Daniel Kraft, Physician-Scientist and Chair for Medicine at Singularity Univ & Exponential Medicine stops by to discuss the promise of Exponential Medicine. Robotics, Nano Technologies, Augmented and Virtual Reality, Artificial Intelligence (Augmented Intelligence), 3D Printing, Brain-Computer Interface to name a few.
Bill Russell: 00:08 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 going to 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 dot com to schedule your free consultation. My name is Bill Russell recovering healthcare cio, 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 get $1,000 for every additional 100 subscribers to our itunes, Google play and youtube channels.
Bill Russell: 00:54 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 a $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 other things, chair for medicine at Singularity University and founder and chair 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. Just a expand your thinking about what is possible. The next one is the first week of November in San Diego.
Bill Russell: 01:46 Today we welcome Dr Daniel Kraft to the show. Good morning, Daniel. Welcome to the show. You well. So let me, uh, you know, you, you amongst our other guests have such great bios. I'm gonna. I'm gonna. Run through this real quick just for our listeners. So Daniel is a Stanford and Harvard trained physician, scientist, inventor, entrepreneur and innovator. Twenty five 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 and 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 in medical device immunology and stem cell related patents through faculty positions at Stanford University School of Medicine and clinical faculty for the pediatric bone marrow transplantation service at UCF, a Daniel is a member of the Kauffman fellows society, member of the inaugural class of the Aspen Institute, Health Innovators Fellowship. Daniels done Some really cool academic research. I'll just for time purposes, you can check that out. DanielKraftmd.net. He was also the inventor of the marrow miner, an FDA approved device for minimally invasive harvest of bone marrow and founded regene med systems, a company developing technologies that enable adult stem, cell based regenerative, regenerative therapies Daniel is an avid pilot and has served in the Massachusetts and California Air National Guard as an officer and flight surgeon with the f15 and f16 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 really have to start there. So
Daniel Kraft: 03:56 you missed that I'm a capricorn. My favorite color is blue. I like long walks on the beach,
Bill Russell: 04:00 you know, I, I the uh, but the amazing thing to me, you read all that amazing stuff you've done in medicine, but I'm, I'm, I'm sort of fascinated with the finalists for astronauts selection. Uh, what does one have to do to become an astronaut these days? And where did you finally get off that path?
Daniel Kraft: 04:16 Well, there's no exact one path, but I always had the space and flying bugs. I grew up in Washington DC area. I think I went to the airspace museum probably 100 times as a kid. Actually when I was three or four years old. I was the very last apollo, apollo 17. I was there. I still remember that. And years later when I was a medical student at Stanford, I did a rotation at Johnson Space Center in medical ops. I met Gene Cernan
Bill Russell: 04:37 oh wow.
Daniel Kraft: 04:40 Just in, in space and flying and you know, I couldn't be a fighter pilot because I didn't have 20 slash 20 vision. But I kept that interest up. And actually during college I spent a summer at Kennedy Space Center while medical student worked on spaces and engineering 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 this space in flying passion going, um, with, you know, never quite losing that desire to want to be an astronaut from being a little kid. And uh, they, I actually applied and there's no exact criteria. It helps if you might be a test pilot in the air force or navy, but most of the medical corps are often scientists or engineers and not necessarily full on aviators and they take a whole subset and there's several physician astronauts, uh, and there's a lot of medically issues particularly if you want to go to back to the moon and on long duration missions to Mars. So it was interesting area for me. It always sort of blend the interest of space flying aviation space. And as mentioned briefly, I didn't get to be a full on fighter pilot, but I joined the international guard as a flight surgeon, which means you're sort of the dock for a bunch of pilots and got to be in the squadron and fly a bunch in the back seat. I got t fly the f15s f16s and get part of that world as well.
Bill Russell: 05:56 So when Elon Musk 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, in, uh, practicing medicine in Mars, Mars. I guess we'll see.
Daniel Kraft: 06:11 I've been to SpaceX. It's incredible how fast that's moving now. Um, and there are a lot of big issues if we're going to go to Mars and have sustainable life radiation issues, 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.
