively controlling every move of that robot. And I know both intuitive and several other new companies verb, which is done by barely. And uh, J and j I believe, are now starting to look at how do you blend AI With robotics, it's kind of the merger of, of, yes, we can now do things at smaller scale instead of the body and connect that to the brain and hands of a surgeon, sometimes even remotely.

But now how do we inform, uh, you know, what you're seeing through your scope? Maybe layering an M R I or CT data to see where the tumor is inside the liver. You resecting, for example, or to guide someone through a surgery. You doing remote mentoring or doing that autonomously? Looking at analyzing videos and.

Seeing that's, that's where the gallbladder duct is. And be careful if you're doing a cholecystectomy. So I think there's this interesting convergence point of robotics with ai, machine learning. And now that you can start to record every move of a, of a surgeon, let's say, on a, on a particular device, to increasingly hopefully use that for training and also to democratize, uh, surgical access when we can put maybe a surgical device in a more remote location with less trained, uh, practitioners.

Um, Obviously robotics goes beyond the surgical space. There's now wearable robotics exoskeletons are not new, but now are being applied to enable some new might be paralyzed from the waist down to walk. There's so version to that ReWalk exo, um, robotics, uh, and being integrated into wheelchairs to enable standup wheelchair that Dean Kaman, uh, developed initially.

That turned into the, um, uh, into the, into more of a commercial device. You know, there's lots of interesting robotic applications, . For someone on a stroke to wear a sort of exoskeleton, help them improve their mobility, um, all the way to aging in place and robotics in your home. My home, we've got, uh, three robots.

We have a Jibo, which is fun to interact with, kind of like a, uh, Alexa with movement. We've got a, a room, but to clean the floors, I've got a, a beam telepresence robot from Suitable Technologies. We're doing telepresence with my kids. Um, So, you know, those are things that are coming to our homes pretty quickly that can help, uh, do remote care, telemedicine or social visits, uh, or enable someone who's older to have, uh, uh, augmented, uh, daily living activities.

So robotics is getting exciting and, and, and more and more accessible. Yeah. And I, I was at a conference where, you know, uh, someone was paralyzed from the waist down and they . Essentially put on a robotic exoskeleton and that person got up and, and started walking. Now it's, it's still bulky. It's still pretty big and pretty expensive.

But that's sort of the, the concept of, of exponentials is that that's where it's at today. But through advances and, and, and uh, technology, you're gonna see the cost of that really come down and become mainstreamed a lot quicker than it would've say, uh, you know, two decades ago. Yeah, well even companies like Exo Bionics, they have, you know, their initial versions were only in stroke recovery centers.

Now you can send folks home with some of those wearable exoskeletons and so they can essentially get around their house. We're seeing Ford Motor Company now for workers are adding sort of exoskeleton suits for certain procedures where it's repetitive or it can prevent injury or help them do things that sort of superhuman strength.

So it's moving across many elements and. Of course healthcare crosses everything from wellness and prevention, including workplace prevention, uh, all the way to diagnostics and therapy, and robotics plays a role in that, including robotic diagnostics or robotics therapy. Speaking of a bit of robotic and AI blended, I just had a call earlier today with the head of the, uh, focus ultrasound foundation, another area where.

You're sort of combining the robotics of an imaging device and focused ultrasound that can do interesting therapies from treating Parkinson's to tumors in a non-invasive way. And that's a bit of a blend of, of many technologies, including clinical robotics and imaging, uh, and focused energy veins. So I'm gonna rifle through the rest of, uh, a couple more of these, but it just gives you some idea.

I mean, we we're just talking about robotics and we could probably talk for . The next two hours just about robotics, but I'm gonna hit a couple more. So, nano technologies, what, what are we, what are we seeing now? And what, what can we expect over the next decade or so? Well, like any field nanotech, VR three D printing, they all have a bit of their Gartner hype cycles.

