hic2012 the future of healthcare: innovation at the edge

Slide! Prepared Remarks!

Rajiv Mehta • [email protected] • 2 August 2012 • HIC2012 Sydney, Australia!

Thank you … for the introduction.!!As mentioned, I’m here representing Quantified Self. I’d especially like to thank the Health Informatics Society of Australia for their boldness in extending this invitation. You see, Quantified Self has been covered by major news organizations such as the Economist magazine and the Guardian newspaper, but usually with a tone of “Aren’t these people odd?” To be invited to share some thoughts on an important topic … it’s a nice change.!!“The Future of Healthcare” Well … predicting the future … tricky stuff. Chances are, no matter what you say, you’re likely to be wrong. !

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Computer scientist Alan Kay famously said “The best way to predict the future is to invent it.” This seems to work for a few people.!

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Another way is to consider author William Gibson’s claim that “The future is already here — it’s just not very evenly distributed.”!!What this means is that ...!

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… somebody, somewhere is already doing something, out on the fringes of society, that in the future will be commonplace. The challenge then is knowing where to look.!!I think I have come across a few of these somebodies. Let me tell you about them.!

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I’ll begin with someone from right here. Well, Melbourne actually.!

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A year ago, in 2011, entrepreneur Jeremy Howard attended the Beijing Language University, the top language school in China. He was placed amongst other advanced students, …!!

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and three months later finished first in his class. What made this especially notable was that Jeremy had only been learning Chinese for one year to that point, while most of his classmates had been studying for much longer, and that he was self-taught.!

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His study was sparked by an article he read in Wired magazine, about the work of Piotr Wozniak of Poland on the best way to memorize material, an approach called spaced repetition learning. !!

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The basic idea is that there is an ideal moment to re-learn something. Wait too long and you’ve completely forgotten, and so you are starting over. Re-learn too quickly and you’re just wasting your time. Ideally you re-learn just before you are about to forget. If you can do that, you will forget more slowly the next time, and so the time for the next re-learning will be longer. The difficulty is in knowing when this right moment is, as it varies not just from person to person, but also from item to item. However, you can use a computer program to track your learning and to tell you the right moment to re-learn the material. Jeremy decided to test this idea by trying to learn Chinese. Obviously it worked!!!

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One of the benefits of using such a program is that you can track your learning. You can gather statistics on your performance, such as how well you recall material, or how quickly you answer questions. Jeremy used these statistics to understand his own learning patterns, and the influence of environmental factors.!

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For example, he found that he learned better when walking slowly on a treadmill — 1.2 mph at a 1 degree incline — than sitting at his desk. While walking he was able to memorize better, and he was able to concentrate for much longer.!!In fact, he discovered that this didn’t just apply to learning Chinese. He found that his mind generally worked better, that he was able to do more and better work, when walking than sitting. It turns out the treadmill was good not just for physical health, but for his mental performance as well. So, he’s purchased many treadmill-desks for the employees in his company. He’ll soon discover whether treadmills are good for productivity generally, or something unique to him.!

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Jeremy told this story a few months ago at a meeting in Silicon Valley of the Quantified Self. This group was started by journalist Gary Wolf, the author of the story that sparked Jeremy’s learning Chinese.!!The Quantified Self is a global collaboration of users and makers of tracking tools. It is full of people, like Jeremy, who track various aspects of their lives with the expectation that they’ll learn something about themselves and perhaps use that knowledge to improve their lives in some way. On one hand it is a very modern phenomenon, the result of the wide availability of powerful and tiny and inexpensive computers. On the other hand, philosophers such as the Buddha have long been advising us to be mindful, to be self-aware. People are simply using new technology to assist their mindfulness.!

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The first meeting of the Quantified Self took place in September 2008, in a home in a San Francisco suburb. About 30 of us were there, pleased and somewhat surprised to discover that there were others with a similar interest. We have been even more surprised to see how rapidly this has grown. We now have over 60 groups around the world, including one right here in Sydney.!!

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People come to the meetings to share stories of personal self-tracking experiments. They address three simple questions. They tell us what they tracked and why. How they did it — what tools they used to collect and analyze their data. And what they learned. The answers are often surprising.!!

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Another recent speaker was Sky Christopherson. Sky had once been an elite athlete. !