Bill Russell: 06:33 So one of the things we like to do 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?
Daniel Kraft: 06:43 Well, I wear a couple of different hats. Um, you know, I sort of interestingly come, it's kind of through the space connections through going to international space. University kind of got hooked into the early stages of singularity university, which is Su.org. And what's interesting about many folks in health and medicine is we get really good at some specialty. I'm an oncologist, cardiology, biotech, Pharma, but it's often rare that you get to the bridge fields and part of my role of chairing 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 help their IT or mobile or sentence or a. and you know, 10 years ago we did our first programs.
Daniel Kraft: 07:29 You know, I was getting people their first 23 and me kits or the very first fitbit that was now, now that 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 very impactful ways. Um, and to bring people out of their silos to look at what are small challenges, big challenges, grand challenge across health and medicine and how do we catalyze that? That's what's the theme of 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 reshaped whatever issue or realm of health and medicine you're involved in.
Daniel Kraft: 08:17 So that's one area I stay excited about. Something that your listeners might want to come to the exponential medicine this November fourth through seventh, exponential medicine.com has a ton of links to prior talks and content. Another fun thing I'm interested in them launching 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 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 will be health, but I'm often asked what technologies should I use for managing a patient's hypertension or diabetes or what apps are there in Vr for therapy? And so, um, uh, I'm launching in the next month or so, a website, digital.health as a new dot health domain to try and help bring together the sort of best of breed apps, devices, platforms, but also inform folks mostly on the clinician side, what's already out there that you could useing if you're trying to manage hypertension or, um, what diagnostic tools out there that connected a stethoscopes or apps that might be already proven to be valuable.
Daniel Kraft: 09:18 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, top of mind.
Bill Russell: 09:25 That's fantastic. So 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 is actually not a single technology, but it's really a confluence and advancements in a lot of different technologies that's changing the landscape. So let's just start at the beginning. Give us an idea of what exponential medicine is.
Daniel Kraft: 09:56 Well, the term exponential is sort of, as many of you know, that idea that things progress in some fields very quickly, you know, instead of linearly, one, two, three, four, five, he goes, one, two, four, eight, 16, 32, 64 with 30 exponential steps here at a billion. And the usual example, we all get, as you know, our, our smartphones, you know, Moore's law impacting these. How much computer power, you know, in my iphone 10 is probably a multifold over my iphone one. My iphone one would feel antique today. 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. Underestimate what happens in a decade. And it was only 10 years ago this week that airbnb launched. It was 11 years ago that that a twitter launched at south by southwest, I'm only 10 years ago since the APP store now obviously the fortunes of apple are looked like the riding partly on, on healthcare, and we've got other big players from Amazon to facebook to, to, to, to many others moving in that space.
Daniel Kraft: 10:55 So the idea is to get people thinking about the exponential technologies that move relatively quickly and thinking about where are we in 2018, what will likely be available in 2020 or 2028. And the one area that's gone past exponentials, is personal genomics, uh, 10 years ago to get your full genome done, wasn't an available commercially. Now it's less than a thousand dollars probably in a couple of years will be readily available for hundred dollars or less. And maybe hopefully integrated into the Emr and personal health records that the clinicians listening and patients who might be listening will have available to them. Not just with the data but applying, as you talked about in prior episodes machine learning and ai to make sense of that data and turn it into actual clinical information. So many things moving quickly. I think exponential can be overused as a term, but we use that kind of to encapsulate what we might want to catalyze the future of health and medicine and bring fields together from vr to synthetic biology to robotics, drones that are moving pretty, uh, pretty quickly.
