Can Generative AI Improve Health Care Relationships?

By MIKE MAGEE

“What exactly does it mean to augment clinical judgement…?”

That’s the question that Stanford Law professor, Michelle Mello, asked in the second paragraph of a May, 2023 article in JAMA exploring the medical legal boundaries of large language model (LLM) generative AI.

This cogent question triggered unease among the nation’s academic and clinical medical leaders who live in constant fear of being financially (and more important, psychically) assaulted for harming patients who have entrusted themselves to their care.

That prescient article came out just one month before news leaked about a revolutionary new generative AI offering from Google called Genesis. And that lit a fire.

Mark Minevich, a “highly regarded and trusted Digital Cognitive Strategist,” writing in a December issue of  Forbes, was knee deep in the issue writing, “Hailed as a potential game-changer across industries, Gemini combines data types like never before to unlock new possibilities in machine learning… Its multimodal nature builds on, yet goes far beyond, predecessors like GPT-3.5 and GPT-4 in its ability to understand our complex world dynamically.”

Health professionals have been negotiating this space (information exchange with their patients) for roughly a half century now. Health consumerism emerged as a force in the late seventies. Within a decade, the patient-physician relationship was rapidly evolving, not just in the United States, but across most democratic societies.

That previous “doctor says – patient does” relationship moved rapidly toward a mutual partnership fueled by health information empowerment. The best patient was now an educated patient. Paternalism must give way to partnership. Teams over individuals, and mutual decision making. Emancipation led to empowerment, which meant information engagement.

In the early days of information exchange, patients literally would appear with clippings from magazines and newspapers (and occasionally the National Inquirer) and present them to their doctors with the open ended question, “What do you think of this?”

But by 2006, when I presented a mega trend analysis to the AMA President’s Forum, the transformative power of the Internet, a globally distributed information system with extraordinary reach and penetration armed now with the capacity to encourage and facilitate personalized research, was fully evident.

Coincident with these new emerging technologies, long hospital length of stays (and with them in-house specialty consults with chart summary reports) were now infrequently-used methods of medical staff continuous education. Instead, “reputable clinical practice guidelines represented evidence-based practice” and these were incorporated into a vast array of “physician-assist” products making smart phones indispensable to the day-to-day provision of care.

At the same time, a several decade struggle to define policy around patient privacy and fund the development of medical records ensued, eventually spawning bureaucratic HIPPA regulations in its wake.

The emergence of generative AI, and new products like Genesis, whose endpoints are remarkably unclear and disputed even among the specialized coding engineers who are unleashing the force, have created a reality where (at best) health professionals are struggling just to keep up with their most motivated (and often mostly complexly ill) patients. Needless to say, the Covid based health crisis and human isolation it provoked, have only made matters worse.

Like clinical practice guidelines, ChatGPT is already finding its “day in court.”  Lawyers for both the prosecution and defense will ask, “whether a reasonable physician would have followed (or departed from the guideline in the circumstances, and about the reliability of the guideline” – whether it exists on paper or smart phone, and whether generated by ChatGPT or Genesis.

Large language models (LLMs), like humans, do make mistakes. These factually incorrect offerings have charmingly been labeled “hallucinations.” But in reality, for health professionals they can feel like an “LSD trip gone bad.” This is because the information is derived from a range of opaque sources, currently non-transparent, with high variability in accuracy.

This is quite different from a physician directed standard Google search where the professional is opening only trusted sources. Instead, Genesis might be equally weighing a NEJM source with the modern day version of the National Inquirer. Generative AI outputs also have been shown to vary depending on day and syntax of the language inquiry.

Supporters of these new technologic applications admit that these tools are currently problematic but expect machine-driven improvement in generative AI to be rapid. They also have the ability to be tailored for individual patients in decision-support and diagnostic settings, and offer real time treatment advice. Finally, they self-updated information in real time, eliminating the troubling lags that accompanied original treatment guidelines.

One thing that is certain is that the field is attracting outsized funding. Experts like Mello predict that specialized applications will flourish. As she writes, “The problem of nontransparent and indiscriminate information sourcing is tractable, and market innovations are already emerging as companies develop LLM products specifically for clinical settings. These models focus on narrower tasks than systems like ChatGPT, making validation easier to perform. Specialized systems can vet LLM outputs against source articles for hallucination, train on electronic health records, or integrate traditional elements of clinical decision support software.”

One serious question remains. In the six-country study I conducted in 2002 (which has yet to be repeated), patients and physicians agreed that the patient-physician relationship was three things – compassion, understanding, and partnership. LLM generative AI products would clearly appear to have a role in informing the last two components. What their impact will be on compassion, which has generally been associated with face to face and flesh to flesh contact, remains to be seen.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020).

