Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet!–Matthew Holt
In this week’s health care tidbits, we’re discussing hedge funds. Not those small private equity funds that are defunding small safety net hospitals and being exposed by Propublica & PBS Frontline. (Did you catch #TCHBGangster Jeff Goldsmith on the latter?). No, I’m talking about big non-profit hedge funds that also provide some health care services. This week two of them reported results.
Famed regional hedge fund Mayo Clinic’s health services business reported $243m profit on $3.7bn revenue for Q1 2021. Not exactly Apple margins, but a respectable 6.5%. While catholic national hedge fund Ascension eeked a $700m profit on $20bn of revenue in the nine months June 2020 to March 2021. The good news is that Mayo has $15bn in its main trading account while in those nine months Ascension made $4.3 Billion on Wall Street bringing its balance to a healthy $25.6 Bn.
And if you were concerned that these hedge funds were in trouble because of the pandemic, well not only do they avoid property, income tax and more they also got plenty of help from the taxpayer. CMS prepaid $2billion of Medicare payments to Ascension; presumably they made a tad more playing the markets with that. Then there’s the non-refundable CARES Act grants. Yes Ascension has been paid $900m since June 2020 ($1.1billion in all) and Mayo received $356m, although they were nice enough to pay $138m back.
I’m sure those Americans who lost their jobs, their houses and waited for months for government help are glad that–despite the pandemic–these hedge funds weren’t having to dip into their main reserves to keep their health services subsidiaries going…..
One recent Friday night, we huddled with our colleagues in the pouring rain at a movie theater parking lot– our cars packed with supplies for our mobile vaccine clinic— trying to find someone who wanted an extra dose of Pfizer’s COVID-19 vaccine before it expired. Five months ago, we would have been inundated with people desperate for that extra dose. But that has changed now that the most willing and able segments of the population have largely been vaccinated.
Amidst this backdrop of slowing vaccination rates in the U.S. and many miles to go before reaching all of those willing to be vaccinated, the CDC has released updated recommendations for mask wearing that we believe to be premature and contrary to the ethic and mindset of public health. Buoyed by mounting evidence supporting the effectiveness of vaccines, the CDC— cheered by the Biden administration— gave fully vaccinated Americans the green light to ditch their masks. As fully vaccinated public health nurses who are as excited as anyone about the vaccines’ real-world effectiveness, we nonetheless find ourselves again asking: what are they thinking?
To be clear, we do not question the evidence showing that all COVID-19 vaccines currently approved in the U.S. are safe and effective. We also crave good news, hope, and allowing the bottom half of our faces to see the light of day. We have also appreciated the Biden administration’s commitment to “following the [biomedical] science” in pandemic policymaking. Our concerns lie with the timing of the recommendation; the lack of regard for social science demonstrating the importance of public policy in influencing community norms and human behavior; and the blatant disregard for health equity. That the nation’s preeminent public health institution has fallen prey to the individualistic mindset that typifies American society, as CDC director Dr. Rochelle Walensky stated herself on Sunday regarding this “science-driven individual assessment” of risk, is frustrating, to say the least.
Currently, only one-third of the U.S. has been fully vaccinated. The news media has been full of accounts of many sub-groups who stubbornly defend their right to refuse a COVID vaccine, but the majority of those in the U.S. who remain unvaccinated belong to communities that have been unable to access a vaccine due to difficulty navigating online appointment scheduling, inability to take time off of work, poorly translated informational resources, or being ineligible due to age restrictions or other medical contraindications. Universal mask-wearing has been a critical stopgap measure to protect these at-risk populations until the majority of Americans are vaccinated. The CDC’s recommendation is therefore not only premature: it sends the message to individuals and other governmental entities alike that we don’t need to care about our neighbors.
In addition to slowing the spread of COVID-19, masks are a visible sign of community solidarity and take the burden of worry off unvaccinated individuals and parents of unvaccinated kids. In a nation where basic infection control principles have somehow become political, the CDC’s recommendation to establish a two-tiered approach to public health seems woefully misguided. Encouraging the third of Americans who have been fully vaccinated to go maskless while encouraging those who remain to be vaccinated to mask up will complicate unvaccinated individuals’ efforts to protect themselves while out in public and at work or school— places that everyone has a right to access regardless of their vaccination status. Further, this type of policy recommendation by the CDC is likely to be interpreted as blanket permission for all to discard their masks. In fact, just days after the announcement, the Texas Governor banned schools and governmental entities from mandating masks. He even went as far to implement fines on institutions that attempt to do so, kneecapping any collective action to protect communities, schools, and workplaces. This type of policy decision is the exact reason that we need the CDC to make public health recommendations using a public health framework, not an individualized, biomedical assessment: public health policies must protect the most vulnerable among us who have not yet been vaccinated, or for whom the vaccination may not be as effective.