Bill Russell: 11:54 Yeah. And we're going to 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 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, yeah, I mean 23 and me, you know, send it off and here you go. Here's or at least a portion of it or um, you know, I went down to a human longevity and 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 exponential in terms of just having that data, having those capabilities, and
Daniel Kraft: 12:36 the most amazing part I found was I was in the full body MRI machine for about an hour. I came out and almost immediately you probably had this experience, you saw the, my full body Mri in the brain color coded so you could quantify, you know, what percentile you're a Thalamus was compared to others, for example. Uh, and, and that really was not available till just about a year or two ago when it's going to be available with another couple of clicks of, of Moore's law. Um, and while human longevity inc nucleus is still a bit expensive, it's getting cheaper and cheaper and as you blend those microbiome genome, full body Mri, digital health exhaust, combine that with coaching as companies like our balers are doing, I think is the early stages of hopefully really catalyzing shifts across health and medicine.
Bill Russell: 13:20 Yeah. So exponential medicine is advances in imaging, robotics, genomics, a nano technology, miniaturization, computing, power, ai all coming together and really creating this, uh, uh, you know, 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 capability. So give us an idea of how exponentials are going to address some of the biggest challenges we have in healthcare. We have, you know, cost access, fragmented care, a care variation even within our communities in the US, but the care variation around the world. Uh, how, how does, how does exponential start to change that paradigm?
Daniel Kraft: 14:02 You know, there's lots of challenges in healthcare is kind of like politics. It's a bit local. So you know, so many of healthcare systems as you know, may 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 in reality today we're still practicing kind one fit, one size fits all medicine, often the same dose of statin we start with your managing a patient with hypertension or diabetes trying out the same drugs, trial and error, broken feedback loops all communicated by fax machine, uh, in many cases. Um, and so the opportunities 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.
Daniel Kraft: 14:50 And, and as you've discussed on prior shows kind of Meld that information to understand what it means, what, what does it mean if my, my fitbit or my Metro Center tells me that my resting heart rates normally 55, but it's on the last couple months, it's creeped up to 75. So that might be happening. How do we take that baseline of data like barely is doing what the baseline trial or now that all of us trial at Nih and start to understand whether some of these new biomarkers, digital omix a social metrics start to mean and be then much more proactive and start to shift our sick care system to more of a healthcare. One where we can utilize this sometimes overwhelming amount of data and turn it into corrective useful information that fits into the workflow of the horrible worked clinician. There's some great solutions are already here today, but they're not being utilized for reimbursement issues or, or someone moving someone's cheese, you know, sort of battles.
Daniel Kraft: 15:40 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.
Bill Russell: 15:47 I'd really like to get back to that data question, but, but before I do that, I do want to 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 do they get integrated into the health system? And I'd love to hear you just talk about some of the things that you're seeing because you visit, you visit a lot of these startups and, and are talking to some real innovators. So I'm just going to go. I'm going to 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?
Daniel Kraft: 16:26 so it's not new now to have robotic surgery tool surgicals been a leader and those have been out for awhile, still debate about whether they improve outcomes or lower cost but remember now Thats surgeon still very intuitively controlling every move of that robot and I know both intuitive and several other new companies verb which is owned by barely and Jnj are now starting to look at how do you blend ai with robotics kind of a merger of, of yes, we can now do things at smaller scale inside 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 MRI or cta to see where the tumor is inside the liver. You're resecting, for example, or to guide someone through a surgery youre doing remote mentoring or doing that.
Daniel Kraft: 17:12 Autonomously looking at analyzing videos and seeing that that's where the gallbladder duct is. And be careful if you're doing a colon cystectomy. So I think there's this interesting convergence point of robotics with ai and machine learning and now that the they start to record every move of a surgeon, let's say on a particular device to increasingly hopefully use that for training and also to democratize surgical access when we can put maybe a surgical device in a more remote location with less trained practitioners. I'm going to say robotics goes beyond the surgical space. There's now wearable robotics. Exoskeletons are not new, but now being applied to enable some new might be paralyzed from the waist down to walk theres a version of that rewalk XO bionics robotics in being integrated to wheelchairs to enable standard wheelchairs. That dean Kamen, a developed initially that turned into the, uh, into the, into more of a commercial device.