Nanotech is one of those broad terms, you know, there's some still amazing thinking and work to think about. We can build machines down at the level of, of a, a red blood cell and to create, you know, nano machines that level, I think of nano medicine even to the point where we're already sort of doing that with engineering viruses.

Um, that's sort of nanoengineering our existing, uh, biology in a sense. Um, But as we get to sort of the, the nano scale, there's some interesting things that can be done, including on the diagnostic side. So, uh, San at m mi t using sort of nano markers to home to a tumor. Uh, and then to catalyze an enzyme that will show up as a signal in your urine.

Maybe a, a, a fantastic nano approach to doing pan cancer screening. Uh, With just as simple as a urine dipstick. Um, you can think about, um, nanotech already coming to coding of implantable devices to prevent clo. So it's a very broad field. Um, and what's getting interesting is it's merging again, this convergence with things like synthetic biology where we can now, uh, there's digital origami where you can literally build d n a, uh, and fold it, uh, uh, based on how you might program it.

And that's moving us to, to the realms of. For example, some early work, uh, at m mi t and elsewhere with nano devices that can encapsulate a chemotherapy agent and deliver it to a local environment with a combination of antibody. So lots of things coming to the nano space. Immunotherapy is essentially, I think, a form of nanotherapy engineering T cells, uh, CAR T cells.

So, uh, we all want health and medicine to get. Targeted, less toxic. And the realm of nano, I think is sort of one way of encapsulating that. So, uh, two more so augmented virtual reality. Uh, you know, we're seeing just some really neat use cases at, uh, at Cedar-Sinai. I know they're using it, um, in, in, in other health systems, are really using it to sort of almost reprogram the, the, the brain as you know.

Just, um, talk a little bit about that. I'm sitting right across the room from me. I already have my antique, uh, um, Oculus, uh, device from Facebook. Um, and I barely ever used that one. It's connected to, you know, it was $600 originally, I think it's now 200, but I had to get the, you know, $2,000 fast computer.

And then just two months ago I got the Oculus Go. It's the same basic form factor, but now I can take it on an airplane. It's really fun to give demos and put people on their first rollercoaster ride. But, uh, work that's been done at Cedar-Sinai led vibrant Spiegel and others. Is really catalyzing use of VR and AR and XR extended reality across so many different areas.

Um, You, you as people Google up. I gave a, the keynote at the augmented, uh, vir, sorry, the virtual medicine conference that was held at Cedar-Sinai last spring. And, you know, some great examples of now taking these often gaming platforms initially catalyzed by the gaming world. And, you know, the, the, the reality engines in there to now enable you to create an environment for someone in pain, for example, to be in a cold environment through snowballs and penguins.

And that has been shown to reduce, uh, the need for opiates, for chronic, uh, for acute. Chronic. There's obviously use and surgical training.

Uh, also vr for example, can take a, uh, an orthopedic surgeon, put them in the virtual operating room, give them the actual kit from Stryker or another orthopedic company, let them practice with essentially the actual instruments on the patient or the fracture type that they're about to do a procedure on.

So, I was trained in a C one D one, teach one world, it's gonna be a future of C one sim one, sim one, sim one, until you get it right. And often simulate that exactly on the anatomy of the patient you're about to operate on. Yeah. And then there's obviously augmented realities, which can be used in a variety of ways of several interesting companies and academic groups.

Blending that so the surgeon can see through the body, uh, or blend that with robotic surgery, um, all the way to patients to, to improve their gamification of, uh, recovery from physical therapy can make it much more, uh, empower, empowering. I think that's a great example. A field that, you know, five years ago you couldn't have bought an Oculus type thing for five.

It's. $200 available on amazon.com and these systems were being democratized where, where folks around the world, you don't need, need to be an academic center or you can be in Timbuktu and be programming for these and, and, and selling them online and even doing virtual trials that could accelerate the use of VR and AR and XR in, in a variety of ways.

