Fortress and Frontier in American Health Care – Robert Graboyes (Keynote) | DPC Nuts & Bolts 2016



a gentleman who has done a tremendous amount of work in in looking at free markets and and he's a scholar at the Mercatus Center at the George Mason University and they do some of the most important work in terms of free medicine and certificate of need and healthcare IT which i think is what dr. Robert gray boys is going to concentrate on tonight so without any further ado please let's have a round of applause for dr. Robert gray boys well good evening delighted to be here thank you so much for having me I have to tell you this has been an incredible conference I've been thoroughly enjoying listening to the speakers which included some old friends and and some new friends as well so it's been a pleasure just a little introductory information so I'm calling this talk fortress in frontier in American healthcare that's the title of a paper studying an e-book you can get it on Amazon Kindle or you can download it on PDF off of the Mercatus website I'm Bob gray boys title is senior research fellow I'm an economist at the Mercatus Center and you've got a couple of bits of other vital information I assume that we can make this available to folks great so we'll have this available to you because there's some information you might find useful to have as a reference afterward there's my email address that is not there in perfunctory manner that's there because it's an invite if you've got ideas if you've got suggestions please write me glad to hear from you that's why I'm here and at the bottom there is my Twitter handle I am very active on Twitter I love to broadcast things about innovation in the sphere of healthcare in innovation and other things and I don't know I'm a pretty funny guy so I I also tweet some pretty amusing things that may have nothing whatsoever to do with it yesterday I was tweeting on Bob Dylan getting the Nobel Prize in Literature so I was pretty happy about that actually so let's see so this is the cover of the paper that I did about two years ago and it's sort of the center of my studies we call it I called it fortress and frontier in American healthcare again it was published by the Mercatus Center it is available on Kindle for some very small price and again it's for free on our website so what's this about my argument in it is that there's a divide in the way we view healthcare in America and it is not a left and right Democrat and Republican liberal and conservative divide my argument is that both sides of the political spectrum are way more similar than either of them would like to be to admit that both of them see health care they have a what I call the fortress viewpoint fortress viewpoint says that public policy law and regulation custom in health care has two major purposes one is to imagine every terrible thing that could happen to any patient in the course of health care and to throw all the vast resources of the country and trying to prevent anything bad from happening so extreme risk aversion and the second purpose of public policy which is kind of parallel is to protect insiders from outside competition insiders can be people in this room physicians it can be hospitals it can be insurers drug manufacturers device manufacturers you name it but it is a sense there I say a sense of entitlement that says they've worked very hard to get this way and we don't want we don't want anyone challenging this hospital is our big employer in this town we don't want other people moving in and opening a better hospital we don't want doctors to be challenged by nurse practitioners or telemedicine or direct primary care or what have you on the other side we have the frontier the frontier is a very different viewpoint the frontier says public policy that it's a worldview that accepts the fact that if you want innovation if you want progress if you want change if you want improvement you have to let people take risks we didn't get medicine the way we have it now because no one ever died in the course of experimental treatments people were allowed to take calculated risks there were conversations between patients and doctors and I'll give you a few specific examples and also it says that if you really want innovation everyone in the business be it hospitals or insurers or drug manufacturers or device manufacturers or the people sitting in this room need to face competition competition that quite frankly could put you out of business it's what other business industries face and the absolute ultimate frontier industry in this country in at least the last 25 years has been information technology has been solidly out there on the frontier because of legislation one of the most remarkable legislative achievements in my lifetime laws and it's very much underwritten somebody could write a great book about it around 1990 91 both sides in Congress stepped back and said we've got these new technologies coming along this thing that's the internet that's been kind of a closed system among the Defense Department and universities and we're gonna open it up and we're gonna let people experiment we're gonna let people commercialize it before that it was forbidden to send a personal message on the Internet you couldn't send any commercial message because you'd be in violation of federal regulations on it Congress stepped back and said let's let people experiment and yeah there'll be problems along the way but you know what we'll fix them as we go rather than trying to prevent every little thing beforehand now people often look at me after I've made this statement said you're talking about two different things apples and oranges medicine it's all about life and death it's all about sickness and pain it's your health information is just a cell phone sitting there on on this podium or a laptop or whatever else