Even more troubling, this approach centers the good fortune of the predominately white, well-educated, and wealthy communities who have had easiest access to the vaccine thus far. This latest recommendation from the CDC is yet another example of the burden of the pandemic falling disproportionately on communities with the least power to protect themselves. They are now forced to wonder if the unmasked person in their checkout line or dining in their section has been vaccinated with little recourse to protect themselves if they have been unable to be vaccinated before the CDC’s latest recommendation.
Many will say that wearing a mask and getting vaccinated are individual decisions and that we should live and let live. We do not seek to argue with the importance of obtaining individual consent for medical care– this is a basic ethical principle that all healthcare providers understand and honor. But our code of ethics also demands that we think of the greater good. Unlike nurses, infectious diseases do not respect the bounds of individual autonomy. This is why we need public health leaders who use their power to establish norms that emphasize the health and safety of the whole community, with the most vulnerable serving as our common denominator rather than being tossed from the equation entirely. The CDC has the authority, ability, and, in our estimation, responsibility to set a different tone about public health practices: we wear masks to protect and respect each other, not just ourselves.
So where does this leave us? The CDC could rescind the recommendation, thus causing further confusion and frustration. But, as with the proverbial can of worms, this new guidance will not be easily re-bottled. Instead, Americans must choose to continue to mask up until more are vaccinated. We as nurses can use our influence as trusted providers to set an example by masking up and encouraging our patients to do the same. Finally, the Biden administration must conduct an in-depth evaluation of our public health response to the pandemic, including what evidence has been used to make recommendations and how such decisions are being communicated to the public. When considering pandemic policymaking, it is critical that we follow all of the science–not just the science that gives us effective vaccines. This includes the science of individual and collective behavior and the science of risk communication. We must emerge from the pandemic with a robust, fully-funded public health infrastructure capable of performing its essential tasks, including promoting— rather than minimizing— our interconnectedness as the way through a collective crisis.
Karen Johnson, PhD, RN, FSAHM, FAAN and Whitney Thurman, PhD, RN are public health nurses and faculty members at the University of Texas at Austin School of Nursing.
Today on Health in 2 Point 00, Jess gives us a little tour of Chicago before we dive into some deals. Noom raises $540 million, bringing their total to $657 million with a $4 billion valuation. What are they going to do now with all this money? Digital therapeutics company Akili raises $160 million – maybe this will bring them out of ADHD. Unmind, a mental health company out of the UK, raises $47 million, Eleanor Health raises $20 million for their addiction-focused mental health clinic, and finally Clearing raises $20 million in a Series A tackling chronic pain. —Matthew Holt
She was a successful corporate lawyer turned professional volunteer and a housewife.
He was a charismatic, successful, and world-renowned researcher in gastrointestinal oncology. He was jealous of all breast cancer research funding and had declared that disease his nemesis.
They were married; life was becoming a routine, and borderline predictable. Both appeared to have lost some appreciation of each other and their sacrifices.
Then, she saw a lump, and was diagnosed with breast cancer. Not any breast cancer, but triple negative breast cancer. The kind that is aggressive and potentially lethal. The year was 2006, and their lives was about to change forever.
This is the story of Liza and John Marshall, who decided after 15 years of Liza’s diagnosis to disclose all, get all their secrets out in the open, and “off their chests”. They did so by writing a book that I read cover to cover and could not put down.
The authors decided to not only share their cancer journey as a patient and a caregiver, but also to share much of their personal and intimate details. They wanted us to know who they are as people, beyond patient and oncologist husband. We got to know how they met, when they met, and how they fell in love from the first sight. We got to know some corky personal details, and as a reader, I felt that I was part of their household. John shares how losing his mother at a young age to lymphoma affected him personally and professionally. We learn that they attend church every Sunday. Both are people of faith and they let us know how their faith helped them during these challenging times. Losing a dear friend to breast cancer took a toll and certainly made them less certain whether Liza’s fate would be any different.
They alternate writing chapters so that we get to know various events and stories from their sometimes-opposing points of view. We get to understand how a cancer diagnosis affects a caregiver, who happens to be a busy academic oncologist with little time to spare in between clinical practice and traveling for his work. At some point, John expresses resentment that all of the attention was being diverted towards his wife -the patient- and that he was left alone with few people caring how he felt and what struggles he was going through.