Yeah. And you know what, the, the first exponential medicine medicine conference I went to as a patient, I was, I was pumped. I was so psyched about what the future looks like, uh, for me and for my children. And, um, but, okay, so I'm at that point I'm a c I O for a health system, and I'm, I'm just hoping beyond hope that none of my physicians are at the conference.

Because what happens, they come outta that conference and you know, Hey, let's buy this, let's do this, whatever. And I think what you're seeing is, and I wanna get into the pragmatic aspects of this. All of this is really exciting. A lot of the, the CIOs, the IT organizations, even the clinicians and the physicians, you're, you're getting a little bit of backlash 'cause there's so much change coming at them.

So I wanna, I wanna talk a little bit about that. Um, So, you know, we as patients wanna go in there and say, Hey, can I, can I hook up my scale to the, the medical record? Can I give you my Fitbit data? Can I give you my, my Health Nucleus data? And, and you start to, uh, really consume this genomics data. And I've sat in meetings with physicians where they say, no more data.

I, I can't handle any more data. I have eight minutes to talk to a patient. I, I, I just can't. So, talk to us about how are we gonna overcome that? Does, does Exponentials offer any, any hope in that? I, I would assume that AI and really augmenting the intelligence of the physician in technologies in terms of, uh, allowing them to interact with the medical record through voice and other things are gonna make them more efficient.

I mean, how, how would that play out? Do. Yeah, well that's a huge pain point, right? If, if, to back up for a little bit, if a clinician comes, uh, to special medicine and sees some of these things, what's exciting about it is you don't need to have a million dollar lab anymore. You can go and buy an Oculus or, or Rift or any, or some of the other commercial platforms and start playing with them.

In fact, at our early exponential medicine programs, we had the first Google Glass shown off by Baba Par who leading glass that surgeon and clinicians to bring those into the operating for the, so what's interesting, and I would argue that. Most hospitals, academic or not, should have a little innovation lab where you can buy some of these things again for a couple hundred dollars and start letting your clinicians try them.

And, and not, not breaking f d a or confidential rules, but seeing a pain point that they might be able to apply it to for surgical training or taking a patient who's bedbound during a bone marrow transplant and putting 'em at the beach in their VR headset. Um, so there's some ways to try these things out that don't need to be always fully implemented across your own healthcare.

But I think to the point about exponentials, we need sort of to integrate the design thinkers, the user, the UI folks. Uh, user-centered design. I mean, I, I like sometimes people call some of the EMRs epic fail for obvious reasons that it's 17 clicks, I think at Stanford to prescribe an aspirin. And I trained at the transition between paper and AMRs.

And there's some benefits to both. You wanna make. You don't want the data, you want the synthesize information. Um, and so I'm hopeful as folks are evolving the EMRs of the near future that you think about the clinician, the burnout issues are real, where you can synthesize your genomic, your h l i data, your 23 information when it's relevant.

Um, So that when you're seeing a patient that's put up just in time, you're about to prescribe a statin, well, you pop up Daniel's pharmacogenomics and you might pick a different dose of some of the statin or, or switch to Atorvastatin based on my pharmacogenomics and the data that's out there, kind of as Anthony Chock talks about, you know, intelligence based medicine, not just evidence based.

Um, so I think there's a lot of need to to blend. Not just the technology, but the way to, to meld it. And if you're a C I O or a C M O of a hospital, how do you incentivize your clinicians to use it? Um, and can they bill for an e-visit or time, uh, looking at, uh, omics information? Um, how could they get rewarded for prescribing a connected blood pressure cuff and using that to improve hypertension control or diabetes with a blood ter?

So lots of issues in there that, uh, be. Be learned from multiple systems and applied across healthcare around the world. Yeah, I love that idea of, you know, these, these technologies have come so far down in price. It used to be, Hey, we're gonna do something. It's, it kicks off a million dollar project within the health system.

Now what you're saying is you could potentially do a pilot for, you know, a couple thousand bucks and then just put the right people, small pilot, see how it goes, and then scale it from there. Um, and there's also, there's often a death by pilot. Like all these digital health companies wanna come to Stanford, U C S F or U C S D and do their thing.