is you're going to type during my talk and I'll say no actually I will contend that the information technology that we carry around in our pockets our phones iPads our laptops whatever can inflict as much maybe more damage to human life to safety to health than anything any doctor in this room could possibly do in a lifetime of malpractice if you think about it 15 years ago the World Trade Center came down it would not have been possible without the coordination of cell phones someone who was frightened to death of information technology in 1990 could have said I don't like this I don't like cell phones will get terrorism will get fraud will get gigantic theft in ways we've never imagined will have foreign governments messing in US finances and elections and whatever you'll have reputations ruined and every one of these worries would have been correct but we didn't stop it Congress somehow said yeah these problems are going to happen let's deal with them one by one as they happen rather than stopping the world out of deadly fear of it and it really was a remarkable moment in American legislative history and I understand how it happened and I think it's it's something that's worth thinking of but what I would like to see is a shift more toward the frontier in medicine and we'll talk a little bit about what that means so what I'm really getting at is to get out of the quandary we're in escalating costs quality spotty quality in American health care inadequate coverage in some areas how the only way we're actually going to solve these problems is the same way that we solve problems in IT I'm holding in my hand here an iPhone 6 this is more powerful than any computer that the CIA owned in the 1980s when I started out in economics it would have cost vast amounts the computing power in this phone would have cost in the around 1960 or their routes would have cost about in theory 100 trillion dollars in today's money today I got it for a couple hundred dollars some of the other speakers today talked about that and the question is how do we get there we got there because of the frontier mentality not staying on the fortress so what do we mean by innovation in healthcare when people talk about innovation healthcare they tend to think of this as the National Institutes of Health just outside of Washington and I don't mean to criticize the NIH I often will say that very likely the NIH is could be you could argue that it is the single most successful federal agency most efficient it does wonderful work I have the highest opinion of the people who work there and the work that they do but the notion here is that innovation means we're gonna we're gonna throw a couple of tens of billions of dollars in cure Alzheimer's cure cancer we're gonna do some gigantic things we're going to when I talk to people in the hill about policy and this would be liberals or conservatives they tend to say yes we need more innovations so therefore federal government is going to throw several tens of billions of dollars and make really cool electronic medical records and we need them to work so we'll tell everyone they got to use it well innovation that's one kind of innovation and I'm not opposed to it and say there the government is actually quite good at certain kinds of innovation and I'll often cite the Manhattan Project to develop the bomb the space program to get to the moon and back governments had a major role in the eradication of smallpox the Defense Department created the internet before it turned it loose on society and the Human Genome Project were all government efforts at least in part and they work magnificently well and I will argue that the government has a terrific role when a couple of conditions hold when the science has already known it's just an engineering problem and secondly when you can say definitively in retrospect did it work or didn't it did the bomb go off yes it did did we go to the moon and back unless you're a little bit odd yeah we did that too and did the internet work magnificently and so forth and the third condition is you have to not care very much how much it costs so those conditions hold this sort of innovation works great but I'm of the belief that an awful lot of what will drive 21st century innovation is going to look very very different it's going to look a lot more like what you saw in the last 25 years in IT we did not have the federal Department of Apps developing the hundreds of thousands of apps that appear on your iPhone's and your iPads and and other devices Facebook was not a federal project now we do not have the Secretary of Twitter health care innovation looks more like the things these people do so first of all a quiz mostly will designate your age who's the person on the left hedy lamarr Headley yes Headley okay does anyone know why I'm showing Hedy Lamarr she wasn't a spy but it was here was the interesting thing Hedy Lamarr was an actress in Europe in the 30s in America in the 40s and a little bit in the 50s and her star somewhat faded after that she was considered the most beautiful woman in Europe she was married in Europe to a piece of scum who was an arms dealer who was an enthusiastic dealer to the Nazis during their rise one of the things her husband did was he liked people to see who he had married so he dragged her from meeting to meeting and told her to just be quiet so she was quiet but listened when she fled him and fled the Nazis and came to the US and became a star here it came to her attention that the Nazis were jamming us radio-controlled torpedoes rendering them useless and she thought about it and unbeknownst to her husband she had become a world-class Arms expert of high-tech arms and so she envisioned I know how to stop the Nazis from jamming torpedoes she didn't know how to build it so she went to a friend of hers who was a composer and a conductor and