Liza recounts her diagnosis, testing, chemotherapy, side effects, seeing a psychiatrist, and the impact all of this had on her and her family. She takes us through her wig selection and how she makes light of a very emotional process. We learn how this detail affects her children and their playdates. We learn about managing side effects and how there is discrepancy between what’s important to a patient and what a physician deems important. She even recounts how John did terribly when he injected her arm with Neulasta – a growth factor shot – causing her pain. John admits that he had some sense of arrogance when he thought he could simply insert a needle in his wife’s arm, but soon thereafter, gets lectured by Liza’s chemotherapy infusion nurse about best injection techniques. Both authors briefly discuss the cost of cancer care when Liza needs Emend, an expensive anti- nausea medication and John tries to advise against it due to cost, telling his wife that she should tolerate a bit of nausea. Liza doesn’t appreciate his callous approach to a disturbing symptom; she needs her nausea alleviated and wants her medicine now. This encounter solidified what I had always believed; when a patient is in distress and is getting treatment for a life-threatening cancer, cost of care to the system and society is of least concern.
Throughout the book, the authors share some of the pearls and challenges in clinical medicine and oncology. They both express their ambivalence about “shared-decision making”. Liza wonders how can she make vital decisions with so much asymmetry in information. John admits that he makes decisions on behalf of his patients all the time, once he understands their values and goals of care. I share John’s sentiment. My patient can decide between two chemotherapy regimens based on the side effect profile, but ultimately, I will have to make the decision if chemotherapy is indicated.
Liza and John explain to us the importance of “second opinions”; we travel with them to their second opinion physician office as Liza artfully describes the differences between the chemotherapy suite at Georgetown and that of a private practice office. While she decides ultimately to have her care at Georgetown because it was where John works, we infer from both the importance of seeking other opinions when diagnosed with a life-threatening illness.
We learn how challenging it is to decide on clinical trials. Liza expresses her dissatisfaction with how trial consents are written, and I, once again, share her concerns. Liza is not shy expressing her frustration when her team of doctors gathered in her exam room discussing her case jointly, but leaving her behind as if she wasn’t there. I suspect that many patients can relate to such an encounter.
John bravely addresses the Direct-to-Consumer (DTC) advertising and proclaims that these DTCs should not be allowed, but yet he did participate in some of these DTCs on behalf of his own employer. He made me feel that he wasn’t too happy about being in these ads. It made me worry whether this disclosure may get him in trouble. I hope not, but knowing John, he won’t have a problem. He would charm his way out of any troublesome encounter.
While Liza is able to capture our empathy and love, John manages to make us feel sorry for him as he describes his busy schedule and how he needs to juggle many balls in order to be present for his wife. He clearly had no idea how to pay bills, switch on the TV, or even handle a remote control. Liza takes him through a household management tutorial just in case she can no longer perform these household tasks, and John is left alone. The authors made me laugh and cry at the same time as I pictured what was going on.
Both authors have a sense of humor, and I could sense the human nature of both of their personalities. John admits that it was “karma” that his wife got diagnosed with the cancer he spent his life attacking. He says, “This was retribution for my long disparagement of the breast cancer machinery”. Liza on the other hand confesses that John is no George Clooney, but he was more accessible.
I smiled, I laughed, I teared, and I cried. Very few books do this to you, but John and Liza were able to take me through all kinds of emotions as I pictured myself consoling Liza, being with her in the chemo suite, trying to calm John down as he was attacking breast cancer research, and sitting with them during their first Christmas after Liza’s diagnosis as John gives his wife an embrace assuring her that she will be okay.
It’s not easy to share your personal story with the world. It’s actually quite difficult and brave. John knows that many patients and colleagues will read this book; but he didn’t care. He needed to get everything off his chest. Seeing John’s smile and charming personality every so often made me take a second look as I read about his burnout, occasional anger, and evolving apathy. It’s not easy to share this with the world. Doctors should be strong and resilient, not weak and going through midlife crises. But the honesty, the painful realities, the ability to explain what led to what, and how this couple emerged winners after all is what makes this book ever so special.
John and Liza got it all off their chest. Their honesty was palpable and raw. There was nothing they were unwilling to share with the universe. Part of me sensed that this was a way for them to get closer to each other and connect. Maybe it was a cathartic experience, as they got to know each other more through reading each other’s writing. I cheered for them to connect like never before and they did.
Chadi Nabhan (@chadinabhan) is a hematologist and oncologist in Chicago whose interests include lymphomas, healthcare delivery, strategy, and business of healthcare.
By VINCE KURAITIS, EDWARD G. ANDERSON, and GEOFFREY PARKER
The COVID-19 pandemic has accelerated calls for the development of EHR 2.0 (electronic health record 2.0) – the next generation of EHRs with extended platform features and capabilities.
Who will answer this call? While existing EHR vendors have made modest efforts, the door is open for big tech companies and start-ups to develop functionality to envelop and disintermediate current EHRs. We highlight early efforts by Google Health Care Studio, an initiative that has been underway for several years but was only formally named in February 2021. We view Care Studio as having the potential to bring platform functionality to a sector of the healthcare industry known for resistance to change and innovation.