Daniel Kraft: 18:03 You know, there's lots of interesting robotic applications might be for someone with a stroke to where wear a sort of exoskeleton help them improve mobility all the way to aging in place and robotics in your home. My home, we've got a three robots. We have a jibo fun to interact with, kind of like a, uh, Alexa with movement. We've got a rhumba to clean the floors, I've got a beam telepresence robots, drones, suitable technologies for 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 or enable someone who's older to have a, uh, augmented, uh, daily living activities. So robotics is getting exciting and, and, and more, more accessible.
Bill Russell: 18:43 Yeah. I was at a conference where someone was paralyzed from the waist down and they essentially put on a robotic exoskeleton and that person got up and started walking. Now it's, it's still bulky. It's still pretty big and pretty expensive, but that's sort of the concept of, of exponentials is that that's where it's at today. But through advances in technology, you're going to see the cost of that really come down and become mainstreamed a lot quicker than it would have, say a, you know, two decades ago.
Daniel Kraft: 19:16 Even companies like Exxon bionics, they have, you know, the initial versions were only in stroke recovery centers. Now you can send folks homeless in those wearable that's skeletons and so they can get around their house. We're seeing at 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, 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 focused ultrasound foundation another area where you're sort of combining robotics of an imaging device and focus ultrasound that can do interesting therapies for treating Parkinson's to tumors in a noninvasive way. And that's a bit of a blend of, of many technologies including robotics and imaging and focused energy beams.
Bill Russell: 20:14 So I'm going to rifle through the rest of the, uh, a couple more of these, but it just gives you some idea. I mean, we were just talking about robotics and we could probably talk for the next two hours just about robotics, but I'm going to hit a couple more. So nanotechnologies what, what are we, what are we seeing now and what can we expect over the next decade or so?
Daniel Kraft: 20:33 Like any field nanotech Vr 3D printing. They will have submitted their gardener hype cycles. Nanotech is one of those broad terms, you know, there's some still amazing thinking and work to think that we can build machines down at the, of, of 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. That's nanoengineering our existing biology in a sense. Um, but as we get to sort of the nanoscale, there's some interesting things that can be done, including on the diagnostic side. So Sangeeta Bhatia at mit and using sort of Nano markers to home to a tumor and then to catalyze an enzyme that will show up as a signal in your urine. Maybe a, a fantastic nano approach to doing pan cancer screening with just simple as a urine dipstick.
Daniel Kraft: 21:27 You can think about nanotech already coming to coding of implantable devices to prevent client. So it's a very broad field in what's getting interesting is it's merging again, this convergence where things like synthetic biology where we can now there's digital origami where you can literally build Dna, uh, and fold it based on how you might program it and that's moving us to the realms of, for example, some early work at Mit and elsewhere with Nano devices that can encapsulate a chemotherapy agent and deliver it to a local environment with a combination of money. So lots of things coming to the nano space. And you know, therapy is essentially, I think a form of nanotherapy engineering, t cells, car t cells. So 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 it.
Bill Russell: 22:16 So two more. So augmented virtual reality. We're seeing just some really neat use cases at a, at Cedar Sinai. I know, they're using it in other health systems are really using it to sort of almost reprogram the brain as you know. You talk a little bit about that
Daniel Kraft: 22:37 for me, I already had my antique oculus device from facebook and I barely ever used that one that's connected to, you know, $600 version. I think it's that $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 for giving demos and put people in their first roller coaster ride. But a work has been done at Cedar Sinai led by Brennan Spiegel and others is really catalyzing use of vr and ar and xr extended reality across so many different areas. Um, people google up. I gave a keynote at the augmented a, started the virtual medicine conference that was held at Cedar Sinai last spring and you know, some great examples and now taking these often gaming platforms initially catalyzed by the gaming world and the reality engines in there too.
Daniel Kraft: 23:28 Now enable you to create an environment for someone in pain, for example, to be in a cold environment, throw snowballs at penguins, and that has been shown to reduce the need for opiates for chronic, for acute and chronic pain patients. There's obviously the use of Vr and ar now in surgical trainings and very something startups from a. also Vr, for example, can take a, uh, an orthopedic surgeon, put them in the virtual operating room, given 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 we, I was trained at a see one, do one teach one world, it's going to be a future of see one, sim one, sim one, sim one until you get it right. You know and simulate that exactly on the anatomy of the patient you're about to operate on.