he said well you know years ago back in the 20s I wrote an opera that required 18 pianos on stage synchronized perfectly and they use piano rolls why don't we just use a piano roll in the torpedo and one in the radio changing the frequency back and forth so the Nazis can never find it wasn't used in World War two but it was used to stop the Soviets jamming our broadcasts during the Cuban Missile Crisis in 62 and ultimately it became the forerunner of Wi-Fi and Bluetooth the remarkable thing here is that she's not someone you would have expected a Hollywood actress to be this genius inventor you won't know the people on the right the one the the two brothers they're the one on the Left grew up with my mother and he was my he was our family's doctor for decades for close to 70 years he was the family's doctor and one day my father told me you know basically Milton that's the doctor on the left said you know basically he kind of invented the idea of stem-cell therapy and I thought dad was just kind of exaggerating a bit until scientific American's some years later acknowledged that he had indeed been a pioneer in a tiny little Hospital in Petersburg Virginia he had performed the world's first stem cell transplants to fight cancer and in the early 60s when he had this epiphany that maybe there was something in infant blood that would restrain the growth of cancer you could do that sort of experimentation today the protocols of experimentation would your institutional review board would take forever if it ever even allowed it and even then because he was a nobody he couldn't get funding and never could get published and it took 40 years for the world to acknowledge that he had done a really remarkable thing and that's his brother who's still around and the pathologist who assisted him in the research the bottom picture is the little girl named Shay Shay was born without fingers on her right hand three years ago if you wanted to buy Shay a prosthetic that would allow her to pick up a glass of water or ride a bike the minimum would have been about five thousand dollars until a carpenter in South Africa accidentally sliced off his fingers couldn't afford prosthetics and the doctors said the way you've sliced them prosthetics aren't gonna work very well anyway so he he emailed a fellow who has become a friend of mine saw him last week I have an Owen a puppet maker in Washington State and he sent these pictures of this mangled hand saying I've seen the hands you build per puffit for puppets is there anything you can do for me and I haven't said let's work on it and by Skype an email they developed the 3d printed hand that you see with Shay and that hand probably cost something on the order of between thirty and fifty dollars and it became a whole wide world network of people building these prosthetic hands for children and others in need and it essentially reduced by 99 percent like that the cost of a workable prosthetic hand and I can go on all day about innovations like this that are occurring now although there's a there are serious restraints on them one so I was talking to the inventor of this I had lunch with him a week week or two ago and he and his wife said you know the interesting thing is the real innovation in this is moving to Colombia and Paraguay why would you guess the innovation is moving to Colombia and Paraguay yeah I mean the FDA has been okay they've you cannot talk about these without a pun here and there they've had a hands-off attitude on the building of these things but within restraints if you try to sell them if you try to motorize them if you attach sensors suddenly it will become an FDA cupboard advice impossible these two countries have said you know what we don't have the resources to bother you so why don't you do it here and all sorts of miraculous innovations are coming out in these countries so one more President Obama assigned Vice President Biden to head up a cancer moonshot to try to find the cure for cancer and gave a billion dollars to the effort I will say it's a noble effort and particularly given the tragedies that Vice President Biden has had in his own family but I'll also note that it would cost a billion dollars to come up with a new analgesic if you wanted a variety of aspirin it would cost a billion and a half probably to bring it you're not going to cure cancer so I wrote an article co-authored with Tom stossel a cancer researcher at Harvard you may know his brother John Stossel the journalist and what we said is curing cancer is not like a moonshot it's not JFK saying here we know the science it's an engineering project and we don't care about the money let's just do it it's much more like interestingly one of the best policies in my view that's come out of the Obama administration which is commercial space policy which is basically said federal government is going to step away from launching rockets and we're going to encourage 50 or 60 companies out there to fight each other over how to do it best and you're getting all these wonderful different innovations in Space Flight and so we argued it's this is the model that that the federal government ought to be looking at rather than the moonshot attempt which again we think is sort of noble but probably isn't gonna work now let me get to an innovation that's of interest to me personally so I have a little device here on my cell phone you probably can't see it I'll show you a picture in a minute so I gave a talk in Phoenix in April about that device it's a it's a device that can do an EKG one I guess it's one lead or Tooley that I forget but it'll do it's fda-approved it's its clinical quality and I spoke to a group of about this size 250 insurance administrators and said how many of you have heard of this I don't think anyone in the room had I said you realize if you have a patient who's one of your subscribers