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Raj Singh, Accolade

Earlier this month I caught up with Raj Singh, the CEO of Accolade. The “navigation” company is publicly traded and now offering its own telehealth, primary care & second opinions as well as helping patients access both digital health services and brick & mortar health systems. How is Accolade dealing by both offering primary care and helping patients manage through complex care situations? And why isn’t this available to everyone, yet? Raj told me how it works and what the likely future will be, including work with health plans, and how Accolade is on a path to a $1b in revenue in 5 years.–Matthew Holt

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Who Could (Possibly) Be the Ideal “Chief Patient Officer”? (And Other Ideas that Sound Better on Paper than in Practice)

By JONATHAN S. FEIT

If ideas presented in essays on The Health Care Blog and other healthcare forums are meant to be rhetorical, without intention of turning notions into reality on behalf of patients who need genuine, intimate, desperate help…then feel free to ignore this essay entirely. 

Some among us—the State of Washington’s Co-Responder Outreach Alliance; Lisa Fitzpatrick’s Grapevine Health, which specializes in “street medicine” and advocacy in and around Washington, D.C.; Thorne Ambulance Service, an inspirational ambulance entrepreneur bringing both emergency and nonemergency medical transportation to underserved rural spaces (and more) across South Carolina; and the RightCare Foundation in Phoenix, a firefighter-driven organization dedicated to ensuring that patients’ needs and wishes are honored during critical moments, spring fast to mind—are stretching hands across the care continuum while pounding the table for interoperability at scale because PEOPLE. ARE. FALLING. THROUGH. THE. CRACKS. AND. DYING.  

Thatincludes responders who run toward the crises; into alleys; who risk their own lives, health, psyches, families, and futures because, as Josh Nultemeier—Chief Paramedic and Operations Manager of San Francisco’s King-American Ambulance, and a volunteer firefighter in the Town of Forestville—put it so simply in a social media post: “People could get hurt.” Moral override—that matter-of-fact willingness to risk himself for strangers who lack any other path to save themselves—is what makes Josh (and others who believe as he does) heroic.

Solving problems like substance use disorder—coupled with an increasing awareness of the lack of interoperability with prescription drug monitoring programs (PDMPs), many of which are run by Bamboo Health, which today imports zero data regarding out-of-hospital overdoses—is urgent. If an overdose is reversed in an alley, an abandoned home, a tent or “under the bridge downtown,” by an ambulance, fire, or police service pumping Narcan to get breathing going again, the agency’s lifesaving efforts get zero “credit” in the data. The downstream effects of this information sharing breakdown make it difficult to settle for less-than-bona fide interoperability: there is neither time to waste nor margin of error, yet hospitals and healthcare systems cannot even “see” the tip-of-the-tip-of-the-spear.

A similar emotionality makes it difficult to tolerate lamentations about information sharing when states like California—and the federal Office of EMS, inside the National Highway Traffic Safety Administration—are transforming interoperability into a standard operating procedure. As a listener to the “Health Tech Talk Show” since its start, I have struggled with hearing Lisa Bari and Kat McDavitt deride whether interoperability is “real.” It is real. It is happening, and has been automated for years—for example, with both the Quality Health Network and Contexture (formerly CORHIO) in Colorado—empowering agencies of all sizes to care for patients experiencing healthcare emergencies, and those who have children with Duchenne’s Muscular Dystrophy and other diseases. Such efforts should be celebrated for their meaningful impact on patients who rely on ambulance services to get them the care that they need—and sometimes to get them to the care that they need. 

Yet no panel at the national conference for CIVITAS was dedicated to interoperability to or from ambulances, despite that some of America’s most active health information exchanges—coast to coast—have automated interoperability involving Fire, EMS, Non-Emergency / Interfacility Medical Transport, Critical Care, and Community Paramedicine. No mention highlighted widespread efforts to make POLST forms accessible to Mobile Medical professionals, thanks to prioritization of the ethical treatment of medically frail patients after COVID-19 and a New York Times piece called “Filing Suit for Wrongful Life.”

Critical document registries are now built into several large HIEs but these are generally invisible to Mobile Medical professionals. No less an enabler of interoperability than Amazon Web Services has acknowledged that caring for underserved patients must incorporate Mobile Medicine because the poorest in America get much of their care from ambulance services. Leading medical directors and the executive director of National POLST have cited interoperability as a key to empowering Responders to best care for our loved ones when seconds count. Yet when the “Health Tech Talk Show” hones in on discussions about public insurance and safety net medicine—“I heard ‘Medicaid is hard,’ more times than I can count. Public health? Barely a word…

Individuals on Medicaid and the underserved make up nearly 25% of the country. Public health? SUD is a public health issue. Behavioral health is a public health issue. Maternal health is a public health issue. CANCER Is [sic] a public health issue. Public health is more than covid tests and flinging around vaccines and we should treat it as such.”—ambulances are not mentioned once. 

Fire and ambulance services are successfully closing information sharing gaps, but they remain left out of the advocacy efforts—and worse, they end up as an unintended target. Mobile Medicine could be a case study in the power of sharing clinical insights in real-time to do what is best for the patient and the healthcare ecosystem simultaneously. Instead, advocacy efforts in the name of interoperability have traversed a path—twice, now—that risks blocking Mobile Medical professionals from participating in the modern healthcare ecosystem, to the detriment of patients, families and the agencies themselves.