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At the age of 19 he was a US national champion in velodrome cycling, he was part of the US Olympics team in Atlanta in 1996 and Sydney in 2000, and had been ranked 4th in the world. In preparation for those Olympics he had participated in the most sophisticated training program in sports, at the time, where they measured every aspect of his performance, training and life as well as they could, and developed training programs tailored for each event.!

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Some years later, in 2006, he started a business and approached the company’s performance with the same mindset — measuring everything and working hard to optimize every aspect of his business. The relentless pursuit of business performance led to business success, but his health suffered. Within a year he had many, many health complaints, from joint pain to bleeding gums to a low sex drive. !

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Things kept getting worse, and at one point he found himself being rushed to the hospital in an ambulance with the medics wondering whether he had suffered a heart attack. The doctors suggested a long list of interventions for his long list of ailments. Especially for someone who had once been in fantastic shape, this was a hard pill to swallow.!!

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Fortuitously he heard a talk by Dr Eric Topol about the new tools available for self-tracking, reminding of his Olympic training, …!

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and he decided to embark on a year of intensive data gathering. Collecting data on sleep, diet, exercise, and general well-being.!!On sleep he was able to see data about when he went to bed and when he woke up, and how much of that time he was awake, in REM sleep, and in deep sleep. The data itself was motivational — if he could see a number, he could tap into his competitive instincts to improve the number. The data also helped him experiment, and he soon made lifestyle changes that stabilized his sleep.!!

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However, over several months, from January to June, he also noticed a steady decline in the amount of deep sleep. After considering various potential causes, he decided it had to do with the weather, that it was the result of the room getting warmer as he didn’t have air conditioning. !

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Sky got a cooling pad, a temperature controlled pad that goes underneath the sheets. And soon discovered that with a setting of 66° Fahrenheit his deep sleep went up significantly.!

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After another year, due to the combination of improvements to sleep, diet, etc., he had an almost complete reversal of symptoms. So much so that last year, at the age of 35, he set a new world record for track cycling.!

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It is worth noting that Sky’s self-monitoring, using his own funds and widely available technologies, is in many ways far more comprehensive, and results in far more personally tailored wellness regimens, than the best-that-money-could-buy for his Olympics training only 10 years earlier.!

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He is now applying all that he has learned about self-tracking, and about the new tools available, to help other athletes improve their performance. He’d thought of calling his new business the Quantified Athlete, but eventually chose the Optimized Athlete. Much better from a marketing perspective! He’s been helping many athletes prepare for the Olympics. We’ll see, over the next couple of weeks, whether he’s had an impact.!!

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The Quantified Self … or rather the self-tracking movement it exemplifies … and the potential impact it may have for the future of healthcare is the focus of my talk today.!!To frame that potential, let’s go back nearly 40 years, to another meeting in Silicon Valley, to another group of hobbyists. It was March 1975, and it was the first meeting of the Homebrew Computer Club. These computer hobbyists had a mission. !!

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At a time when only elite universities and large corporations could afford computers, when only professionals in lab coats ensconced in special rooms had access to computers, they dreamed of making computing personal. They dreamed of liberating computing for the masses.!!One of the attendees at that first meeting was Steve Wozniack. Three months later, inspired by what he saw and heard that day, he had built a working personal computer. Ten months later, he and a friend named Steve Jobs founded Apple Computer.!!The Homebrew hobbyists foresaw and led a movement to change computing from the province of a limited elite to a tool for the masses.!!And they changed the world.!

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There had indeed been a lot of innovation in the past from the centers of computing, from the academics at universities like Princeton and Stanford, and researchers at corporations like IBM and Bell Labs.!

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But, the personal computing revolution unleashed the power of creativity everywhere. Lone geniuses and creative students the world over have dramatically increased the pace of innovation. In addition to Jobs &Wozniack, here are some other companies started by innovators outside the centers of power.!!Not everything can be done in a garage or in a college dorm room of course. Some things require the financial resources that only large institutions can provide. But those companies, which started as fringe projects, have become very mainstream. And the innovation occurring at the edge, where millions of people are experimenting, continues to have a powerful impact.!!Similarly, the self-tracking movement is liberating health science, moving health science from professional lab-coats to the masses.!

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Innovation in ideas and tools that further health and well-being has come, for much of the last century, from centers of the healthcare profession. In the US, that’s been from the 150 medical schools, !

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from the 7,000 hospitals and clinics, !!

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from the 700,000 doctors, !!

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from the 7,000,000 health professionals.!