with atrial fibrillation you give one of these things you can prevent who knows how many unnecessary visits to the ER when they hold this thing for 30 seconds and it says no you are not having afib or you might prevent one of your subscribers from having you know a killer or non killer stroke when it says yes indeed you better get to the ER the wording is a little bit more subtle than that but that's basically what the message is so I flew home from Phoenix the next morning I woke up around 6:00 a.m. and for the first time in my life I felt my heart going and I sort of you know and and I said to my wife something's going on here I think you better get me to the ER and I went to the ER and indeed one day after giving this talk I was in atrial fibrillation and anyway they just for what it's worth they did every test in the book and there was not a physiological thing wrong from cat-scan whatever so I don't need any coumadin or whatever I'm hoping it's a lone-wolf but we shall see six months this week and I haven't had a recurrence but a there are a couple times I didn't know if I was having a recurrence so about ten or eleven days into this after this they they had put me on metoprolol and then they said my cardiologist said stop it for two days because I want to do a treadmill test and it's not gonna work you could take it so I stopped it and I was sitting there playing piano at home at 7:00 p.m. after dinner and I started feeling it speeding and I said and I was at this point it was early in this and I was still a little panicky I said to my wife I think you better take me over again so they hooked me up they said a little tachycardia you've gone up from 50 or 60 to about a hundred but it's perfect sinus rhythm so no there's no problem you can go home and I thought well that's good I feel reassured and somebody just spent three thousand dollars to reassure me that was this visit it was evening it was evening so I darkened it a little bit now for giving talks like this I I had been meaning even before I had afib I wanted to buy one of these things just to demonstrate it when I give talks like this so I bought it it arrived I gave a talk to another group like this up in the wilds of western Pennsylvania I finished my talk hopped in my car and I was driving on this road and let me tell you after driving on it this what you're seeing here is a heavy day of traffic on that road as I'm driving along and I was on my medications everything was as calm as could be there was certainly no stress on this drive it was a beautiful time I started feeling my heartbeat accelerating and I started getting worried because I was probably 15 to 20 miles from the nearest significant town there were no cars on the road and I was thinking what if what if something's happening to me out here and again this was still early I'm a lot these days since I've had six months to think about this and figure out my patterns but fortunately I had bought two devices I bought this Fitbit and as I was driving I could do this every 15 20 seconds and see yup 50 55 60 63 clever and it went up to 118 and I was getting pretty scared and I pulled into there was fortunately a gas station I pulled in oh here's my Fitbit and by the way that is from that from that evening June 3rd I can pull up any day in the last four or five months and show you the whole course of my heartbeat you can see about seven o'clock p.m. where it went up there for no apparent reason where I was getting worried and I pulled into a service station and I took out my alive core a product built by the way invented up in Oklahoma City it seems to be something about that town that does a lot of good stuff so I took it out sat there when I took it I produced this again from that night 757 p.m. June 3rd 2016 97 beats per minute perfect sinus rhythm I looked in and said I guess I'm okay I walked around a little I think I took one more and said I guess I can get back on the road and I thought I probably just saved at the end of the year when you add up how much we spent on American health care in 2016 I probably just cut it by two or three thousand dollars because I didn't go to the ER I'm not sure I would have but I might have and I calmed myself and I didn't have to spend any money on a hotel I didn't have to ruin my trip home and arrive a day late it was just it was magnificent and I just you know I don't like having the condition but I said if I if I had to get a condition this the one to get because I can show it off all over the place so anyway so I'm now six months and nothing's ever happened and I'm fine and there are lots of other innovations 23andme just show hands as I go through these how many of you are familiar with the story of 23andme okay I would say half so 23andme wife of one of the Google founders this is a DNA test it was $99 spit in a little bag mail it to them they would send you back 250 readings of your genetics and tell you you know it looks like you're kind of you might be prone to alcoholism or obesity or cystic fibrosis or this at you it would it would sort of tell you how to manage your health when the fda swooped in and said you can't do this here you can you can get people to spit in the bag and tell them who they're related to you can use it for genealogy but you are forbidden to use it the company was forbidden to provide any information on how you analyze the genetic readings if you want you can go to Britain and do it they're fine with it plenty of other countries you can use it but not here where it was invented this is alternative I wear eyeglasses I have been for a long time they're pretty expensive alternative how many of heard of this not very many alternative you take your laptop and your smartphone and you stand there and it says walk backwards walk backwards stop cover your right eye read the top line xD well f whatever okay cover your