This first such instance occurred when the “Health Tech Talk Show” fanned the flames of the Health Data Utility (HDU) movement. In America and globally, ambulance services are unique, as the only health care providers that routinely engage Unknown Patients (patients who need care while unconscious, unable to communicate, and/or “altered mental status” so one cannot trust their self-assessment). Mobile Medical professionals routinely engage patients in places like alleyways and in abandoned basements. It is worth noting that none of the above pertains necessarily to emergency care, as Mobile Medical professionals engage the most severely ill and underserved chronic care patients wherever they are, and that frequently is on the streets. 

Estimates of the size of the non-emergency medical transport sector range from par to double that of emergency medical transportation. Yet Mobile Medical professionals are largely shut out of the national healthcare data interoperability discussion because they don’t document in HL7-based data systems; they use a different, essential, standard called the National EMS Information System. 

The Office of the National Coordinator of Healthcare IT (ONC) has focused on bringing Mobile Medical data into the broader health data fold, including most recently by holding the second EMS data summit concurrently with the 2023 ONC annual meeting. The movement toward implementation of Health Data Utilities (HDU) risks undoing this critical progress to date, careening Mobile Medical professionals toward second-class status. The advocates of this approach do not appear to be considering its downstream effects: HDUs risks devolving Mobile Medical professionals into shoppers on Christmas Day who are forced to watch sales happening inside the store, while standing outside in the snow. 

Put another way: “Where the HDUs do not currently consume Mobile Medical data, the ambulance, fire and CP/MIH agencies will stay shut out until outsized pressure forces a change (say, an adverse encounter that could that have avoided if the crew had had real-time access to the more complete information in real-time).”

More recently, the Health Tech Talk Show team has begun advancing the notion that America needs a “Chief Patient Officer” (they even went so far as to propose a candidate). Like the HDU concept, this proposal is risky for Mobile Medicine professionals, which is why this author is speaking up. It obviates the reality that, for many, ambulance-based care is nothing short of a lifeline—an entryway to the healthcare ecosystem where no other exists. In their article for The Health Care Blog, Lisa Bari and Kat McDavitt write that “Because of this lack of access, resources, and representation, and because there is no single senior staff member in the federal government dedicated to ensuring the voice of the patient is represented, the needs and experiences of patients are deprioritized by corporate interests.” What about Americans whose needs and challenges are so basic, fundamental, and neglected over time that they’re utterly irrelevant to corporate interests?

There are many such people, and they deserve attention. 

They receive it from caregivers who work in ambulances.

Put another way: What realistic hope is there for a white, educated, socioeconomically “just fine,” city (or countryside) dwelling caregiver hope to muster sufficient empathy for the reality of being a single parent of color, whose child has a major disability, who lives far away from everything that they need to care for their kid? What does it feel like to be a Black woman, who is pregnant, short of breath, living in a one room apartment that smells of feces, whose doctor is all the way over there while she’s in an ambulance going nowhere in rush hour traffic? (Note: this is no theoretical situation—I did a ridealong with just such a patient in Pittsburgh, Pennsylvania). How can one person purport to represent America’s “So Many Patients”, channeling the challenges of race, lack of access to care, language, disability, religion, understanding of healthcare, fear of maltreatment, and more?

If one purports to advocate seriously for a Chief Patient Officer…where will they come from? Will they speak English as a second (or third) language? Will they have a child, spouse, or parent with a mortal disability (or must they have already lost one or more of the above)? Will they be straight, gay, intersex, or transgender? Must they have processed an end-of-life medical order for themselves or for a loved one, to know what it’s like to contemplate the ethics of demise? Must they have an implant that failed, or “get” why patients use ambulances as doctor’s offices? 

“We need a Chief Patient Officer” makes a catchy bumper sticker message, just like “QHINs aren’t real” makes a snazzy alien-themed shirt. But in reality, lightheartedness about life-and-death issues can feel disrespectful of the minutes, hours, and lifetimes that are being invested in making such necessities a reality. The varieties of human experience are so diverse that to suggest enough empathy can be found in one person—anywhere but in a committee of Chief Patient Officers—denigrates the struggle that ambulance-based care providers face in their mission to bring care to patients, families, and communities that lack options but face critical needs. 

Worse yet is that Mobile Medical professionals can end up with the short end of the stick: not just kept outside the glass, pining for a seat at Healthcare’s Table at the Future, but indeed, being blamed for the lack of such tools, made to look like Luddites. This author hopes we will collectively adjust our investments of time and passion into spreading ideas that make things easier—more effective in terms of time and medicine—for those who work to deliver care, with fewer resources than they need, to those who lack the basics.

Jonathan Feit is the CEO of Beyond Lucid Technologies

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Zombie Viruses of the Permafrost

By KIM BELLARD

We’ve had some cold weather here lately, as has much of the nation. Not necessarily record-breaking, but uncomfortable for millions of people. It’s the kind of weather that causes climate change skeptics to sneer “where’s the global warming now?” This despite 2023 being the warmest year on record — “by far” — and the fact that the ten warmest years since 1850 have all been in the last decade, according to NOAA.