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By contrast, in the US there are roughly 300,000,000 people who, by design or otherwise, are constantly experimenting with their health. We might all learn a lot as people like Jeremy and Sky experiment and as others invent.!!

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Yoni Donner is an inventor. Yoni is pursuing a PhD at Stanford, studying machine learning and artificial intelligence, while also working at Google. !

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A few years ago he became interested in the topic of cognitive performance. He surveyed the tools that have been developed over the past 50 years for measuring cognitive performance and found that nothing quite addressed what he wanted to do. The existing tools were good for comparing groups, for developing population norms, but weren’t good for measuring small changes, for intra-personal and day-to-day variation.!!He wanted to understand his mental performance at a much more granular level. He didn’t simply want to know whether he was smarter than average. He wanted to know the impact of different meals or different hours of the day on how well his mind worked.!

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So, he spent a couple of years designing and developing such tools. He has made them available to all at a website called Quantified Mind. Think of these tools as short simple video games. His challenge in creating these tools was to balance competing goals. The games had to take very little time, so that one could fit them into normal life, but they also had to generate meaningful data. They had to be simple to play, but also had to minimize learning effects, so that they are useful through frequent and ongoing use.!!Yoni has developed about 25 such games so far, and is constantly working on more. A wide variety of cognitive domains — processing speed, motor function, context switching, memory, visuo-spatial acuity, etc. — are tested through simple games. !

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One tool is “choice reaction time”. There are three circles on the screen. The circles randomly light up in green, and you press the appropriate key 1, 2 or 3. This goes on for a couple of minutes. At the end of which you get some statistics on your performance — how quickly you responded and how many mistakes you made. It’s quite simple, but do it at the end of a long day and you’ll find it is also quite effective at detecting your tiredness.!

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Another tool is “sor-ng”. There are four images: one red snail, two green jelly fish, three blue whales, and four yellow dinosaurs. Another image appears below and you’re asked to match something — the color, the number OR the species — and press the appropriate key 1, 2, 3, or 4. In this case you’re asked to match the color, so you’d press 3. It turns out that this is much harder than it seems.

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He decided to use his own tool to prove something about himself that he was quite confident about: that his work performance, the quality of his programming, was much better when he skipped lunch. He wanted to prove that he wasn’t being unsociable; he was being smart.!

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Turns out he was wrong. He performed more poorly when he fasted. This chart shows the results of a simple motor-function test — how rapidly he could tap the space bar. Faster tapping means a higher bar. Blue is when he had lunch; green is when he did not. He did the exercise with both left and right hands. For his right hand, on average he did 7.1 taps per second with lunch, and about 6.7 taps per second without. The difference is slight, a fraction of a second slower, but consistent, as you can see from the error bars.!!

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Here are the results from the “choice reaction time” test — the one with the three circles. A faster response time is a shorter bar. Again blue is with lunch, and green is without. This metric also shows that he was slower when he fasted.!

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But there’s more. The tools measure a variety of cognitive functions, not just speed, and it turns out that his performance — fasting versus eating — depended on the type of task to be performed. If the work involved critical thinking, something complicated that he had to think through carefully, fasting was detrimental. On the other hand, if the task was mundane and monotonous he would actually perform better if he fasted. Now, he is able to tailor his lunch to the work he has to do.!!

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Others are now taking advantage of Yoni’s tools to conduct their own experiments, evaluating the impact of sleep, diet, exercise, and many other things on their cognitive performance.!

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Alex Grey is another young inventor. At an early age he became familiar with surface electromyography, a noninvasive method of quantifying muscle activity by measuring the muscle’s electrical output.!

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This technology is used widely. Sensors are placed on appropriate muscles, and the electrical activity is recorded. It is used to study muscle movements large and small, and to treat injuries for everyone from athletes to musicians.!

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Alex’s parents ran a clinic which used such technology to help treat people with repetitive strain injury and other such muscular chronic pain. This diagram shows the amount of muscle energy used for hand writing and using a computer mouse before and after treatment. He personally benefited from his parent’s expertise when he himself developed an issue as he was growing up.!

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Years later, Alex decided to start a company to broaden the use of sEMG technology. Current sEMG systems are expensive, and they’re confined to lab use — you saw all those wires. He believes such technology could have a much bigger impact if we can get it out of the lab and into everyday use. !!Alex set himself a challenging goal: to design an sEMG system that would be usable in the real world — something that could readily be worn while going about normal life, something that was small, light, comfortable, and without wires. And, it had to be inexpensive. His company Somaxis has created such a sensor. !!The quality of data his sensor collects isn’t as good as the laboratory equipment, but it is proving to be more than adequate. Most importantly the data is obtained in real-world conditions.!