left eye now walk back whatever stop it's sensing how far back you are and this is all free and it will analyze it will write a prescription it will figure I forget what that's called how far apart your yeah how far apart they are and the next morning and up mala gist will read it to just make sure that it was all done right and within for $40 you get a prescription and if you want to spend a modest amount I think it's something under $100 they'll mail you a pair of glasses but in the state of Georgia they just made it illegal under pressure from the optometrists this is friend of mine Ian Tong chief medical officer for dr. on-demand I have used their service when my own doctor was away for a three or four-day long weekend I had a sinus infection I didn't want to wait and I certainly did not want to go to the ER and you know I it within almost always within 90 seconds you go on your iPad click there's a doctor looking at you just as ian is there and the doctor said open your mouth put it over the camera say ahh and whatever and she examined and said okay I can see what you got in ten minutes there was a prescription waiting down the corner from me she was in another state California company New York dr. Virginia patient however in some places including this one they're fighting tooth and nail to stop this so in Texas the state medical board has issued regulations that would essentially say well you can do teleMed but only if you have personally gone and a lot of shaking hands with the doctor somewhere ever been examined so if you as I understand it if you've been checked for athlete's foot five years ago you can have your sinus checked by this and I wrote I'm writing an eighteen part series I've got on the last slide that'll have the URL where you can find it's on the Mercatus website I'm writing about all of these things and I'm writing my doctrine to man and I had an explained to a group of legislators from across the country he saved a woman's life using their app who probably would have died had she gone through her usual path of waiting til the next day calling the doctor making an appointment etc this is a matter of life and death I've also written how am i through a bit of amateur teleMed my mother's life was extended by one year from 92 to 93 because my nephew who was an ER doc looked at her through skype or facetime saw her discoloration and her breathing whatever thought she was going into sepsis said I can tell it because my poor mother is down dearly departed said grandma you want to show me the wound was down here and she said I'm 92 what do I care so she took her iPad shut in the wound and he called my brother who's a doctor and said get her to the hospital I think she's going septic and she was she probably would have died had it not been for a little in the family a mature teleMed I don't have to talk to you about Keith sink Keith told you well today about his transparent pricing and the obstacles that he faces this is the neuron I health Hospital in the Cayman Islands arguably the best cardiology hospitals in the world today are the Narayan a system in India you can read about Debbie Shetty's work legendary I've met people who've been to the hospital and it's apparently astounding so they wanted to build a hospital for the American market where you get lower cost probably higher quality cardiac surgery cardiac care and they built it in the Caymans why because it's out of reach of the American regulators it's close enough that you can get down there it's a short hop from Miami but again can you spend your Medicare dollars there or your BlueCross dollars probably not I teach it a couple of universities my students are mid-career professionals doctors nurses administrators just like one in this room and they have all sorts of fears of why do you really want to go out of the country and I can pretty well shoot down any of them and I'm right one of my articles will be on rashiku Fernando Cooley and I don't have to tell you about DPC the virtues it brings to the market I don't have to tell you about the obstacles that insurance commissioners and others bring against it so I'm on Twitter a lot and one of my friends on Twitter who's in a DPC practice I don't know if he's here I meant to look to see if he's on the list but he wrote an article why there will never be an uber of health care and I wrote to him and said do you mind if I use your good name because I'm gonna write an article that says why they're gonna be many ubers of health care and his article head it was a good article I disagreed with it and said that getting a ride is a transaction medicine is a relationship that it's your PCP your gatekeeper there who has who really holds the key to your life and that now if I'm not misinterpreting but you can read both articles and he said ubers about ease and convenience and I said no uber is way more than that uber is about safety uber is that when your daughter is trying to hail a ride at 2:00 in the morning in a dangerous neighborhood she can be pretty well assured of getting a ride and if knowing before the ride gets there what the driver looks like what the license plate is what the number is and if there's a thunderstorm going on she's a lot less likely to be hit by hit by lightning for a long wait for a standard cab said first of all I agree that the relationship in today's medicine is a pretty important thing I'm not sure it says import as most doctors do but I'm willing to say fine let's we can we can talk about that but I would be much happier in a world where the personal relationship with my PCP is not as important where I can walk into an ER in California and somehow give that doctor access to my e in the electronic medical record electronic health record and that doctor can quickly get up to speed on Who I am and what my needs are and I won't go on too much longer on it because