One of the parts of the globe warming the fastest is the Arctic, which is warming four times as fast as the rest of the planet. That sounds like good news if you run a shipping company looking for shorter routes (or to avoid the troubled Red Sea area), but may be bad news for everyone else.  If you don’t know why, I have two words for you: zombie viruses.

Most people are at least vaguely aware of permafrost, which covers vast portions of Siberia, Alaska, and Canada. Historically, it’s been literally frozen, not just seasonally but for years, decades, centuries, millennia, or even longer. Well, it’s starting to thaw.

Now, maybe its kind of cool that we’re finding bodies of extinct species like the woolly mammoth (which some geniuses want to revive). But also buried in the permafrost are lots of microorganisms, many of which are not, in fact, dead but are in kind of a statis. As geneticist Jean-Michel Claverie of Aix-Marseille University, recently explained to The Observer: “The crucial point about permafrost is that it is cold, dark and lacks oxygen, which is perfect for preserving biological material. You could put a yoghurt in permafrost and it might still be edible 50,000 years later.”

Dr. Claverie and his team first revived such a virus – some 30,000 years old — in 2014 and last year did the same for some that were 48,000 years old. There are believed to be organisms that ae perhaps a million years old, far older than we’ve been around. Scientists prefer to call them Methuselah microbes, although “zombie viruses” is more likely to get people’s attention.

He’s worried about the risks they pose.

He told The Observer: “At the moment, analyses of pandemic threats focus on diseases that might emerge in southern regions and then spread north. By contrast, little attention has been given to an outbreak that might emerge in the far north and then travel south – and that is an oversight, I believe. There are viruses up there that have the potential to infect humans and start a new disease outbreak.”

Well, you might shrug; there’s new viruses and pathogens coming along all the time, as COVID reminded us. The difference, Dr. Claverie pointed out, is this: “Our immune systems may have never been in contact with some of those microbes, and that is another worry. The scenario of an unknown virus once infecting a Neanderthal coming back at us, although unlikely, has become a real possibility.”

Jill Brandenberger, climate security research lead at the Pacific Northwest National Laboratory told USA Today. “We know there’s bacterial, fungal and viral pathogens that are in permafrost. We know that upon thaw, all three of those classes of pathogens could be released. What we don’t know is how viable it is for them to stay alive and then infect.” Tell that to the people who died in the anthrax outbreak in 2016, in northwest Siberia.

It’s worse than just the permafrost warming. Dr. Claverie warns:

The danger comes from another global warming impact: the disappearance of Arctic sea ice. That is allowing increases in shipping, traffic and industrial development in Siberia. Huge mining operations are being planned, and are going to drive vast holes into the deep permafrost to extract oil and ores.

Those operations will release vast amounts of pathogens that still thrive there. Miners will walk in and breath the viruses. The effects could be calamitous.

Marion Koopmans, of the Erasmus Medical Center in Rotterdam, agrees, telling The Observer:

If you look at the history of epidemic outbreaks, one of the key drivers has been change in land use. Nipah virus was spread by fruit bats who were driven from their habitats by humans. Similarly, monkeypox has been linked to the spread of urbanisation in Africa. And that is what we are about to witness in the Arctic: a complete change in land use, and that could be dangerous, as we have seen elsewhere.

And, if you’ve started to get your head around all that, if the permafrost thawing isn’t scaring us enough with the zombie viruses, there’s also a vicious global warming cycle involved. It turns out that permafrost is believed to have double the amount of carbon than is currently in the atmosphere, and which thawing permafrost releases in the form of methane and carbon dioxide.

“Methane is a potent greenhouse gas,” said Dr. Thomas Birchall of the University Center in Svalbard, who was the lead author on a new study. “At present, the leakage from below permafrost is very low, but factors such as glacial retreat and permafrost thawing may ‘lift the lid’ on this in the future.”  And, as it turns out, another new report concluded, such leakage is not being factored into most of our existing climate models.

“What happens to the carbon in permafrost is one of the biggest unknowns about our future climate,” said Christina Schaedel, senior research scientist at Woodwell Climate Research Center and lead author of the report. “Earth system models are critical to predicting where, how and when this carbon will be released, but modeling teams currently don’t have the resources they need to depict permafrost accurately. If we want more accurate climate predictions, that needs to change.”

We don’t even have good ways to accurately estimate the thawing of the permafrost, although we’re starting to use satellite data and – you guessed it! — AI to help improve those estimates.