We coin a new term – “EHR Envelopment” to describe novel EHR platform capabilities under development by third parties. By “envelopment,” we mean the entry by one platform provider into another provider’s market by adding functionality and exploiting overlapping user bases. New EHR capabilities threaten to dislodge existing EHRs, e.g. through 1) new user interfaces (UIs) that sit above the current EHR, and/or 2) a focus on new value created by integrating, analyzing, and presenting disparate sources of data.
Through the lens of platform strategy, we focus on the impact that EHR Envelopment initiatives could have on the market for electronic health records for large integrated delivery systems. This market has been dominated by a few vendors for decades, but EHR Envelopment projects have the potential to disrupt EHR market dynamics.
The remaining sections of this essay will address:
The Current EHR Market for Health Systems: Ossified
Google’s “Care Studio” — What is It?
Disrupting and Platformizing the EHR Market
Challenges for Google Health
The Current Market for Health System EHRs: Ossified
The U.S. hospital EHR market has been highly concentrated; in 2020 two firms were dominant, with Epic controlling 29% and Cerner 26% of overall market share.
The EHR market for large health systems is even more highly concentrated. Among large hospitals (with 500+ beds), they collectively control 85% of the market, with Epic owning 58% market share and Cerner 27%.
COVID-19 also is accelerating many trends that already have slowly been transforming the healthcare industry. Andreesen Horowitz venture capitalist Julie Yoo listed six “tectonic shifts bringing about major changes in care delivery,” including “a push toward greater interoperability of data”.
For over a decade we’ve been reading about the need for EHR 2.0. This next generation of EHR capabilities bring platform features such as: vendors with a mindset of orchestrating vs. controlling; a fertile ecosystem of 3rd party apps; and a focus on value creation through seamless data interoperability.
A recent article in Harvard Business Review painted a vision of desired platform-like features for future EHRs. For example, EHRs need to move from simply being “transaction oriented to intelligence oriented;” they must also migrate from a “record to a plan.”
Google’s “Care Studio” — What is it?
Alphabet (more widely known as Google), is one of the largest cloud services technology companies. It has a substantial and increasing presence in healthcare and represents an example of how technology firms can enter the healthcare market. An analysis in Beckers Hospital Review, found that “7% of its searches are health-related” and that Google investments include “57 digital health startups in its portfolio.” Google Health is a new product area, employing over 500 people.
A centerpiece of Google Health’s initiatives is “Care Studio” — its EHR search and related capabilities enabled through artificial intelligence (AI), machine learning (ML), and companion technologies.
Perhaps the simplest way to think about Care Studio is as Google bringing some of its existing capabilities — e.g., search, artificial intelligence (AI), machine learning (ML) — to health care records and data. Dr. David Feinberg — the head of Google Health — capsulized their objectives: “Google has spent two decades on similar problems for consumers, building products such as Search, Translate and Gmail, and we believe we can adapt our technology to help.”
Care Studio capabilities were described in a February 2021 Google blog post by Paul Muret, VP, Product & Design. As we read about these capabilities, we found ourselves asking “Isn’t this what you would expect an EHR to do?”:
provides a comprehensive view of a patient’s records
allows clinicians to quickly search through complex patient information
streamlines workflows and supports more proactive care
brings together patient records from the multiple EHRs an organization uses
[gives] clinicians a centralized view of patient data and the ability to search across these records
harmonizes medical data across different systems
Here’s a screen shot from a Care Studio video. It displays medical record data compiled in an “Overview” tab:
Clinicians will receive real time recommendations to guide diagnostic and treatment decisions for individual patients.
Care Studio initially was developed under the internal name of Project Nightingale, a cooperative project between Google Health and Ascension Health System. Ascension is one of the nation’s largest health systems with hospitals in 21 states.
Disrupting & Platformizing the EHR Market
Does an initiative like Care Studio have the potential to disrupt and platformize the EHR market? We believe the potential is dramatic but the timeframe of analysis is critical.
Short-term: Not Much Impact
While they have the potential for significant disruption and innovation, EHR Envelopment schemes are still under development and unproven. In the near-term, we predict that initiatives like Care Studio will function more as a complement to existing EHRs, not a substitute. Current EHRs serve as a database for health records — and Google’s initial efforts do not attempt to take over that role.
Large health systems make EHR purchase decisions that are expected to play out over a decade or longer. Thus, in the short-term it is unlikely that any EHR Envelopment initiative will shift EHR market share.
Longer-term: Potential to Commoditize EHRs
The long-term implications of EHR Envelopment efforts are much more interesting, although speculative at this time.
Care Studio essentially will sit “on top” of existing EHRs. One of the biggest unknowns is the potential to become a primary UI for at least part of clinicians’ workflows. The greater its ability to become integrated into clinician workflow, the greater the potential for disruption.