I want to make sure I get through everything I have to say but my articles on it are there you can see the full discussion of it so how do we turn what what we really want to do is to take the routine parts of medicine even parts we never thought were routine but we realize they are now and commoditize them to take as much as you can about the doctor-patient relationship and turn it into the repetitive tasks into a commodity that you can computerize and leave the doctor for the high level functions that you cannot automate so that you folks instead of being typists will actually be doctors and doing serious cognitive work which current practice is keeping you away from so this is my upcoming research effort and this is kind of the key to tonight so people talk about electronic health records or medical records and I've even heard people talk about smart EHRs I don't want smart ones I want brilliant ones I want ones that really take the rote tasks away from the doctor and put it into this to make the relation to make it much more of a transaction so that I'm not dependent on my doctor who may move away or die or be on vacation or I might be on the road so what I want and I'll just very quickly give you my idea of what it all look like where we ought to be going and I'll start by saying spent my whole career being an outsider coming in and giving opinions on things that I don't know anything about I'm not I'm not a technologist I'm not a programmer and I was hired many 30-some years ago to be a specialist for Chase Manhattan Bank on sub-saharan Africa and I was hired because I had no experience in sub-saharan Africa and my the guy who hired me was sick to death of everyone who did he wanted an outsider's opinion to look take a fresh look and that's what I'm doing here and I will invite you as a talk if you think that what I'm saying is interesting or wrong or you have some suggestion or you say oh what you're talking about we're already doing I want to hear about it so again my email address is there so what I imagine is an EHR it doesn't belong to my PCP belongs to me so I've got Bob's EHR and on the left you see it's got data flowing in from my primary care doc the emergency room my Fitbit my musings if I want to say you know I'm not sure I ever told the doctor that my father developed macular degeneration at about age 18 and that probably ought to be in the record banging so I can feed into my own EHR my alivecor the EKGs when I go to the pharmacy when I go to doctor on-demand telemedicine when I go to my gastroenterologist I want it all going into one place and so what I pictured here is a chronological record of every entry that's been put in there unordered and then I'd like fierce competition among in column browsers and calling EHR browser reader I want Google doing it I want Apple doing it I want Microsoft to me I want companies I've never heard of someone in the audience saying I know how to do it better I want fighting and importantly I don't think the skills and the qualities that make for a good input side are the same skills and qualities that make for good output there are a lot of different products that are feeding information right now into the internet all different computers cell phones tablets using different programs different data sets the one thing that the federal government did very well was they developed an excellent protocol that allowed all these machines and all these data types to feed into the hrs I think to end to the Internet and interestingly the government didn't say anyone had to use it there was no mandate it was here's a protocol Defense Department's been using it you want to use it use it if you don't don't and it became a standard and there are other challenges coming up to that standard but for 25 years it changed the world and on the reader side if you think about the Internet the the people I feed the information into the internet with when I do my website that's not how I read it I read it on a browser it might be an internet explorer browser it might be Firefox it might be who knows what and I use different search engines and I can imagine a Google EHR reader that my cardiologist uses that sucks all the relevant information using artificial intelligence sucks all the data points that the cardiologist needs and leaves the rest and organizes it and puts it into a form that a cardiologist I've never written that before can look over it in a couple of minutes and get a very good idea of who I am and what I'm about on the other end if I have a sinus infection I can go to the doc in the box and it'll give a few little data it didn't gonna tell them that I had a broken toe it might not tell them this or that and I didn't have to give them my Fitbit information just what's relevant and the technologies are already there to do this and I even want it I want my own reader I want something that puts it into a form that I can read and adjust I just had a small situation my primary care doctors got a pretty forward practice I can go on and read really quite a bit of data on myself on her portal I can look at my recent results my lab panels and what have you and I noticed it said that I suffered an allergic reaction to penicillin in 2014 so I typed a message and said yeah actually it was in 1958 it might be relevant if you need to treat me for something to know that I didn't have this two years ago I had it I don't even want to do the math I don't know but so I want to be able to feed it in I wanted to put it into a form that's organized not a big mishmash of things in chronological order as they tend to be present this was the original internet browser this was Holly web it came out and I think 1993 what do you notice about it it kind of looks like a small aircraft panel dashboard you put in your search term it asks you well do you want to look at the URL do you