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In this simple example, Alex put a sensor on his left and right thighs and went for a run. As he got tired, the change showed up clearly in what the sensors record.!

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With more sophisticated experiments, he has learned interesting things about himself. For example, he wondered for a given running speed, what cadence or stride rate would use the least amount of energy, and so delay the onset of fatigue. He created an audio track of snippets of ever faster music, and then ran on a treadmill at constant speed. As the music got faster, he would have to take shorter steps to match his cadence to the rhythm. He wore sensors on the quadriceps, hamstrings, and calves of both legs, and combined these measurements for an overall score on the amount of energy he was expending. He discovered that when running at 6.5 mph, a comfortable speed for him, he used the least energy at a cadence of 130 bpm.!

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Alex’s technology has attracted the attention of professional athletes. They want to discover their own particular efficient motions to improve their performance. Alex is also starting to apply his technology to the very same people his parents treated, people such as office workers who hurt themselves from too much typing or writing. These workers will be able to learn directly, sitting at their own desks, how to minimize their strain.!!The technology is also starting to find interest in unexpected places. I’ll tell you more about that in a moment.!

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Alex and Yoni and Jeremy and Sky … just a few of those whose efforts are currently at the edge, at the fringes of healthcare.!!How are such efforts going to impact the future of healthcare? !!

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For one thing, it will move us from talking about “patient” empowerment, to “personal” empowerment. !!

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A patient only exists as a client of a health professional. A person exists on his own, whether or not a health professional is in the picture. Much patient-oriented health innovation assumes a professional presence, professional supervision. Tools for personal health empowerment assume that the person himself leads and chooses who else he brings into the picture.!!

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Similarly, we talk about “personalized medicine” as something in which the health professional has detailed data about his patient that he uses to make better decisions. !

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In contrast “personal medicine” is about the person himself having detailed data about his condition that he uses to make his own decisions.!!

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Much health research aspires to know what works, what makes a statistically significant difference, to some group of people. !

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In contrast self-tracking is about discovering what works for me, what makes a difference to me, in my life, right now … whether or not it is good for anyone else.!

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We’re talking about health innovations being developed for use by individuals by themselves. !

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Does this mean that healthcare professionals are optional? Well, yes and no. In all aspects of life we turn to experts when we believe such expertise is valuable. Most of us are unlikely to set a broken bone, do surgery, or deal with cancer by ourselves. But, for day-to-day health there will be less and less inclination to “consult your doctor first”.!

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Some may argue that these people at the edge, these so-called innovators are amateurs, who don’t know what they’re doing and whose work should have no place in the health profession.!!Others might feel that their experiments are risky. That without proper supervision from health experts such experimenters might hurt themselves.!

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Many point out obvious and legitimate concerns about the quality of such self-experimentation. And they’re right. Many, perhaps most, of the self-experiments I come across are flawed in some important ways. And often the results are inconsequential. But, to point out the obvious, so is much formal science. Let us hope that overall scientific-literacy is higher in future generations.!!

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True breakthroughs are rare. Earlier in my talk when I noted some of the very successful technology companies that were started by amateurs I neglected to mention that there were tens of thousands of similar efforts that failed.!!However, true breakthroughs do exist. There are diamonds amongst the failures, people such as those I’ve told you about.!!

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The arguments about the amateurishness of much self-tracking efforts are also besides the point.!!I believe it is inevitable that such tools and such self-experimentation will become ever more mainstream. Technology — sensors, smartphones, web access — continues to become cheaper, faster, and more widely available. Information, and admittedly mis-information, is everywhere. And skepticism about expert knowledge and bias is increasing. All leading to greater self-experimentation, self-direction.!!

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With all this innovation going on at the edge, how can the core healthcare industry play a part? Even if these changes are inevitable, what can you do to influence the changes?!!

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First of all, you’ve got to follow, you’ve got to know, what’s going on. Once upon a time, huge IBM wanting to get into personal computing turned to tiny Microsoft for a key component. Today, despite its tremendous size, IBM continues to seek out innovation in tiny startups. And those once-tiny startups and now major players — Microsoft, Apple, Google, Facebook — do the same, constantly looking for innovation at the edge.!!