So if your five-year-old is worried that global warming will impact Santa’s North Pole home, you can still reassure him/her about that, but there’s not much reassurance we can give kids about what permafrost thawing means for zombie viruses and accelerated global warming.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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Kota Kubo, Ubie

Kota Kubo is the CEO of Ubie, a Japan-based symptom-checking company. Ubie has raised over $75m including a $45m round in 2022. They were focusing on the Japanese market but have been available in the US since 2022, and are expanding their presence there dramatically in 2024. It’s a direct to consumer product with a business model of helping pharma companies understand their patients better–while of course not letting them have patients’ private or identifiable information. This is a little different than most symptom checkers who tend to work with providers or plans, and I met Kota in Tokyo late last year to discuss the business and get a little demo–Matthew Holt

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Au Contraire

By KIM BELLARD

Last week HHS announced the appointment of its first Chief Competition Officer. I probably would have normally skipped it, except that also last week, writing in The Health Care Blog, Kat McDavitt and Lisa Bari called for HHS to name a Chief Patient Officer. I’ll touch on each of those shortly, but it made me think about all the Chiefs healthcare is getting, such as Chief Innovation Officer or Chief Customer Experience Officer.  

But what healthcare may need even more than those is a Chief Contrarian. 

The new HHS role “is responsible for coordinating, identifying, and elevating opportunities across the Department to promote competition in health care markets,” and “will play a leading role in working with the Federal Trade Commission and Department of Justice to address concentration in health care markets through data-sharing, reciprocal training programs, and the further development of additional health care competition policy initiatives.” All good stuff, to be sure.

Similarly., Ms. McDevitt and Ms, Bari point out that large healthcare organizations have the staff, time, and financial resources to ensure their points of view are heard by HHS and the rest of the federal government, whereas: “Patients do not have the resources to hire lobbyists or high-profile legal teams, nor do they have a large and well-funded trade association to represent their interests.” They go on to lament: “Because of this lack of access, resources, and representation, and because there is no single senior staff member in the federal government dedicated to ensuring the voice of the patient is represented, the needs and experiences of patients are deprioritized by corporate interests.” Thus the need for a Chief Patient Officer. Again, bravo.

The need for a Chief Contrarian – and not just at HHS – came to me from an article in The Conversation by Dana Brakman Reiser, a Professor of Law at Brooklyn Law School. She and colleague Claire Hill, a University of Minnesota law professor, argue that non-profit boards need to have “designated contrarians.”

They propose:

We believe nonprofit boards should require their members to take turns serving as “designated contrarians.” When it’s their turn for this role, board members would be responsible for asking critical questions and pushing for deeper debate about organizational decisions.

Their idea draws upon research from Lindred (Lindy) Greer, a professor of organizational behavior then at Stanford GSB and now at Michigan Ross. Her research suggested that teams need a “skilled contrarian” to improve its effectiveness. “It’s important for teams to have a devil’s advocate who is constructive and careful in communication, who carefully and artfully facilitates discussion,” Professor Ross concluded.

Her research, conducted with Ruchi Sinha, Niranjan Janardhanan, Donald Conlon, and Jeff Edwards, found that teams with a lone dissenter outperformed teams with no dissenters, or teams where everyone dissents. The key, they believe, was not to create conflict but to help identify differences and resolve resulting conflicts in non-confrontational ways.

Professors Reiser and Hill worry that “board members often fail to ask hard questions and challenge the organization’s paid staff – especially when there are more than a dozen or so people serving as directors.” They might assume everyone shares their “good intentions,” or they might just be uncomfortable “rocking the boat.”

I would argue that the same is true throughout most organizations, whether in the C-Suite or in the rest of workforce. Who is asking the hard questions?

Professors Reiser and Hill believe they have a solution:

We propose that trustees take turns being a designated contrarian, temporarily becoming a devil’s advocate obliged to challenge proposed board actions.

To be clear, they wouldn’t be naysayers out to block everything. They would instead ask probing questions and offer feedback on reports by executives and officers. They would also initiate critical discussions by challenging conventional wisdom.

The goal, they say, “would be to encourage debate and reflection about the nonprofit’s decisions, slowing – or halting, if necessary – the approval of business as usual.” Again, there’s nothing unique about non-profits or even about boards here.

If you have a team, a management staff, a C-Suite, a board (non-profit or not), or a federal agency, you need a contrarian. Someone who is not afraid to point out when, as they say, the emperor has no clothes. Who is not afraid to ask those hard questions, to rock that boat. Who realizes the status quo is not only not good enough but also never is going to last.

Organizations whose boats don’t get rocked enough are likely to capsize sooner or later.

Picking the right person(s) is crucial. Someone who is too abrasive will just create more conflict and will eventually get frozen out. On the other hand, as Professor Reiser points out: “Serving a term as contrarian will not magically transform a passive and deferential person into someone who actively challenges dominant voices or forcefully advocates alternatives. And directors wearing the contrarian hat may be too easily discounted if others perceive them as merely mouthing their assigned lines.”

It’s not a role that anyone can fill, or that everyone should, but a role that is important which someone does.

———

It has been said that organizations that need innovation units or a Chief Innovation Officer aren’t truly innovative; it needs to be baked into the culture. Similarly, needing a Chief Customer Experience Officer means customer experience is not integral to the mission. If HHS needs a Chief Competition Officer or a Chief Patient Officer, it is validation that HHS has been coopted by the special interests that healthcare is full of, and those interests aren’t primarily about patients. We need to reflect upon that; simply naming those Officers won’t be enough.

