Break out of the prison of the American health care delivery system

Speaker after speaker at the recent Care Innovations Summit in Washington, DC concluded that increasing the quality and decreasing the per-capita cost of health care is the dominant political, social, and economic issue of our time. More than one expert called for a “jailbreak.”

“Jailbreak” for me meant either an obscure English reality television show or an expression applied to overriding the software limitations deliberately placed on computer systems for security or administrative reasons. The speakers in DC seemed to be calling for a jailbreak out of the prison of the status quo of the American health care delivery system and into an era of digital medicine and understanding the ill patient as a complex emergent system that does not need to be fully understood to be cared for.

Two new books make the case that American medicine is at an inflection point and about to undergo “its biggest shakeup in history.” Eric Topol, MD in The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care is no fan of the traditional approach which he labels as “conservative to the point of being properly characterized as sclerotic, even ossified.” David B. Agus, MD in The End of Illness applies systems biology to his field of oncology and concludes: “Cancer is not something the body has or gets; it’s something the body does.”

Medicine is notorious for being slow to catch up to the rest of the world. The following statement by H. Thomas Johnson, former President of the Academy of Accounting Historians, indicates that medicine is even more recalcitrant to change than accounting:

Quantum physicists and evolutionary biologists now believe that it is best to describe reality as a web of interconnected relationships that give rise to an ever-changing and evolving universe of objects that we perceive only partially with our senses. In that systemic view of the world nothing is merely the sum of the parts; parts have meaning only in reference to a greater whole in which everything is related to everything else. The Cartesian/Newtonian worldview has influenced thought far beyond the physical sciences, and accounting is no exception. Double entry bookkeeping and the systems of income and wealth measurement that evolved from it since the 16th century are eminently Cartesian and Newtonian. They are predicated on ideas such as the whole being equal to the sum of the parts and effects being the result of infinitely divisible, linear causes. Why should accountants continue to believe that human organizations behave like machines if the scientists from whom they borrowed that mechanistic worldview now see the universe from a very different perspective? Never again should management accounting be seen as a tool to drive people with measures. Its purpose must be to promote inquiry into the relationships, patterns, and processes that give rise to accounting measures.

Having graduated from Case Western Reserve School of Medicine in 1980 and having trained at UCSF as an academic anatomic pathologist, I am steeped in the traditional approach to health care. The biomedical model reduces every illness to a biological mechanism of cause and effect, and physicians diagnose diseases and then treat them. Health is defined as absence of disease. The patient story and experience is subjective and untrustworthy in comparison to the test results emanating from my pathology laboratory, which are objective and true. Generalists are replaced by specialists who regard cure as the only important goal. And pathologists are the most important of the specialists because treatment selection and administration has to await the diagnosis rendered in the pathology laboratory.

Agus labels the traditional approach “the germ theory of disease, which dominated, and in many ways defined, medicine in the twentieth century … The treatment only cared about the invading organism … it didn’t care to define or understand the host (the human being).”

Agus, an academic oncologist and founder of both a proteomics and a genomics biotech start up company, replaces the medical status quo with a system biology approach. “It is important to approach your health in general from a lack of understanding. Honor the body and its relationship to disease as a complex emergent system that you many never fully comprehend.” His conclusion that one does not need to understand cancer to control it is controversial.

In discussing the recent Susan G. Komen-Planned Parenthood controversy, Susan Love, MD argues that finding the cause of breast cancer is far more important than refining the screening techniques we use today. Dr. Love concludes her article with “We must move breast cancer advocacy to the next level, beyond screening for cancers that are already there, even beyond the cure, to finding the cause. That is true prevention.”

The human body is so complex that we may never really understand it, but the systems biology theory has already yielded new ways of helping patients. Zoledronic acid is a drug that affects bone metabolism to reduce fractures, but does nothing to cancer cells. And yet this drug has decreased breast cancer recurrence by 36%, presumably because it changes the environment of bones so that cancer does not spread so readily. Avastin is too large a molecule to get past the blood-brain barrier, but Agus describes how it is being used experimentally to treat some malignant brain tumors, perhaps by changing the pressure in the brain. The Mayo Clinic and Cincinnati Children’s Hospital have studied how the cytochrome P450 superfamily of genes affects the metabolism of drugs used in treating mental illness. Although we do not fully understand what causes these diseases, the GeneSightRx test for five genes has allowed physicians to tailor drug therapy to 12,000 patients’ individual metabolism.

Topol would replace the traditional approach to medicine with digital medicine. For Topol, digital medicine is now possible because of the convergence of genomics, wireless sensors, digital imaging, information systems, social networks, the ubiquity of smartphones, and the unlimited computing power of cloud server farms.

The iPad and the Kindle have forced us to come to grips with what it means to digitize a book. What does it mean to digitize a human being? The technology exists for every personal health record to contain our genome, our physiologic metrics such as blood pressure and brain waves measured morning, noon, and night, digital scans of any organ, and the cumulative radiation exposure from every scan and x-ray. When one realizes that all of this information can be readily available from our smartphones connected to the cloud, physicians will soon have a window into each person’s health and wellness that has implications across the continuum of care. In the emerging digital medicine, information at the point of care will ensure the most up to date treatment and the avoidance of the medication and coordination errors that plague current American health care delivery. There are 13,600 medical diagnoses, 4,000 medical procedures, and 6,000 medications currently available. This is precisely the kind of complex data problems that digital technology solves.

Topol, a cardiologist, proposes digitizing humans to identify those susceptible to heart attacks. Sequencing the genome for cardiac risk variants could be combined with identifying arterial lining cells that are sloughed off into the blood stream during the early stages of a heart attack. Individuals who are at high risk could be monitored with an implanted nanosensor that communicates with the patient’s smartphone. Topol even envisions eventually having the nanosensor automatically release medications in response to high levels of worrisome markers.