We don’t know how Google Health will price Care Studio, or whether it will charge anything at all. Dr. Feinberg has said he operates on a personal directive from Mr. Schmidt: “Don’t worry about making money.” Such pricing dynamics would be consistent with the way that platforms operate in many markets where, at launch, they offer a number of services at zero price, often with the goal of amassing a large userbase before attempting to monetize that user base.
In any event, EHR Envelopment initiatives are likely to put severe pricing pressure on existing EHRs. There is potential to commoditize existing EHRs — at the extreme current EHRs could be relegated to becoming data repositories.
Pressure for Existing EHRs to Become Even More Platform Like
EHR vendors have developed some platform-like capabilities but have faced a steep learning curve in working fluidly with industry partners. It is relatively common for firms that long controlled their vendor relationships to face challenges when attempting to work with ecosystem partners in a more open manner. Nonetheless, we predict that EHR vendors will feel pressured to allow more 3rd party apps to complement their base EHR as a way to compete with and differentiate from Google Health’s Care Studio.
EHR Envelopment projects will bring EHR 2.0 capabilities to clinicians. While it hasn’t announced plans to do so, Google could supplement Care Studio functionality by allowing 3rd parties to build apps that plug into and complement its functionality.
New Competitive Dynamics
It’s not clear how existing EHR and health IT vendors will view Google Health Care Studio capabilities. Friend or foe? Both?
For example, in January 2020 Epic abruptly announced it would no longer be pursuing integrations with Google Cloud. The reason provided was “insufficient interest among our customers.” Given a broad move toward the adoption of cloud service technologies across many industries, we question this explanation and wonder instead whether this represents Epic’s explicit identification of Google Health as a potential competitor.
Google Health’s Care Studio also has potential to shift market share among existing EHR vendors. For example, will Cerner view a close alliance with Google Health as a way to gain market share from Epic?
Challenges for Google Health
Care Studio faces challenges. Many of these are applicable to the broader EHR and health IT markets, e.g., the lack of a national identifier for patient matching, the need to harmonize patient data across disparate hospital systems, and security concerns. Technology initiatives like Care Studio will also need to address many unique issues:
Public and Legislative Scrutiny
Google Health’s efforts became controversial late in 2019. The Wall Street Journal broke an investigative article entitled “Google’s ‘Project Nightingale’ Gathers Personal Health Data on Millions of Americans.” The article revealed that Google’s deal with Ascension gave it access to personally identifiable patient information on millions of Ascension’s patients.
A range of repercussions followed for Google and Ascension: fallout in the press and from privacy advocates; scolding statements expressing privacy concerns from at least four members of Congress; an investigation by the federal Health and Human Services Office of Civil Rights regarding possible HIPAA violations.
The latest Congressional salvo was fired in March 2020. Senators were not satisfied with Google’s initial responses to their inquiries and they pressed for more information. Although the controversy has not made headlines since the onset of COVID-19, it is not yet over.
Patient Trust
In the long run, we believe that successful market entry by technology firms such as Google will require them to work to gain and maintain trust from patients. Along these lines, in April 2020 Google Health announced an initiative to help patients organize and view their health records.
A recent study by Rock Health found that only 11% of respondents would be willing to share their data with a technology company. This becomes increasingly important as COVID-19 has educated patients about the potential for tech to become an integral aspect of their health and care, e.g., through virtual visits.
Clinician Buy-In and Workflow Integration
Google has many product offerings but it is not known for the user-friendliness of its interfaces. There are many aspects of Care Studio that won’t be evident until they are tested in the broader market. For example, will the offering fit into clinicians’ daily workflow? Will clinicians use these new capabilities and features, or will they bypass them? TBD.
Regulatory Issues
Google is used to operating in a market environment that is lightly regulated; health care is an industry that has been heavily regulated. One recent example is the new regulatory landscape of the 21st Century Cures Act and the hundreds of pages of rules that need to be navigated.
Offerings from Other Big Tech Companies
Although we have highlighted Google’s Care Studio to provide a specific example, it is not the only offering aimed at EHRs coming from technology companies. We note that most or all of the major technology companies are developing healthcare offerings and we should expect to see a range of strategies. For example, Apple has taken a more consumer-focused approach toward addressing EHR challenges.
Conclusion
The era of ossified EHRs is likely coming to an end. EHRs originated as software to be installed on client’s servers. While they’ve mostly made the transition to the cloud – there’s one huge step yet to be completed — the pipe to platform transition. We see signs that EHRs are finally being reimagined as platforms. As a result, we would expect to see ripples if not outright disruption throughout the industry as firms jockey to maintain or gain access to users in order to bring their solutions to market, thereby significantly increasing the rate of innovation.