There's now some folks building platforms. So you could share pilot information from folks on East Coast or Europe or Latin America. Um, you can have do clinical trials in a sense, it lowered cheaper ways on, on mobile. There was a company, we had an exp called ible, where you can now basically without much technical training, build an an iOS app that will let you do trials and democratize it.

So there's some really interesting ways to lower costs. Test some assumptions. We now know that there is hype in digital health. There's no . You know, not just giving someone a Fitbit is not gonna make them lose weight. How do you align the, I like to think about it as the, um, sort of the behavioral phenotype of a patient.

So imagine your E M R actually start to pick up on, you know, what is your. What are your carrots and sticks? How do you, when you send someone home, maybe they already have an Amazon Alexa or Google Voice and you can use that as part of the interface to keep them on top of their meds. Maybe, you know, they like badges versus points or like dollars and use that to help their digital nudges that show up on their smartwatch.

Um, same thing for the clinicians. Um, so there's, I think, some big opportunities to pull in and integrate. These elements and show that they work, uh, before we roll them out at scale. Yeah. So, uh, I do wanna talk about engagement a little bit, but um, before we get there, let's talk about some of the data challenges.

So lack of standards, uh, governance have led to sort of data silos. Um, and in some cases the data's just really hard to use. Um, and we're we're struggling to make the data actionable. Um, You know, where should we be looking at? I mean, it's, it's not just a technology solution, I would assume, and it's not just a c m s government solution, uh, and not just an internal data governance solution.

Is, is this one of the things that's holding back, uh, exponentials and really, really moving healthcare forward or. Yeah, I mean, absolutely. We're in the, you know, fourth industrial age. Many other fields have accelerated, and again, we're still often using fax machines. I think the news out this week from In New Verma was that, uh, c fax machines by 2020.

Oh, great. Uh, what about yesterday? Uh, or the other news from the same week that we're doing this? Podcast is that where Salesforce and Amazon and a couple others, not Apple yet are, are looking to do fire, f h r standardization. But you know, that's a huge issue. Not with just data silos, but ways to access, um, to do normalization.

I think the only metric that is normalized across the planet is, is i n r for, for, for Coumadin, uh, or, you know, measuring how thin your blood is, but many others are, are very different. Um, That creates challenges in, in normalizing that data and interpreting it with machine learning and ai. So, you know, I know HIMS and other conferences really look at that.

Uh, there's still huge challenges there. Uh, I don't have the exact answer, but I think now we're seeing enough catalyzation and seeing the value of opening up. Portals and enabling data to flow, hopefully even the regulatory side. You know, I think we love to hate, uh, hipaa. It, it used to be about portability.

Now it's almost all about privacy. And there's been many examples and I've had clinical cases including where the patient died with a privacy attack. 'cause you couldn't get their records released in the right timely manner. So I think we need to think, you know, uh, as things evolve, including on the d a side, Some very effective programs like the pre-check program and, you know, uh, software as a medical device.

Think about how we both regulate and catalyze information to flow, maintaining privacy, but catalyzing, uh, a bit of what I like to think is the crowdsource future of medicine. Just like, you know, 10 years ago, we were still driving with paper maps. Now you couldn't imagine driving without your Google maps or ways.

And part of that is we're all sharing our data sometimes, whether we like it or not, and can build that traffic map. What if we could build some of those healthcare maps, um, to know where the bad, uh, disease elements are, or person with a certain phenotype or genetic subtype would require different, uh, different highway.

Yeah. So, um, yeah. Let's, let's go in this direction. So I, I'd like to do two hypotheticals with you. Um, in, in the first we're going to design a health system from really from scratch that we're gonna launch in 2020, say, in the Southern California market and just say, Hey, it's Greenfield, we're starting over.