Agus, Topol and the speakers at the Care Innovations Summit all foresee a new paradigm of health care that will enable us to decrease the per-capita cost and increase the quality of care that Americans receive. Instead of waiting until a disease has developed or the patient visits the doctor once a year to diagnose and treat an illness, the patient will know what diseases are likely due to genetic predisposition and he will be monitored with wireless and implantable sensors so that the disease can be predicted and prevented. Instead of considering health to be absence of disease, we will embrace the WHO definition of a state of complete physical, mental, and social well-being. Instead of focusing on cures, we will concentrate on managing chronic diseases.

Agus and the others contemplate the end of disease which seems a little overly optimistic but intriguing nonetheless:

Take a moment to imagine what it would be like to live robustly to a ripe old age of one hundred or more. Then, as if your master switch clicked off, your body just goes kaput. You die peacefully in your sleep after your last dance that evening. You don’t die of any particular illness, and you haven’t gradually been wasting away under the spell of some awful, enfeebling disease that began years or decades earlier.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • Steven Reznick

    Pascal Goldschmitt MD, Chief of Medical Staff at the University of Miami Miller School of Medicine and former director of the Human Genome Project recently advocated at Pri Med South in a Keynote address that when the cost of an individual DNA analysis fell to less than $1000 per individual, we should be doing such an analysis on every newborn in America. The data obtained could be used to prevent and alter disease.

    This is a wonderful article with great insight and creativity. I sit at the other end of the spectrum agreeing with the need to find the root cause of these diseases but struggling with implementing and electronic medical record that connects and integrates with our own office PC’s and with our hospital systems computer systems and clearly disappointed in the ” clinical summary” required for meaningful use certification.  Listening to the chatter about advances and technology reminds me of watching the successful NASA lunar missions in the 1970′s and the plans for the 1984 mission to Mars.  It never occurred nor is it in the plans. It disappeared due to underfunding and human frailty and greed . I am not sure the same will not happen to the plans for digitalization of medical records and care.

  • Margalit Gur-Arie

    I love Star Trek. Please note that the WHO definition of health includes social well-being. Technology is not and will not be the limiting factor in the preservation of health.
    We can prevent and alter many diseases today, and yet millions of people perish from those diseases on a daily basis. We can also prevent and alter the course of hunger and education (or lack thereof), yet we choose not to. Instead we choose to perfect the ways in which we kill and maim each other.
    There is a huge hurdle in our way to perfect health status and this problem will not be addressed by iPhones.

    • Marya Zilberberg

      Margalit, as usual you hit the nail on the head. We have to be very careful not to confuse what technology can and should do for disease with what it can (but perhaps should not) do for health. I think this is a great and thought-provoking post by Kent,and thank him for making me think and learn more about this. But I have to say that health and disease require different paradigms. I blogged about this yesterday here, if you are interested

      • Margalit Gur-Arie

         Thanks, Marya. I was reading your excellent blog and I suddenly remembered seeing Dr. Agus on Jon Stewart’s show a while ago, pitching his new book. The “aspirin mandate” caught my attention that night (I thought it was a joke), so now I know where this is coming from.
        Now that I read your summary I’ll have to listen to the entire talk, I guess…. or maybe not :-)

  • Anonymous

    “The iPad and the Kindle have forced us to come to grips with what it means to digitize a book.”

    What it means? It means a slightly different shape and feel, a form that may be more or less convenient for different people. It mean almost nothing.

    What a book “means” is the words, the intellect, the emotions and artistry of Shakespeare, Homer, Keats. Whether the words are on a screen, in a book, in smoke signals in the sky, what it means doesn’t change.

    Is it really so hard to distinguish between form and content? 

  • Anonymous

    The death of my mother from a virulent form of breast cancer is what drove me out of the aerospace industry 20 years ago and into healthcare and healthcare research. I applaud this article and am encouraged to find many like-minded individuals who see what medicine can become by thinking outside of the status quo. I only wish my mother had lived to see it.

  • Anonymous

    While we need to think outside the box with technology, genomics etc for healthcare we also MUST think about “Back to the Future” farming.  The diseases costing the most money aren’t those from genetic expression but rather the fact that “addiction is part of the human condition”.  The greatest addictions now are to all the processed sugars, fats and salt prevasion in what we eat. 

    I cannot see a future of creamsicle flavored Kale or so many other gimmicy foods in the name of nutrition.  I can see vegetables and fruits growing on rooftops, front and back yards, community gardens, green houses – in walkways, pots, in layers, under grids with worm farms, composters, water where everything is recycled, reclaimed back into our soil, all monitored by the latest technology for natural nutrients, diseases, when to harvest using digitized, modulized and GPSized  stuff developed by agri- engineers and cared for from planting to market by agri – farmers (many of them and with liveable salaries) all decentralized into communities - reducing Big agribusiness to a nitch.  Healthy food becomes accessible to all as will  gyms, bike and walking paths, dancing halls – all kinds of sports activities.    

    At the same time many problems to saving our environment will be resolved as well with technology new green energy, inventions we don’t even know about yet.  

    What is left for health care will be a fraction of what we are dealing with now and we will be able to rid the human of cancer, neuromuscular and other elusive diseases by the digital, genomics, cloud computing etc on the horizon. 

    We will live lives like the One Horse Shay – perfect in everyway to  a 100 years and then “poof we just go away” 

  • Anonymous

    Innovation is the key to a “jail break” in healthcare.  Innovation in the form of new business models and new operational processes for care delivery.  Innovation in the form of applying the elements of mass production to care delivery.  My article “American Healthcare Industrial Revolution” details this.  You can find this

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