Daniel Kraft: 24:14 And then there's obviously augmented reality 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 or blend that with robotic surgery. I'm all the way do patients to improve their gamification of recovery from physical therapy can make it much more empowered, empowering. And so I think that's a great example of field that, you know, five years ago you couldn't have bought an Oculus type thing for $5,000,000. Now it's essentially a $200 available on Amazon.com and these systems are being democratized for folks around the world. You don't even 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 a variety of ways.
Bill Russell: 24:58 Yeah. And you know, 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 for me and for my children. And, um, but okay, so at that point I'm a cio for a health system and I'm just hoping beyond hope that none of my physicians are at the conference because what happens, they come out of 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 want to get into the pragmatic aspects of this, all of this is really exciting. A lot of the CIO, the it organizations, even the clinicians and the physicians, you're, you're getting a little bit of backlash because there's so much change coming at them. So I want to, I want to talk a little bit about that.
Bill Russell: 25:41 Um, so you know, we, as patients want to go in there and say, Hey, can I, can I hook up my scale to the medical record? Can I give you my fitbit data? Can I give you my, my health nucleus data? And you start to really consume this genomic data. And I've sat in meetings with physicians where they say, no more data. I can't handle any more data. I have eight minutes to talk to a patient. I just can't, so talk to us about how are we going to overcome that. Does exponentials offer, any, any hope in that. I would assume that ai and really augmenting the intelligence of the physician and technologies in terms of allowing them to interact with the medical record through voice and other things are going to make them more efficient. I mean, how. How would that play out do you think?
Daniel Kraft: 26:27 Well, that's a huge pain point right? To back up a little bit. If a clinician comes a to a special medicine and see 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 rift or some of the other commercial platforms and start playing with them. In fact, in their early exponential medicine programs, we had the first google glass shown off by the parties, who was on reading glass that inspired civil surgeon, the coalitions to bring those into the operating room for the first time. So what's interesting, and I would argue that most hospital academic or not should have a little innovation lab where you can buy some of these things for, again, for a couple hundred dollars and start letting your clinicians try them and not breaking FDA or confidentiality rules, but seeing the pain point that they might be able to apply it to the for surgical training or taking a patient who's bed bound, doing a bone marrow transplant and putting them at the beach in the Vr headset.
Daniel Kraft: 27:16 Um, so there's some waysd to try these things out that don't need to be always fully implemented across your whole healthcare system. That add expense and reimbursement levels. Um, but I think to the point about exponentials, we need sort of to integrate the design thing. There's the user and the Ui folks. A user centered design. I mean I like sometimes people call some of the Emr epic fail for obvious reasons that it's 17 clicks. I think Stanford to prescribe an aspirin and I trained at the transition between paper and Amr and there's some benefits to both, but you want to make, you don't want the data you want to synthesize information. And so I'm hopeful as folks are evolving the Emr of the near future that you think about the clinician, the burnout issues are real, where you can synthesize your genomic, your Hli data, you're 23 information whats relevant, so that what you're seeing the patient that's put up just in time you're about to prescribe a staton?
Daniel Kraft: 28:09 Well, we pop up Daniel's pharmacogenomics and you might pick a different dose of some of the staton or switched to a tourbastanton based on my pharmacogenomics and the data that's out there kind of as anthony chang talks about, you know, intelligence based within us and not just evidence based. Um, so I think there's a lot of need to blend not just the technology but the way to, to Meld it. And if you're a cio or cmo of a hospital, how do you incentivize your clinicians to use it? And can they bill for an e-visit or time? Uh, looking at, uh, omix 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 connected blood pressure cuff or a glucometer. So lots of issues in there that hopefully can be lessons can be learned from multiple systems and apply it across healthcare around the world.
Bill Russell: 28:59 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 going to do something. If 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.
