Sunday, May 20, 2012

Topol-logy 101: Healthcare for Homo Digitus

Cardiologist Eric Topol's recent book The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care was quite an eye-opening and thought-provoking read. We live in an age where our lives are heavily reliant on smartphones and other digital gadgets. Be it navigation, finding a nearby restaurant, or simple event reminders, digital practice has transformed our lives. Yet healthcare continues to be a different (and alarmingly primitive) experience. Some radical change is called for in this arena, be it in small matters like eliminating the annoying paperwork preceding a doctor appointment or getting your physician to respond to your emails quicker or bigger matters like conquering deadly diseases, saving lives, and reducing healthcare costs. This "transformation that accompanies radical innovation" is what Dr. Topol refers to as "creative destruction" in the title of his book. The key to it lies in the unified incorporation of four digital domains into healthcare: wireless physiological monitoring, genomics, imaging, and health information technology.
Wireless Sensors: Continuous monitoring of physiology using wireless sensors can not only improve patient lifestyle but also reduce the numbers of hospitalizations (thereby cutting healthcare cost and eliminating risks of hospital-acquired infections). The book offers an extensive coverage of currently available wireless physiological monitoring options, including continuous glucose monitors (CGM) and heart rhythm monitors like CardioNet or iRhythm (the latter being referred to as the "Netflix model" since it involves mailing the adhesive chest patch for interpretation). In addition, it proposes interesting ideas for the future such as color-changing contact lenses and nanoparticle-embedded digital tattoos for glucose monitoring and insulin pumps operated by feedback from CGM to enable blood glucose autoregulation!
Genomics: As we know, medicine today is geared toward a population rather than an individual. That is the spirit of the expensive large-scale phase III clinical trials conducted before approving each drug. The example of Plavix in this book is a compelling one demonstrating the downside of this approach. Plavix is a drug intended to prevent strokes and heart attacks in patients at risk for these problems. It was the second largest prescription drug in the world when a study showed that bearers of a particular gene variant (which plays a role in the metabolism of this drug in the liver) actually have a higher risk of stent clotting with this drug. Medicine of the future, therefore, needs to be founded on an individual's omics profile, including genomics, transcriptomics (the RNA transcripts from genes or noncoding RNAs), proteomics (all the proteins that are translated), metabolomics (all the metabolites), epigenomics, and microbiomics (the species of bacteria, fungi, and viruses inside an individual's body). 
Imaging: Diagnosis and therapeutic assessment of a wide range of diseases is reliant on medical imaging procedures. The cost, safety, and accuracy of these procedures therefore tend to be critical. While some imaging methods have portable alternatives (Vscan in place of a cardiac echo), this is not realizable for all methods (e.g. MRI which uses a bulky super-conducting magnet). Then there is the question of financial burden from unnecessary procedures, patient distress due to false positives, and, finally, radiation dose. Turns out approximately 30 percent of the overall radiation exposure to the U.S. population related to medical imaging is attributed to heart imaging alone. Imaging breakthroughs can impact healthcare in profound ways. One example is the development of the PIB PET tracer for tagging beta-amyloid plaque—a hallmark of Alzheimer's disease. Multimodal imaging options (e.g. PET-CT for staging lung cancer, ultrasound-MRI for breast cancer) can go great lengths in transforming healthcare.
Health Information Technology: The first step to health information technology (HIT) is certainly the use of electronic healthcare records (EHR). Quoting from the book: "'at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented,' but which arose because 'faulty systems, processes, and conditions' led people either to make mistakes or to fail to prevent them. Beyond the human toll, these errors cost between 17 billion 29 billion USD." The realm of HIT extends beyond EHR. Examples of its capabilities include automated alerts about patient medication allergies sent to the physician writing a prescription, reminder of a pending vaccination, or suggested revision of diagnostic or treatment plans based on latest literature. 
Challenges: The convergence of these four digital domains promises a whole new world of possibilities. Yet the hurdles are many. For one, current medical instruction has negligible to zero emphasis on the four digital domains that can potentially resurrect the healthcare system. I was shocked to know that only two out of some 150 medical schools in the US have "more than a brief, cursory curriculum dedicated to genomics of complex traits or pharmacogenomics; traditional genetics of simple but rare Mendelian traits was taught in 62 percent of schools for a total of twenty to forty hours of instruction"! The second major hurdle is linked to the innovation freeze in the pharmaceutical arena. With most major companies tumbling down or resting on the precarious edges of their "patent cliffs," the current emphasis is on consolidation (akin to the state of airline companies). The resulting air of desperation has often paved the way for pharmaceutical scandals (e.g. Merck and the Vioxx story) involving medical malpractice, data suppression, ghostwritten literature, and other such wrongdoings.  
The Path to Creative Destruction: 
(1) Wikimedicine: This can be defined as the enablement of collaboration, interaction,  and transparency across academia, industry, government regulatory bodies, and the public. 
(2) The guaranteed-to-succeed model: The current blockbuster model focuses on a population, with emphasis on quantity rather than quality. Instead of a large clinical phase III trial, the trial should focus on individuals with specific gene variants thought to be associated with a disease and continuously monitor them wirelessly to detect and quantify therapeutic effects. Based on the outcome, "conditional approval" should be granted to the drug. In the future, it may be possible to use wirelessly tagged pills to ensure they were actually taken. "Every new drug needs to have a pharmacogenomic study embedded into its development to identify genomic variation in individuals who derive particular benefit and those who have an unanticipated major side effect." 
(3) Innovative digital marketing and tracking of new products: The current marketing model involves sales representatives offering advertising content to physicians and millions being spent on broadcasting TV ads. Innovative digital marketing will involve personalized advertising and social media networking. 
These are but guidelines. Several caveats remain. In this context, I would like to share a quote from the book which I find simultaneously amusing and depressing: "In the United States, harnessing the full potential of digital medicine requires, for the first time, extensive cooperation between two governmental regulatory agencies—the FDA and the Federal Communication Commission (FCC). The FCC needs to be involved because of the oversight of body area networks—wireless sensors, the Internet, and cell phones. From past experience of two different government agencies each wanting to exert control, such as the FBI and CIA in national security, this may be a recipe for 'guarantee to fail'." The possibility of change is rendered even more remote by the intrinsically conservative nature of medicine ("sclerotic" and "ossified" are some of the other words the author uses). The book uses a rather amusing analogy between the priests and the Gutenberg press and physicians and the digital transformation of medicine. Like the Gutenberg press, which made the Bible directly accessible to commoners, the creative destruction of medicine will hopefully one day put us in direct contact of our digital selves—the new species Homo digitus. Hopefully, like the retail industry, medicine too will be "'Amazonized'—with bricks overtaken by clicks." 


  1. Good review!
    How can this wave of digital healthcare revolution impact the medicine in developing countries such as India and China?

    1. Thanks, Wei. That's an interesting question. An apt historical analogy might be the industrial revolution and how it started in Europe but spread all over the world. It is true that a large part of the digital healthcare revolution will require infrastructure that many developing countries lack today. But a subset of the solutions that will emerge from it is likely to be cost-effective and feasible to implement within the limited infrastructure of these nations. Rural areas in third world countries can benefit immensely from video consultation facilities with doctors. While there will be a lag, the wave should reach all corners of the world eventually.

  2. Enjoyed reading this. Rightly put in perspective.

    1. @Unknown: Glad you enjoyed it!