Edward G. Anderson Jr., Ph.D is the Mr. and Mrs. William Wright Jr. Centennial Professor for Innovative Technology at the University of Texas McCombs School of Business.
Geoffrey G. Parker, Ph.D. is Professor of Engineering at Dartmouth College and a Fellow at the MIT Initiative on the Digital Economy.
The Teladoc Health-Livongo merger continues to expand Teladoc Health’s virtual care capabilities — this time in mental health. Dr. Julia Hoffman, Head of Mental Health Strategy for Teladoc Health, gives us the inside story on the launch of myStrength Complete, the souped-up, next-gen version of the digital mental health app that Livongo acquired in 2019 and integrated into its “AI-plus-AI whole person health” platform. So, what’s new now that all this is part of Teladoc? Think full-service mental health care, akin to what you might find in a digital mental health point solution, but with more providers… sitting on top of a gold-standard telehealth and remote monitoring infrastructure… and ready-to-move on an outsized opportunity for integration into Teladoc’s virtual primary care offering, Livongo for Diabetes, Livongo for Hypertension, and so on.
myStength Complete is now more than just a smart, cognitive behavioral therapy app; it’s the entry point into an entire mental health care continuum of services. Teladoc Health’s physicians stand ready for telehealth consults alongside a robust portfolio of coaching and self-service mental health care programs that are bolstered by the data-driven “health nudges” made famous by Livongo’s ever-improving AI-AI engine. Looking forward, the data integration strategy has a lot of potential to do a lot of good. Julia talks about how her team is already leveraging learnings from the Livongo products into a better intake process for members, helping them more quickly, easily, and accurately find the type of care they need. This is no small feat, especially when we find out that Teladoc Health consumer survey data shows that about 60% of people seeking mental health care say they have no idea where to start, or what their diagnosis would be. We get into all those survey findings (a little gold mine for those interested in consumer sentiment and digital mental health) and a full “under-the-hood” poking around of myStrength Complete in advance of its July roll-out to employers. This interview is one to watch now for the full details on how Teladoc Health is pushing further into virtual mental health care.
Google is getting much (deserved) publicity for its Project Starline, announced at last week’s I/O conference. Project Starline is a new 3D video chat capability that promises to make your Zoom experience seem even more tedious. That’s great, but I’m expecting much more from holograms – or even better technologies. Fortunately, there are several such candidates.
For anyone who has been excited about advances in telehealth, you haven’t seen anything yet.
If you missed Google’s announcement, Project Starline was described thusly:
Imagine looking through a sort of magic window, and through that window, you see another person, life-size and in three dimensions. You can talk naturally, gesture and make eye contact.
Google says: “We believe this is where person-to-person communication technology can and should go,” because: “The effect is the feeling of a person sitting just across from you, like they are right there.”
Sounds pretty cool. The thing, though, is that you’re still looking at the images through a screen. Google can call it a “magic window” if it wants, but there’s still a screen between you and what you’re seeing.
Not so with Optical Trap Displays (OTDs). These were pioneered by the BYU holography research group three years ago, and, in their latest advance, they’ve created – what else? – floating lightsabers that emit actual beams:
Optical trap displays are not, strictly speaking, holograms. They use a laser beam to trap a particle in the air and then push it around, leaving a luminated, floating path. As the researchers describe it, it’s like “a 3D printer for light.”
The authors explain:
The particle moves through every point in the image several times a second, creating an image by persistence of vision. The higher the resolution and the refresh rate of the system, the more convincing this effect can be made, where the user will not be able to perceive updates to the imagery displayed to them, and at sufficient resolution will have difficulty distinguishing display image points from real-world image points.
Lead researcher Dan Smalley notes:
Most 3D displays require you to look at a screen, but our technology allows us to create images floating in space — and they’re physical; not some mirage. This technology can make it possible to create vibrant animated content that orbits around or crawls on or explodes out of every day physical objects.
Co-author Wesley Rogers adds: “We can play some fancy tricks with motion parallax and we can make the display look a lot bigger than it physically is. This methodology would allow us to create the illusion of a much deeper display up to theoretically an infinite size display.”
Indeed, their paper in Nature speculates: “This result leads us to contemplate the possibility of immersive OTD environments that not only include real images capable of wrapping around physical objects (or the user themselves), but that also provide simulated virtual windows into expansive exterior spaces.”
I don’t know what all of that means, but it sounds awfully impressive.
The BYU researchers believe: “Unlike OTDs, holograms are extremely computationally intensive and their computational complexity scales rapidly with display size. Neither is true for OTD displays.” They need to meet Liang Shi, a Ph.D. student at MIT who is leading a team developing “tensor holography.”
Before anyone with mathemaphobia freaks out about the “tensor,” let’s just say that it is a way to produce holograms almost instantly.