Daniel Kraft: 29:20 There's nothing to death by pilot, like all these digital health companies to come to Stanford, of UCSF, or UCSD and do their thing. And there's now some folks building platforms. So you could share pilot information from folks on the East Coast or Europe or Latin America. Um, you can have clinical trials in the sense it lower, cheaper ways on mobile. There was a company we had an exhibition was called Netable, where you can have basically without much technical training, building an Ios app that will let you do trials and democratize it. So there's some really interesting ways to lower cost test some assumptions. We now know that there is hype in digital health. There's now you know that just giving someone a fitbit is not going to make them lose weight. How do you align the, I like to think about it as the sort of the behavioral phenotype of a patient.
Daniel Kraft: 30:03 So imagine your Emr 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 and 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 are 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 before we roll them out at scale.
Bill Russell: 30:35 Yeah. So, uh, I do want to talk about engagement a little bit, but before we get there, let's talk about some of the data challenges. So lack of standards. A governance have led to this sort of data silos and in some cases the data is just really hard to use. Uh, and we're struggling to make the data actionable. Um, you know, where should we be looking at? I mean it's not just the technology solution I would assume and it's not just a cms government solution, uh, and not just an internal data governance solution. Is this one of the things that's holding back a exponentials and really, really moving healthcare forward or
Daniel Kraft: 31:13 in the fourth industrial age, many other fields have accelerated. And again, we're still up and using fax machines. I think the news out this week from New Burma was that a eliminating fax machines by 2020 how great, uh, what about yesterday or the other news from the same week that we're doing this podcast is that with salesforce and Amazon and a couple others, not apple yet, or looking to do fire fhr 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 his inr for, for, for Coumadin or measuring how thin your blood is, but many others are, are very different. Um, and that creates challenges and normalizing the data and interpreting it with machine learning and ai. So, you know, I know himss and other conferences really look at that.
Daniel Kraft: 32:04 There's still a huge challenges there. 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 a Hipaa. It used to be about portability. Now it's almost all about privacy and there's been many examples. I've had clinical cases including where a patient died with their privacy in tact because 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 FDA side, which they're doing with, with um, great effective programs like the precheck program and you know, a software as a medical device thinking about how we regulate and catalyze information to flow, maintaining privacy, but catalyzing 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 would it be for those health care maps to know where the bad a disease elements are or person with a certain phenotype or genetic subtype would require different. A different highway.
Bill Russell: 33:17 Yeah. So, um, let's, let's go into this direction. So I'd like to do two hypotheticals with you, um, and, and the first we're going to design a health system from really from scratch that we're going to launch in 20 slash 20, say in the southern California market and just say, hey, Greenfield, we're starting over. And in the second scenario I want to talk to you about, you know, I'm going to make you the exponential consultant to, uh, uh, Dr Gawande on this new role at Jpm, Amazon, Berkshire, and just take a few minutes to understand how exponentials might be used in care. And wellness of his $1.2 million, uh, employees that he's going to be overseeing. So, uh, let's start with this one. So we're designing something from scratch. It's going to have to integrate with what's already in our market. It's going to have to, uh, leverage the various things that are already present. But let's assume we just got $5,000,000,000. You and I are going to start a new health system. It's in southern California. And let's just dream a little bit on, you know, where do we start to invest that money to provide really proactive care versus reactive care, continuous care versus a sort of a intermittent sporadic care. And uh, where, where would you start? What would it look completely different? Like we're, we should be thinking about buildings and acute care facilities or our how, where would we start, do you think?
Daniel Kraft: 34:40 Well, 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 start remanned reimagining what would like when you might join that system I'm using what's here now, 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 Document, see my digital exhaust from my smartphone. That's not, that's not necessarily being utilized. So imagine a system where when folks joined this healthcare system. They get essentially a bit of the Hli are avail type element where they get their genome done. Um, and that information isn't just a data file, it gets synthesized into your personal health record and the one that you're, let's say a primary care doctor sees so that when you're coming in for even your annual visit, we can look at that and help tune some of your prevention.