want to look at the text what kind of records would you like to search what kind of fields do you want check all these boxes you can restrict the results to this say okay stop after how many matches it was a it was an amazing invention for its time but now we have this and it's completely replaced it why are there no check boxes because Google knows what you which boxes you would check better than you know Google has spent a fortune to figure out how to read your mind and to do this simply so that you don't have to fill in the check boxes and when you see this I want you to be thinking of the check boxes that drive you nuts on an EHR and I also will note the cute little top and the Google Doodle at the top Google didn't do that because they just felt like putting cute pictures they put it there because it attracts people because there's something kind of entertaining about going on Google and I imagine that in the future there will be a certain entertainment value in a doctor going to an EHR which there certainly is not now I can give you one example where there was the doctor kind of a quirky emergency room doctor at George Washington University wanted to develop a database of what actually works in ER how should you do triage optimally when a patient is presenting with certain symptoms what do you actually want to do because up to that time it had been almost entirely intuition nice intuition but not really very studied he needed a lot of data he needed his his colleagues to be entering lots of information on their patients and what happened and he knew his his colleagues the last thing in the world they wanted to do was enter data for him so he did the equivalent of a Google doodle he knew I've got to make them want to do this his approach was he put a sign on it saying do not touch and all of his colleagues said I'm gonna touch and they started and he had built it so it was sort of interesting and okay well that's this actually I'm learning a little something as I'm entering the data and before they figured out that they were being used he had built essentially an ultimate ER database which became one of the industry standards and became a commercial package for er's if you picture the way we're doing EHRs now it is as if the federal government in 1993 had said search engines are the future they're going to change the world they're very important once people are using search engines life will be better on planet Earth so we're going to declare Ali Wehbe the official search engine of the United States government and we're gonna give Ali Wehbe forty billion dollars to add more check boxes to it and honest to god I think that's where we would be today we would never have gotten the revolution that all of us are carrying in our pocket what happened was Google was the 21st search engine to come onto the market over those years from over about a five to six year period you had a succession of Alta Vista and HotBot and Yahoo and others and they all improved in different ways some of them made them graphically easy Ali Wehbe as nice as it is it would be a lot of improved with better fonts it's not a trivial issue if your eyes are staring at ugly fonts you get tired of looking at the thing and so there's been a lot of effort put into figuring how can this thing be intrusive kind of entertaining informative and when the person finishes with it they feel I've actually gotten something out of this experience and of course at the bottom of it is EHRs today are primarily for reimbursement purpose and very little for therapeutic purpose and I think that will change but I think you're gonna ultimately have to go to something like Congress did 25 years ago stop mandating and stop subsidizing picking winners you know getting people like me in Washington who have no business picking winners in this sort of realm doing so and let the market fight just one other little product how many of you are familiar with augment –ax see you oughta be yeah see a couple of hands this is the end shaquille I've got an article coming out on him in about two weeks three weeks that's Google glass in developed this system company in out in San Francisco that when doctor is interviewing a patient examining a patient patient comes in ask the doctor plans to wear Google glass and livestream your exam to the back office are you okay with that and interesting question I thought an awful lot of people would say no that's kind of creepy I don't want to be live stream while the doctors talking to me and examining then I asked him how many people say no and he said a couple percent most people say fine I don't care anyway what happens is the doctors got no computer no tablet no nothing the doctor is talking to the patient looking the patient in the eye doing all of the touch and whatever the doctor has to do meanwhile it's being live streamed audio and video to a back office which is assembling an EHR in real time by the time the exam is done the EHR is done if the patient wants to walk out with it the doctor pushes a button here you are sir it's all finished and there are early estimates and it's in beta testing some hospitals are using it it cuts out basically about 35% of the doctors work week so the doctor can take 35 percent more patients or spend 35 percent more with each patient on average or play a lot more golf and again this is this is just dividing up the work of a doctor taking away the rote annoying things that you hate to do and splitting it up in a way that was not possible before and it'll be interesting to see what the regulations do what HIPAA does with it it it is HIPAA compliant not that that's not that I'm a huge fan there of HIPAA but anyway it's these are the innovations I think that are gonna change medicine that are gonna change the way it's gonna put more power into a patient I cannot tell you how empowered I feel having