By the same token, if your organization needs a Chief Contrarian or designated contrarians, that means it doesn’t encourage healthy dissent or seek ideas that don’t reflect existing paradigms. That’s a problem.

I am, I have to admit, something of a contrarian by nature. I never had an official role as such, but I never shied away from speaking up (even when it wasn’t in my best career interests).  But, boy, if I’d had the chance to be a Chief Contrarian or a designated contrarian, I’d have loved it!

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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Nicola Tessler, CEO, BeMe Health

Nikki Tessler is the CEO of BeMe Health. She is a psychologist who has built a relatively new company with a self service tool and coaching service for teens. It’s essentially trying to convert teens’ social media time to good use with support, affirmations, coaching and safety–and much more.. I interviewed Nikki and got a full demo over the holiday break. There’s a lot of information here about the teen mental health question (yes it’s bad!), about the company funding & strategy, and great understanding of the product…which is pretty unusual and growing fast!—Matthew Holt

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25th Amendment Still Not the Right Response to a Mentally Ill Trump

By MIKE MAGEE

On May 16, 2017 New York Times conservative columnist, Russ Douthat, wrote “The 25th Amendment Solution for Removing Trump.” 

That column was the starting point for a Spring course I taught on the 25th Amendment at the President’s College in Hartford, CT. I will not summarize the entire course here, but would like to emphasize four points:

1. The American public was adequately warned (now 7 years ago) of the risk that Trump represented to our nation and our democracy.
2. Douthat’s piece triggered a journalistic debate which I summarize below with four slides drawn from my lectures.
3. Had Pence and the cabinet chosen to activate the 25th Amendment, as it is written, Trump would have had the right to appeal “his inability”, forcing the Congress to decide whether there was cause to remove the President.
4. Judging from the later impeachment of Trump in the House, but failure to convict in the Senate, it is unlikely a courageous Pence and Cabinet would have been backed by their own party.

Let’s look at four archived slides from the 2017 lecture, and then discuss our current options in the case of 2024 Trump against Democracy. 

Slide 1. Russ Douthat

        Slide 2. Jamal Greene (in response)

        Slide 3. Dahlia Lithwick (in response in SLATE)

        Slide 4. The 25th Amendment 

In 2017, Scott Bomboy, chief of the National Constitution Center, wrote:

“Section 4 is the most controversial part of the 25th Amendment: It allows the Vice President and either the Cabinet, or a body approved ‘by law’ formed by Congress, to jointly agree that ‘the President is unable to discharge the powers and duties of his office.’ This clause was designed to deal with a situation where an incapacitated President couldn’t tell Congress that the Vice President needed to act as President.”

“It also allows the President to protest such a decision, and for two-thirds of Congress to decide in the end if the President is unable to serve due to a condition perceived by the Vice President, and either the Cabinet or a body approved by Congress. So the Cabinet, on its own, can’t block a President from using his or her powers if the President objects in writing. Congress would settle that dispute and the Vice President is the key actor in the process.” What might have been (but was not) would have played out this way according to Constitutional scholars:

“… scholars Brian C. Kalt and David Pozen explain the problematic process if the Vice President and the Cabinet agree the President can’t serve.”

1. “If this group declares a President ‘unable to discharge the powers and duties of his office,’ the Vice President immediately becomes Acting President.
2. If and when the President pronounces himself able, the deciding group has four days to disagree.
3. If it does not, the President retakes his powers.
4. But if it does, the Vice President keeps control while Congress quickly meets and makes a decision…
5. The Vice President continues acting as President only if two-thirds majorities of both chambers agree that the President is unable to serve.”

Had our leaders followed Russ Douthat’s advice seven years ago, it is highly unlikely that a 2/3rds majority of both chambers of Congress would have had their back. Instead, they went for Impeachment and failed, as Republicans chose rather to let voters decide. And they did, in 2020.

Few likely envisioned that mentally deranged (now former) President  Trump would launch a January 6th insurrection, embolden white nationalists militia across the nation, and follow thru on threats to run and win a 2nd term in 2024–intending to then free his followers from jail, to then fill their cells with those who attempted to hold him accountable for his historic misdeeds.

The 25th Amendment is no more a solution today than it was in 2017. Instead citizens loyal to our form of government rely in 2024 on two protective backstops:

1. Our third pillar of government – The Courts (most especially the Supreme Court.
2. The voter, whose second day of reckoning fast approaches.

Some believe we are once again engaged in a great Civil War. In its’ summary of the Gettysburg Address, National Geographic states that “Despite (or perhaps because of) its brevity, since (Abraham Lincoln’s) speech was delivered, it has come to be recognized as one of the most powerful statements in the English language and, in fact, one of the most important expressions of freedom and liberty in any language.”

The last paragraph of that two minute speech, delivered now 180 years and two months ago, reminds us that Americans died on “the battlefield” on January 6, 2021 defending our democratic government, and Lincoln’s words are today, more relevant than ever.

As described by historians, Lincoln made it clear that the stakes could not have been higher, well before the Dobbs decision and the appropriation of Hitler’s words by Trump. “Lincoln tied the current struggle to the days of the signing of the Declaration of Independence, speaking of the principles that the nation was conceived in: liberty and the proposition that all men are created equal. Moreover, he tied both to the abolition of slavery—a new birth of freedom—and the maintenance of representative government.