Um, and in the second scenario, I wanna talk to you about, you know, I'm gonna make you the exponential consultant to. Dr. Oul Gawande on this new role at J P M, Amazon Berkshire. Uh, and just take a few minutes to understand how exponentials might be used, uh, in care and wellness of his, uh, 1.2 million, uh, employees that he's gonna be overseeing.

So, uh, let's start with this one. So we're designing something from, from scratch. It's gonna have to integrate with what's already in our market. It's gonna have to, uh, leverage the, the, the various things that are already present. But let's assume we just got $5 billion. You and I are gonna start a new health system.

Uh, it's in Southern California. And let's just stream a little bit on, uh, you know, where do we start to invest that money to provide really proactive care versus reactive care, continuous care versus uh, sort of, uh, intermittent, sporadic care. And, uh, I mean, where, where would you start? Would it look completely different?

Like we're we should be thinking about buildings and acute care facilities or, or how, how, where would we start do you think? I. Well, any, if it's a full on system, of course you want to go from soup to nuts, from prevention, longevity through diagnostics, therapy. So you can still need the acute care facility.

But let's, let's start Rema reimagining what it would like when you might join that system. Um, using what's here now and what's coming. Um, so this is starting to bubble up. You know, the fact that I can now go my phone and get my, my Epic record from Stanford and my Stanford doc and see my digital exhaust from my smartphone, that's, but not, that's not necessarily being utilized.

So imagine a system where, When folks join this healthcare system, they get essentially a bit of the H L I R L L type element where they get their genome done. Um, and that information isn't just a, a, a data file. It gets synthesized into your personal health record and the one that you're, let's say, your primary care doctor sees, so that, uh, when you're coming in for even your annual visit, we can look at that and help tune some of your prevention, uh, uh, and maybe therapy.

It was an interesting paper out this week from SEC Cathar who was actually a resident with me at Mass General, and I'm looking at multiple genes, uh, for risk factors for let's say, uh, cardiovascular disease. So it won't be any one gene, many diseases are multifactoral. But imagine when I'm seeing you in my PA clinic, I, I can already get a look at that genetic risk score and use that to tune whether you might really need to be on a statin or what might be your optimal prevention regimen given some of those risk factors, lifestyle elements, and then obviously, Again, overused term, but patient engagement.

Uh, the fact that hopefully everyone in your system can, can touch their healthcare, how and when it fits them, right? If you're a millennial versus a baby boomer, you can interact differently with your technology and user interface than even if you have the same type one diabetes issue. Um, So melding that so it's not one size fits all precision, uh, ui uh, as well.

So then just riffing here a little bit, you know when when you have a patient with an issue, let's say something common like hypertension, um, they may now be . Uh, not just with the usual once a day blood pressure device that might be able to know, to watch. There's one coming out from online, which might squeeze your wrist, or several startups doing non-invasive, almost radar based hypertension.

So you can have essentially real-time hypertension numbers and use that in a seamless way to, to tune often two or three different drug classes. So building in these sort of algorithms and feedback loops that continue to learn. Um, and fit into both the prevention side and, and disease management. So, and that requires good user interface.

It requires some smart reimbursement elements. It maybe requires you to have a bit of a digital pharmacopia. Um, and there are clinics like Forward and others are trying to build what's the, the next generation of that primary care visit, uh, look like. Um, that's a little bit of what I would think about in terms of building a system from scratch with on the exponential, not just building it with 2018 in mind.

What kind of. Data elements or platforms or pipes might you need to preserve for what's likely to be here in a couple years. Five G is rolling out in many cities, including Southern California within the year. So what could you be doing to be thinking about five G and six G? Um, where could you be building in?

Uh, platform integrated telehealth where, uh, asynchronous or synchronous care could be used again, across the care care paradigm. So those are a few things I'd be thinking about and not just with the lens of 2018, uh, as well. Yeah. So, you know, some of the forward thinking health systems, I, I think of Geisinger who says, uh, with, uh, primary care visits, they're gonna start collecting, uh, genomic data.