Daniel Kraft: 35:32 Uh, maybe therapy with an interesting paper out this week from Sec Authority who was actually a resident with me and mass general and I'm looking at multiple genes for risk factors for lets say cardiovascular disease. So it won't be any one gene we've got many diseases are multifactoral. Imagine when I'm seeing you in my clinic, I can already get a look at that genetic risk score and use that to tune whether you rightly need to be on staten or what might be your optimal prevention regimen given some of those risk factors. Lifestyle elements. Um, and then obviously again, overused term, but patient engagement, 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're gonna interact differently with your technology and user interface than even if you have the same type one diabetes issue. So melding that so it's not one size fits all.
Daniel Kraft: 36:24 Precision a Ui as well. So then just riffing here a little bit, you know, when, when you have a patient with an issue, say something common like hypertension, they may now be a not just with the usual, once a day blood pressure device, it might be able to go to a watch there's one coming Omron, which might squeeze your risks or several startups doing noninvasive, almost radar based hypertension so you can have essentially realtime hypertension numbers and use that in a seamless way to tune often two or three different drug classes. So building in these sort of algorithms and feedback loops to continue to learn, um, and fit into both the prevention side and disease management. So that requires good user interface that requires some smart reimbursement elements. It requires you to have a bit of a digital Pharmacopeia, um, and there are clinics like forward and others are trying to build what's the, the next generation of that primary care visit look like.
Daniel Kraft: 37:19 Um, that's a little bit of, 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 a platform integrated telehealth where a asynchronous or synchronous care it could be used, again across the care paradigms. So those are a few things I'd be thinking about and not just with leds of 2018 as well.
Bill Russell: 37:56 Yeah. So some of the forward thinking, health systems, I think of geisinger who says a with a primary care visits, they're going to start collecting genomic data. Um, the other thing is I love the quote from their CEO said, uh, our goal is to eliminate all waiting rooms within the health system. And really what he's talking about is a redesigning. It's designed thinking, right? So it's redesigning it from a, we designed weight rooms because we designed the entire thing around the physician and the patients can wait and we have a limited resource of, of physicians and what he's saying is we're going to redesign it and it doesn't necessarily mean that you're going to put a different additional burden on the physician, but you're going to think you're going to do the design thinking to say, all right, well how many of these visits is it? Sixty percent of these visits. They don't even need to be in that room at all and we can just push these back 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? So we've got $5,000,000,000, we're going to Redo this in southern California. What kinds of different groups or different thought processes would you want to encapsulate as we tried to design this new thing?
Daniel Kraft: 39:07 You want to build solutions, not just fragmented pieces of technology. So one of course which is sometimes underutilized is the patient, my friend Lucy in England, often notes that patients included he often is one of our core faculty at exponential medicine that, you know, and I went through the Stanford biodesign program as a fellow, you need to really understand the condition, whether it's type one diabetes or how to manage a 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 then how will you integrate some of the new and emerging data and information streams are going to come so that you can do things just in time continuously, proactively now do you have digital empathy.
Daniel Kraft: 39:53 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 clot in their leg that might lead to a pulmonary embolus, lots of lessons that could be learned and pulled together. So I need a multidisciplinary team, nurses, patients, docs, the cio, the Cmo to to think about putting together their system that connects and is less fragmented. That's what's so frustrating for clinicians and patients were spending a good percentage of our time with friction, whether it's getting preauthorization or faxing data or filling out the, the Emr for billing purposes, not for clinical purposes. So a really kind of seeing it from all these different angles and maybe even piloting ab models and learning what works and being able to intergrate quickly.
Bill Russell: 40:40 Interesting. That's awesome. So, uh, so let's switch gears here and talk about, Atul Gawandes new roll jpm, Amazon, Berkshire Health, a great hire for a position, tons of potential. Uh, the entity is going to cover one point 2 million employees of. We've talked about the potential impact is far beyond those one point 2 million employees because it's going to be closely 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, or 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 one point 2 million of a population that he's been tasked with improving their health or keeping them healthy?