As they were spoken, November 19, 1863, here are Lincoln’s final words, ones that deserve a most careful reading: “It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they here gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom, and that government of the people, by the people, for the people, shall not perish from the earth.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

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AI Inside

by KIM BELLARD

Well: 2024. I’m excited about the Paris Olympics, but otherwise I’d be just as happy to sleep through all the nonsense that the November elections will bring. In any event, I might as well start out talking about one of the hottest topics of 2023 that will get even more so in 2024: AI.

In particular, I want to look at what is being billed as the “AI PC.” 

Most of us have come to know about ChatGPT. Google has Bard (plus DeepMind’s Gemini), Microsoft is building AI into Bing and its other products, Meta released an open source AI, and Apple is building its AI framework. There is a plethora of others. You probably have used “AI assistants” like Alexa or Siri.

What most of the large language model (LLM) versions of AI have in common is that they are cloud-based. What AI PCs offer to do is to take AI down to your own hardware, not dissimilar to how PCs took mainframe computing down to your desktop.  

As The Wall Street Journal tech gurus write in their 2024 predictions in their 2024 predictions:

In 2024, every major manufacturer is aiming to give you access to AI on your devices, quickly and easily, even when they’re not connected to the internet, which current technology requires. Welcome to the age of the AI PC. (And, yes, the AI Mac.)

What’s coming is what engineers call “on-device AI.” Like our smartphones, our laptops will gain the ability to do the specialized computing required to perform AI-boosted tasks without connecting to the cloud. They will be able to understand our speech, search and summarize information, even generate images and text, all without the slow and costly round trip to a tech company’s server.

The chip companies are ready. Intel just announced their new AI PC chip. It believes that its new Intel® Core Ultra processor will change PCs forever: “Now, AI is for everyone.” If you’re used to thinking about CPU and GPU, now you’ll have to think about “NPU” – neural processing units.

Intel promises: “With AI-acceleration built into every Intel® Core Ultra processor, you now have access to a variety of experiences – enhanced collaboration, productivity, and creativity – right at your desktop.” It further claims it is working with over 100 developers and expects those developers to offer over 300 “AI-accelerated features” in 2024.

Rival AMD has also released its own AI chips. “We continue to deliver high performance and power-efficient NPUs with Ryzen AI technology to reimagine the PC,” said Jack Huynh, SVP and GM of AMD computing and graphics business. “The increased AI capabilities of the 8040 series will now handle larger models to enable the next phase of AI user experiences.”

And, of course, AI chip powerhouse Nvidia isn’t sitting idly in the AI PC race.  It says that already: “For GeForce RTX users, AI is now running on your PC. It’s personal, enhancing every keystroke, every frame and every moment.”

Nvidia sees four advantages to AI PCs:

• Availability: Whether a gamer or a researcher, everyone needs tools — from games to sophisticated AI models used by wildlife researchers in the field — that can function even when offline.
• Speed: Some applications need instantaneous results. Cloud latency doesn’t always cut it.
• Data size: Uploading and downloading large datasets from the cloud can be inefficient and cumbersome.
• Privacy: Whether you’re a Fortune 500 company or just editing family photos and videos, we all have data we want to keep close to home.

The PC manufacturers are getting ready. DigitalTrends’ Fionna Agomuoh spoke to multiple Lenovo executives, who are all-in on AI PCs. “Put simply,” she writes. “Lenovo sees the “AI PC” as a PC where AI is integrated at every level of the system, including both software and hardware.”  Lenovo Executive Vice President of Intelligent Devices Group, Luca Rossi, cited an example with gaming: “We apply certain AI techniques to improve the gaming experience. By making the machine understand what kind of usage model you’re going to do and then a machine fine tunes, the speed, the temperature, etc.”

AMD’s Jason Banta believes “the AI PC will be the next technological revolution since the graphical interface,” which is a pretty startling statement. He elaborated:

Prior to this, you kind of just typed commands. It wasn’t quite as intuitive. You saw the graphical interface with the mouse, and it really changed the way you interacted the productivity. How you got things done, how it felt. I think AI PC is going to be that powerful if not more powerful.

Mr. Banta also believes that having AI built into the PC will make AI cheaper, more secure, and more private.

HP’s CEO Enrique Lores told CNBC in November that AI capabilities will spur PC sales: “we think this is going to double the growth of the PC category starting next year.” Technology research form Canalys predicts 60% of PCs shipped in 2027 will be AI-capable. IDC analysts are similarly bullish, saying: “The integration of AI capabilities into PCs is expected to serve as a catalyst for upgrades, hitting shelves in 2024.”

Windows Central reports that Microsoft plans to release Surface Pro 10 as its first AI PC. Surface Laptop 6 may also feature AI capabilities, although what exactly those capabilities are for either device remain unclear.