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And, of course, you’ve got to get involved …!

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To have any credibility, you have to lead from the front. Talking about the opportunities or dangers of self-tracking carries little weight unless you’ve tried it yourself. Familiarity with academic literature alone carries little weight. So, learn about yourself. Track your sleep, or your mood, or your office tasks and their relation to your stress, … anything really — and see what you learn about yourself, as well as the difficulty of doing, of learning, and of making changes.!

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You might find that you have to remind yourself of what constitutes good science. Blindly assuming that the protocols of large clinical trials are the only way to do good science is as much “cargo cult science” mentality as anything you might find to criticize of the amateurs.!!You might also come to appreciate that messy data obtained in real-world conditions is far more valuable than clean data obtained in sterile laboratory conditions or highly-circumscribed clinical trials.!!

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Then you can use your clout to accelerate widespread adoption of innovations for personal health, to encourage and support your patients to learn more about themselves and to make their own decisions.!!

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I’d like to close with two examples of ideas from the edge that may be starting to influence the mainstream. They are both things I’m involved in.!!One has to do with seeing opportunities to applying new tools to address major problems.!

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The issue is that of fatigue in hazardous industries. Think of miners and oil rig workers, farmers, construction workers, sailors, and such. Their work often involves hard physical labor in harsh environments, while also being mentally alert. It’s not just labor; there’s a lot of thinking as well. They work in situations in which small, simple mistakes can lead to immediate and major physical harm, and on to major disasters.!!It is well known in these fields that fatigue is a major safety problem. Fatigue leads to those small but momentous mistakes. Lots of studies have been conducted, leading to common-sense advice — get lots of sleep and eat properly — and safety-oriented policies — shifts can only last so many hours, places to rest must be provided, etc.!

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However, they don’t help in-the-moment. Nothing exists today to help the worker know in-the-moment that he is too fatigued, mentally or physically, to continue with his work. One concept being evaluated is to combine Alex’s sensors + Yoni’s cognition-measurement tools to develop a personal fatigue detector. Something that can help a worker know how fatigued he is right now. And then using such a meter to help each worker understand for himself what works best for him to recover from as well as to minimize fatigue. Neither Yoni nor Alex had this use in mind when they developed their tools, but they came to the attention of a safety expert in the oil industry who started imagining how they might help with the issues he cared about.!!

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A second example has to do with how the experience of self-trackers is shining a new light on a familiar problem.!!

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The problem is that of adherence. As we all know, patients often do not follow the directions of their doctors, and that non-adherence is a major challenge.!!One might think that self-trackers would have no adherence problems. After all, they decide for themselves what they want to do, are inherently motivated to follow-through, and their experimental regimens are generally much simpler than what people dealing with serious health conditions have to deal with. Other adherence-related issues such as side-effects, costs, and availability are also minimal.!!According to theory, these people should have near-perfect adherence. Well, so much for theory.!!Self-trackers often find it difficult to remember to do what they’ve set out to do. They forget just like everyone else. And they often find it difficult to keep track of things, to jot down what they’ve done and their observations. It turns out that the practical challenges of remembering and tracking small things, in the course of our normal, busy lives, is in fact very difficult.!!Learning from your experiments is very difficult if you can’t even carry out the experiments properly.!!

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So, they’ve been developing tools to help them remember and track their regimens, their experiments. These self-tracking adherence tools are more flexible than healthcare-oriented adherence tools. This flexibility often meets users’ health needs better than traditional adherence tools. Toolmakers are also experimenting widely with visual design, with integrating gaming mechanisms, with social support mechanisms, and many other things. Different toolmakers often make diametrically opposed design decisions, and then find that both kinds succeed, each appealing to a different audience.!!All this experimentation may prove a boon to those dealing with patient adherence. You can see what people are adopting, are finding useful, and start from there, rather than starting from traditional, academic adherence approaches. !!Take advantage of what is working in practice, rather than hoping for what works in theory.!

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In my talk today I have made the argument the future of healthcare is already here, just not widely distributed. The future is already here, but it’s out at the edges, and if you want to take advantage of it sooner rather than later you need to actively seek it out. The future of healthcare is also much more personal, and so, perhaps counter-intuitively, you will be in a much better position to understand and influence this future if you take the trouble to look inwards.!!Thank you.!

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hic2012 the future of healthcare: innovation at the edge

Health & Medicine