The work was published in Nature last March. The technique uses deep neural networks to generate 3D holograms in near real time. I’ll skip the technical details of how this all works, but you can watch their video:
Their approach doesn’t require supercomputers or long calculations, instead allowing neural networks to teach themselves how to generate the holograms. Amazingly, the “compact tensor network” requires less than 1 MB of memory. The images can be calculated from a multi-camera setup or LiDAR sensor, which are becoming standard on smartphones.
“People previously thought that with existing consumer-grade hardware, it was impossible to do real-time 3D holography computations,” Mr. Shi says.
Joel Kollin, a Microsoft researcher who was not involved in the research, told MIT News that the research “shows that true 3D holographic displays are practical with only moderate computational requirements.”
All of the efforts are already thinking about healthcare. Google is currently testing Project Starline in a few of its offices, but is betting big on its future It has explicitly picked healthcare as one of the first industries it is working with, aiming for trial demos later this year.
The BYU researchers see medicine as a good use for OTDs, helping doctors plan complicated surgeries: “a high-resolution MRI with an optical-trap display could show, in three dimensions, the specific issues they are likely to encounter. Like a real-life game of Operation, surgical teams will be able to plan how to navigate delicate aspects of their upcoming procedures.”
The MIT researchers believe the approach offers much promise for VR, volumetric 3D printing, microscopy, visualization of medical data, and the design of surfaces with unique optical properties.
If you don’t know what “volumetric 3D printing” is (and I didn’t), it’s been described as like an MRI in reverse: “the form of the object is projected to form the model instead of scanning the object.” It could revolutionize 3D printing, and, for healthcare specifically, “Being able to 3D print from all spatial dimensions at the same time could be instrumental in producing complex organs…This would enable better and more functional vascularity and multi-cellular-material structures.”
As for “visualization of medical data,” for example, surgeons at The Ohio State University Wexner Medical Center are already using “mixed reality 3D holograms” to assist in shoulder surgery. Holograms have also been used for cardiac, liver, and spine surgeries, among others, as well as in imaging.
2020 was, in essence, a coming out party for video conferencing in general and for telehealth in particular. The capabilities had been around, but it wasn’t until we were locked down and reluctant to be around others that we started to experience its possibilities. Still, though, we should be thinking of it as version 1.0.
Versions 2.0 and beyond are going to be more realistic, more interactive, and less constrained by screens. They might be holograms, tensor holograms, optical trap displays, or other technologies I’ve not aware of. I just hope it doesn’t take another pandemic for us to realize their potential.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
This week on Health in 2 Point 00, we’ve got big money, acquisitions, CVS Health starting its own decentralized clinical trials business, AND we’ve got Morgan Health. On Episode 210, Jess asks me about Babylon buying Meritage IPA, looking to add their digital front end to this doctors’ network, and Ro acquiring Modern Fertility for $225 million. Next, telehealth company Wheel gets $50 million in a Series B and digital pathology startup PathAI gets $165 million. Finally, SymphonyRM gets $25 million in a Series B. —Matthew Holt
Today a patient told me a cancer doctor had told her husband that he only had a year to live. She was angry, because she felt that statement robbed her husband of hope and she knew well enough that doctors don’t always know a patient’s prognosis in such detail.
“Would you want to know if you only had a year to live”, she asked me.
I thought for a moment and then answered that I probably would want to know. I explained that I would want to make decisions and provisions because I live alone and am responsible for my animals. As I told her, I am well aware that if I dropped dead right now, things would be pretty chaotic for a while.
Two and a half years ago, I wrote a post titled Be the Doctor Each Patient Needs. In it I presumptuously coined the phrase I later put right on top of the sidebar of this blog:
Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.
I still believe we need to be incredibly sensitive to all the verbal and nonverbal clues our patients give us about what they need. In my 2018 post, I used the analogy of being like a chameleon. That’s not the same as being dishonest. It is a matter of knowing that your education and title give you an authority, an opportunity and an obligation to use your position of trust in your patient’s life to say things they need to hear in order to carry on or perhaps to take the first step in a new direction. We all wear the mantle of a superhero in a sense, and we can use this symbol for good. But that carries a responsibility to use our powers wisely.
We must strive to know our patients well enough to know what they need. Those things are seldom apparent from the medical record. They are subtle, subjective and often in some degree of flux through time and the course of life and disease.
The other day, a colleague who was scheduled to see a patient of mine I couldn’t accommodate in my schedule asked me if there was anything she should know before seeing this patient. What I did, in less than two minutes, was explain this person’s track record of resourcefulness, comprehension and follow-through.
Those qualities or capabilities in a patient must determine our behavior and care planning. I sometimes have a very full schedule because I think I know when I need to monitor each step in some patients’ treatment or they will get lost in terms of what to do and maybe even lost to followup entirely.