Daniel Kraft: 41:29 Well, part of the question, what do you count as a win, right? In traditional metrics that may be saving lives or hospitalizations or dollar. So, and one of the challenges we have with many insurance or payers is they don't have folks from more than a couple of years at the time. So why are they incentivized to help prevent diabetes from developing, etc. 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 mean they can hopefully knock out the middleman, the pbm, they can use the engine of amazon to do just in time, same day delivery. Amazon just bought pillpack 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 healthcare delIvery when it makes sense.
Daniel Kraft: 42:12 Particularly, uh, bring things to the home environment. everything from the amazon. Alexa help, I've fallen, I can't get up or alexa make my doctor's appointment can be done in that system. Obviously others. Um, so part of that I think is interesting as they can start to align incentives and redesigned some of the, the care pathways, some of the quick wins I think would be how do they get an interesting pacing engagement of their mostly hopefully healthy members of an earlier in their, in their life realm where they can make a big difference in and, and prevent the need later for treating cancers, depression, a number of other issues get folks a measurably healthier on the precision wellness side. I think that's. And, and, and being able to use some of the tools that amazon has learned and the berkshire hathaway's to think about saving for dollars.
Daniel Kraft: 43:03 The number one cause of bankruptcy in the us is his medical. Um, so there's some interesting probably other elements beyond the amazon side. They can get folks thinking about how do they think about longevity, the saving elements in there as well. And then I went 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 leveraging voices they're already doing. taking some of the digital breadcrumbs at amazon is good at and, and offering the right services to the right people. They have to have a digital kind of shares, uh, for health and for therapy I think 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 members, it can be a proving ground for things that could expand even to, uh, some of, uh, some folks think a national health plan that other countries have as an norm.
Bill Russell: 43:59 Yeah, it is. Um, I think there's a lot of potential there and I'm really looking forward to seeing where they go with that. Unbelievably. We are at the end of the show. I made a promise to, uh, to, to end this on time. So I want to thank you for coming on the show. Is there a good way for people to follow you?
Daniel Kraft: 44:17 Yep. I'm on twitter @Daniel_kraft k r a, f t. I can find me at danielkraftmd.net, a exponentialmedicine.com has a ton of content from our conference, which 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 and see an early adopter, but playing with some of these technologies, you get a certain wearable and see that impacts your behavior. A connected scale, look at your microbiome, your personal genetic information. Start to share it with your clinician or cio and see if we can catalyze them to implement some of these things and opened people's minds to what's here and what's coming because the future is coming faster than you think.
Bill Russell: 44:55 Yeah. Um, so, um, you still have spots open at the conference. I assume
Daniel Kraft: 45:00 we sell out every year. Uh, it's an application process. We don't want to have all pharma or orthopedic people or dermatologist. So it's when you kind of curate a very interesting mix. But, um, uh, we still have some room and usually fills up by early fall, a exponential medicine.com and 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 people's eyes and minds open to again what's already here, what's possible and the ways we can collaborate and converge and catalyze health and medicine in new ways and not always waiting to be invented here or to, to cross the dots from another Planet in a, in a faster and sometimes in an exponential manner.
Bill Russell: 45:42 Yeah. OBviously great presentations, but I found the conversation in the halls and whatnot just to be a, just really exciting to, uh, to talk with. UM, I mean across the board, I mean a money, people, entrepreneurs, a pharma. I mean it was just, it was just really fun conversations.
Daniel Kraft: 46:03 A disco beach runs meditation. It's a bit of a unusual conference as well.
Bill Russell: 46:10 Yeah. And, and the, the, the hotel is, is historic and it's worth going, uh, just to spend some time in that, in that place. It's, it's amazing. Uh, awesome. You can follow me on twitter @thepatientscio, my writing on the health lyrics's website. Don't forget to follow show on twitter @thisweekinHit and check out the website @thisweekinhealthit.com. Catch the videos on our youtube channel. The easiest way to get there thisweekinhealthit.com/video. Please come back every friday for more news, information and commentary from industry influencers. That's all for now.