Um, the other thing is, I, I love the quote. Uh, from their c e o who said, uh, our goal is to eliminate all waiting rooms within, uh, the health system. And really what he was talking about is, uh, redesigning from it's design thinking, right? So it's redesigning it from, Hey, we designed weight rooms because we designed the entire thing around the physician and the, the patients can wait.

And we have a limited resource of, of physicians. And what he's saying is, we're gonna redesign it. And it doesn't necessarily mean that you're gonna put a diff additional burden on the physician, but you're gonna think, you're gonna do the design thinking to say, alright, well how many of these visits is it, 60% of these visits, they don't even need to be in that room at all.

And we could just push these back, uh, into the home or on the device. So if you're putting a team together to think about this, you're, you're bringing together, who would you bring together? We've got $5 billion. We're gonna redo this in Southern California. What kinds of different groups or different, uh, thought processes would you wanna encapsulate as we try to design this new thing?

Yeah, you wanna build, you know, solutions, not just fragmented pieces of technology. So one of course, which is sometimes underutilized is the, the patient, my friend Lucy Englin, open notes that patient's included, he often, uh, is one of our core faculty at, at Exponential Medicine that you know, and I went through the Stanford Biodesign program.

As a fellow, you need to really understand the. The condition, whether it's type one diabetes or how to manage, uh, you know, lung cancer with the perspective of the patient, the payer, the home environment. Um, so it would be, I think, useful to run through these sort of design elements, thinking about from all sorts of angles playing out different scenarios.

And, and then how would you integrate some of the new and emerging data? And information streams are gonna come so that you could do things just in time, continuously, proactively. The idea of digital empathy, how do you send someone home, you know, after their total hip or total knee? Give them gentle questions and nudges and encouragement.

So structural enables you to pick up that they might have a, a clot in their leg that might lead to a pulmonary ables. Lots of lessons that could be learned, um, and pulled together. So he needed multidisciplinary team nurses, patients docs, the, the C I O, the the C M O. To, to think about, um, putting together a system that that connects and is less fragmented.

That's what's so frustrating for clinicians and patients. We're spending a good percentage of our time with friction, whether it's getting pre-authorizations or faxing data or filling out the, the E M R for billing purposes, not for clinical purposes. So, uh, really kind of seeing it from all these different angles and maybe even piloting ab models and learning what works and being able to iterate quickly.

Interesting. Uh, that's awesome. So, uh, so let's switch gears here and talk about, uh, uh, wan's new role, J P m, Amazon Berkshire Health. Um, Great hire for a position, tons of potential. Uh, the entity's gonna cover 1.2 million employees. As we've talked about, the potential impact is far beyond those 1.2 million employees because it's gonna be closely mo looked at potentially modeled as we go forward.

So, uh, let's break this down in two areas. One is quick wins. One is long-term ways of thinking about it. Uh, if you were his exponential , Technology consultant, uh, what technology should he be thinking about and looking at today to provide quick wins in the area of that, that 1.2 million, uh, uh, population that he's been tasked with improving their health or keeping them healthy.

Well, part of the question is what do you count as a win, right? Uh, in traditional, uh, metrics that may be saving lives or hospitalizations or dollars. So, and one of the challenges with many insurance or payers is they don't have folks from more than a couple years from the time. So why are they incentivized to help prevent, uh, diabetes from developing, et cetera.

So part of what I think is interesting about this new conglomerate, And I don't have any insider information, is that they can start to align certain incentives. I mean, they can hopefully knock out the middleman, the P B M, they can use the engine of Amazon to do just in time, same day delivery. Amazon just bought pill pack, for example.

Uh, so getting just in time meds and sort of some of the mechanics of now that have been worked out from the consumer. Angle can come to some elements of, of healthcare delivery when it makes sense, particularly, uh, bringing things to the home environment. Um, everybody from the, from from the Amazon Alexa help I phone.