When I think about medicine being an art, I see the art in reading people and the art in applying basic treatment principles in an individualized way. This takes time to learn and hone, and it sometimes requires extra time in the patient encounter. My aim and my desire in practice is to automate and delegate the many mandated aspects of healthcare so I can focus on what only a treating physician can do: Pull together all the objective and subjective data, develop a treatment plan that makes sense for the patient and help them see the direction and steps needed to put that plan into action.
Another phrase I coined, perhaps equally presumptuous as the first one I quoted, and which I tried out on my boss a while ago (I can’t quite read the reaction I got) was “I’m an artist, not a bookkeeper”. I do believe that is what my patients need and are looking for.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
John Maynard Keynes, the famous British economist, was born and raised in Cambridge, England, and taught at King’s College. He died in 1946. He is widely recognized today as the father of Keynesian economics that promoted a predominantly private sector driven, market economy, with an activist government sector hanging in the wings ready to assume center stage during emergencies.
Declines in demand pointed to recession. Irrationally exuberant spending signaled inflationary increases in pricing, eroding the value of your money. Under these conditions, Keynes encouraged the government and central bank to adjust fiscal and monetary policy to dampen the highs and lows of the business cycles.
Keynesian economics were popularized in America in the 1930’s by a University of Minnesota economist who would go on to become Chairman of Economics at Harvard. For this, he is often referred to as “The American Keynes”, and was highlighted this week in the New York Times by Nobel economist, Paul Krugman, for his association with another tagline, “Secular Stagnation.”
When that economist, Alvin Hansen, first described the condition, he was working on FDR’s Social Security Plan. He defined it as “persistent spending weakness even in the face of very low inflation.” Krugman’s modern-day description? “What we’re looking at here is a world awash in savings with nowhere to go.”
Krugman is not the only economist sounding the alarm. Larry Summers, Harvard economist and Treasury Secretary under Bill Clinton, recently wrote, “The relevance of economic theories depends on context.” On the top of his list of current environmental concerns restricting investment and growth is the strong belief that the number of available workers is in steep decline.
Just days ago the CDC added fuel to the fire when they reported a 2020 birth rate in the U.S. of 55.8 births per 1,000 women ages 15 to 44. That was 4% lower than in 2019, and the lowest recorded rate since we started collecting these numbers in 1909. Our lower birthrate is further aggravated by declines in numbers of immigrants and a flattening of the movement of women into the workforce. Add to this the general aging of our population. To put it in perspective, Americans over 80 now outnumber Americans 2 and under.
But Summers’ concerns extend well beyond worker and product line shortages. More significant in his view are two other factors. The first is low demand fueled by population stasis. As he states, “These demographic developments eliminate the demand for new capital goods to equip and house a growing workforce.” Or stated in a different way, growing families buy things – lots of things. Shrinking families do not.
The second trend that concerns him is information technology enabled efficiencies that further dampen demand. Why? Because products today work much better and for much longer. Just one example – today’s $500 iPhone has the power of a Cray supercomputer from a generation ago. And, with no end in sight, Summers says consumers will likely continue to withhold spending in anticipation of lower prices in the future.
To make matters worse, IT connectivity has also increased renting and sharing opportunities. You don’t need to own everything (or anything) yourself. There appear to be few limits on what you can share.
What Krugman and Summers agree on is that there is plenty of money in the system, and more to come, through government infusions. But growth requires participation, not sitting on the sideline. Hansen’s “secular stagnation” suggests a reluctance to invest in the immediate future. If unchecked, it can lead to a prolonged, Japan-like, period of deflation and hardship.
Krugman’s prescription is to spend, and spend big, in government-sponsored projects that draw out citizen participation, and encourage mobility, productivity, and confidence in the future. He says we need to ignore “deficit hawks”, noting that the current deficit (twice as large as in 1990) is carrying an interest payment burden only half as large as three decades ago because of persistent low interest rates.
Krugmen believes “cheap money” should be advantaged, but in a purposeful and targeted manner. What are his two top priorities?
1) Infrastructure projects – to create immediate jobs in and for the communities they serve.
2) Universal Health Care – to promote mobility, productivity and confidence in our combined and interdependent futures.
Alvin Hansen died at the age of 87 in 1975. Hansen’s first book, Full Recovery or Stagnation, published in 1938, was prescient in suggesting that, if employment and growth are stagnant, in an economic cycle, government intervention may be required to stimulate demand.
A few years before his death, Paul McCracken, chairman of the President’s Council of Economic Advisers under LBJ, said of Hansen: “It is certainly a statement of fact that you have influenced the nation’s thinking about economic policy more profoundly than any other economist in this century.”
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