And, yes, when we say “AI PC,” we’ll also be seeing AI Mac. “Apple may not wax eloquent about AI but it knows very well that the use cases for this technology are booming and that the development work will require unprecedented computing power,” Dipanjan Chatterjee, an analyst at Forrester, told CNN. “That’s a huge emerging opportunity, and Apple wants a piece of that pie.”

The people who aren’t quite ready are us.

Moral of the story: in the not-too-distant future, saying “AI PC” will be redundant. AI capabilities will be built-in, assumed – and not just in your PC but also your phone, your watch, your car, all of your devices. Some of those capabilities will be local, some may be boosted by nearby networked devices, others will rely on the cloud.

I’ll be interested in how any learning that a local AI gains is passed along to other versions, and vice-versa. E.g., my health devices will know things about how my health is impacted by various treatments, and some of those should be pooled with other patient data for broader meaning.

Just like 2023, AI is going to continue to surprise and impress us in 2024.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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The US needs a Chief Patient Officer

By KAT McDAVITT and LISA BARI

Regulations are created by well-intentioned government employees who, understandably, focus on the loudest voices they hear. The loudest voices tend to be from organizations — vendors, associations, large corporations — that have the internal and external resources needed to access the federal government, navigate the 80,000-employee Department of Health and Human Services (HHS), and ensure that the perspectives of their employers and members are heard.

Patients do not have the resources to hire lobbyists or high-profile legal teams, nor do they have a large and well-funded trade association to represent their interests. Traditional patient advocacy organizations, while generally well intentioned, are often structured around specific conditions and often are financially supported by pharmaceutical and biotech companies. Because of this lack of access, resources, and representation, and because there is no single senior staff member in the federal government dedicated to ensuring the voice of the patient is represented, the needs and experiences of patients are deprioritized by corporate interests. As noted by Grace Cordovano, PhD, BCPA, a board-certified patient advocate, while speaking during a 2023 Health Datapalooza session on transparency and trust, “We hear a lot about provider burnout, but patients are also burnt out, and we need to take that into consideration when developing our policies.”

Policy implementation matters—and implementation is where patient interests fall through the cracks

Meaningful Use, a part of the HITECH Act within the American Recovery & Reinvestment Act, was well intentioned: Get records digitized for better care coordination.

But implementation and execution matters. Each stage of the $35 billion-plus Electronic Health Record (EHR) Incentive Programs, which evolved into the Promoting Interoperability Programs, was increasingly complex. Pieced together through administrative rulemaking, the program was eroded, mainly by corporate interests, and resulted in clinicians having less time for face-to-face patient interaction. Certified EHR requirements were driven by the most prominent vendors in an objectively fantastic demonstration of regulatory capture. Today, most provider offices use an electronic health record, but patients still do not have seamless access to their complete records. Although we are seeing improvements in interoperability, patients need more than access; they need to be able to act using insights from their health data.

Another example of corporate interests overtaking better outcomes for patients can be seen in the implementation of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018, which required states to establish a qualified prescription drug monitoring program (PDMP). A single vendor runs the PDMP in more than 46 states and territories. Thus, instead of sharing protected information with other health data organizations, like health information exchanges, these systems silo it. Many states mandate that that physicians check their state PDMP system separately and then charge those physicians a fee for mandatory access. Instead of helping to coordinate the care of a patient who may be struggling with an opioid use disorder, vendors have used a fear-based regulatory capture strategy at the federal and state levels to ensure these systems are separate from other health data—preserving market share and raising the barrier to entry for new competitive solutions.

Often, patients have no idea what data a PDMP has on them — which, in some states, can include opioids prescribed to pets under their name — and are unable to access it on their own. They also have no way to correct wrong information. Who suffers here? Patients, families, and the physicians who coordinate their care.

The Trusted Exchange Framework and Common Agreement (TEFCA), a part of the 21st Century Cures Act, is also well intentioned. One of the framework’s most significant promises was that, despite leveraging inferior data transfer standards, it would provide a uniform way for patients to request their records at no charge to them. In practice, after multiple delays, false starts, and many rounds of public notice and comment, TEFCA has launched without the requirement that its qualified health information networks (QHINs) and their participants must provide individual access services to patients for their own records.

The regulatory capture strategies of several QHINs and QHIN candidates have been textbook-worthy, ensuring those who have the resources to dominate the market will be locked in. What isn’t locked in? Any mandated access for patients, who were the audience most likely to benefit from TEFCA.

Will individual access services be reinforced in subsequent TEFCA requirements? Maybe, if someone within HHS — like an objective chief patient officer —is fighting for them like their mission and job depends on it.

A step toward progress

Patients, especially our country’s most vulnerable, underserved, and those suffering from financial toxicity, will never be able to afford the lobbying resources and access that corporations and large trade associations have. Consequently, our system will continue to be built to appease the private sector and to put finances over progress. That is, unless we start to ensure the patient voice is heard by creating a senior position within HHS dedicated to improving the experience and lives of 340 million Americans.

Kat McDavitt is president of Innsena and CEO of the Zorya Foundation. Lisa Bari is CEO of Civitas Networks for Health.

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