I can't get up or Alexa make my doctor's appointment can be done in that system. Uh, obviously others. Um, So part of it I get, I think is interesting is they can start to align incentives and redesign some of the, the, the care pathways. Some of the quick wins, I think would be how do they get an interesting pace and engagement of their mostly hopefully healthy members, often earlier in their, in, in their, in their life realm where they can make a big difference in, in, in.

Prevent the need later for treating cancers depression. Um, a number of other issues, uh, and get folks, uh, measurably healthier on the precision wellness side. Um, I think that's, and, and, and being able to use some of the tools that, let's say Amazon has learned, and the Berkshire Hathaway to think about saving for dollars.

The big number one. Cause of bankruptcy in the US is, is, is medical. Um, so there's some interesting le probably other elements beyond the Amazon side. They can get folks thinking about how do they think about longevity elements in there as. And then I would on the exponential side, make sure that they're mapping out some of these technologies so that they're building a platform that can, that can grow.

Like, oh, we forgot the silo for personal genomes. That wouldn't be a good thing to, to miss, um, to think about, you know, leveraging voices they're already doing. Um, Taking some of the digital breadcrumbs that Amazon is good at and, and, and, and offering the right services to the right people. The idea of a digital concierge, uh, for health and for therapy.

I think it is all some of the potentials in there. Um, so it's gonna be super interesting and I think even though it's only an only a million or so, uh, members, it can be a proving ground for things that could expand even to a. Some of, uh, some folks think a national health plan, uh, that other countries have as a norm.

Yeah, it is. Um, I think there's a lot of potential there and I'm really looking forward to seeing, uh, where they go with that. Uh, unbelievably we are at the end of the show. I, I've, uh, uh, you know, promised to, uh, to, to end this on time. So, uh, you know, I wanna thank you for coming on the show. Is there a good way for people to follow you?

Yep. I'm on Twitter at Daniel Craft, k r f T. Uh, you can find me@danielcraftmd.net. Uh, exponential medicine.com has a ton of content from our conference, which, uh, is free to take a good look at and dive into. And I would encourage everybody out there whether you're, whatever role you might be in healthcare, outside of healthcare to start.

Being early, not say an early adopter, but playing with some of these technologies. You can get a certain wearable and see if that impacts your behavior, a connected scale. Look at your microbiome, your personal genetic information. Start to share it with your clinician or c i o and see if you can catalyze them to implement some of these things and open people's minds to what's here and what's coming.

'cause the future's coming faster than you think. Yeah. And so, um, do you still have spots open at the conference? I assume we sell out every year. Uh, it's an application process. We don't wanna have all pharma, orthopedic people or dermatologists, so it's a, we kind of curate a very interesting mix. But, um, uh, we still have, uh, some room, it usually fills up by early fall, uh, existential medicine com and, uh, has everything you need to know, um, and, you know, you've been there.

Hopefully it's changed a bit of your mindset about what's possible. And my favorite thing to see happen is, Eyes and minds open to, again, what's already here, what's possible, and the ways we can collaborate and converge and, and catalyze health and medicine in new ways, and not always waiting to, to invent it here or to, to, to cross the dots around the planet in a, in a faster and sometimes an exponential manner.

Obviously great presentations, but I, I found the conversation in the halls and, and whatnot just to be, uh, just really exciting to, uh, to talk with. Um, I mean, across the board, I mean, uh, uh, money people, entrepreneurs, uh, pharma, uh, I mean, it was just, it was just really fun conversations. Uh, it's drumming circle, silent disco beach runs, meditation.

It's a bit of a, uh, not your usual conference, uh, as well. Yeah. And, and, and the, the ob the hotel is, is historic and it's, it's, uh, worth going, uh, just to spend some time in that, in that place. It's, it's amazing. Uh, awesome. Uh, you could follow me on Twitter at the patient cio by writing on the Health Lys website.

Don't forget to follow the show on Twitter this week, init and check out the website at this week in health it.com. Catch the videos on our YouTube channel. Uh, easiest way to get there is this, this week, health it com video. Please come back every Friday for more news information and commentary from industry influencers.

That's all for now.

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