that little device on my phone how much peace of mind it has brought me in the last six months I cannot tell you how much it is kept me from calling with annoying phone calls to my PCP or my cardiologist to say this happened is there any problem here do I need to be worried about this and increasingly we're going to be taking charge of our own health you as doctors will be able to do much more what you actually wanted to do in medicine as long as we allow it to happen in the last two slides if you want to read more about this stuff here are 10 books I would recommend including David gold Hill's book but these are some others that will give you a very different view over here is Bronson Smith who was a former student of mine he's been subjected to some of these books in my class three or four years ago and these are some of my writings on on the on these subjects including at the top one is the 18 part series and with that I don't know let's go to some questions thank you questions spitballs you name it anything goes so if you had to predict something big in medicine where where do you what do you see the next big thing coming from or or what do you think it is big thing see I think it's a ton of small things okay I tend to think it is you know I've shown you a huge number of these little innovations I think I think if you want a big trend we have some huge things going now 3d printing nanotechnology wearable telemetry I don't I could name a few more and special especially specialized medical care the immunotherapy right and they are converging to slowed down somewhat by the fact that we have institutional obstacles government regulation laws and by the way the intransigence of kind of old-school medical professionals who don't want things to happen there are a lot there you can point blame a lot of places but these things are coming together as one of the books I had was Eric Topol the patient will see you now who argues that this device will very likely prove to be the most important medical device in human history my little EKG reader is just one thing there are vast number of apps and we are at a very very early stage and I would I would okay here's here's a big trend that will sum up what I'm saying historically medical science has been largely a sort of a branch of biology of biological science in the 21st century I think it will be as much a branch of information science as it is biological science it is the it is our ability to capture data we had never imagined before and torturing it and twisting it and reading squeezing information out of it that will very likely do more to improve our than the drugs devices that we do how's that one I just took a picture of that on my eye seven terrific terrific what else well in part that's political question the if you wanted fast action the states actually have considerably more power right now in the federal government yes people in Washington want to talk about the affordable care act and whether it repeal whether to change whatever it's gonna be a big struggle and who knows how it'll turn out but right now state legislatures and governors can get rid of certificate of need laws they can open up to physician extenders like nurse practitioners or nurse anesthetists they can they can eliminate corporate practice of medicine doctrine which was a strange progressive era essentially anti-capitalist piece of legislation which somehow a lot of people regardless of politics have absorbed as well that must be a good idea because we've been doing it for a long time there are all sorts of things the state level that could make a huge difference now and the states tend to be saying I want them to fix Obamacare and it's fix your own house right now now I argue unfortunate and frontier actually that there's a chapter in which I say that there were two approaches in the Pacific War in World War two there was one where you sent the fleet on mass or you can even look at the European theater where it's we're gonna establish a line and push and push and push and then there was the strategy that was used in the Pacific called island hopping which is we're gonna do one little thing we capture this island and once we secure it we're gonna look around and find another vulnerable island and do that one and we're gonna keep doing that until we own the whole ocean and I think when you ask I don't know of any one thing you could do that would change the world I think it is going to be we're suffering from death by death by a thousand cuts you got to start stanching the bleeding in all thousand and you'd have to find the ones that are easiest to start with and move one by one yeah I mean the the opening of the internet was an interesting one at first there was a bipartisan consensus that said let's establish a big regulatory framework to control the thing and it was on the verge of sailing through Congress no one really was thinking twice we regulated everything why not regulate the Internet technology community and others started saying hold on a second you're about to kill everything it's about to happen and they started picking off Democrats and Republicans who eventually swarmed over to the side of let's open the thing and as I was saying here when I talked to a lot of conservative groups I talked to some liberal groups when I talked to the liberal groups I loved to say and by the way yes indeed Al Gore had a big role in opening up the Internet he may have spoken injudiciously about it wording but in fact he was one of the movers and shakers in that and and it truly did open the world but it was not a for ordained thing it was in fact going exactly the opposite direction so there are a see and I'll see if I can remember all five I usually list there are five big things that you know I'm getting back to what would I change so the biggest single biggest problem in American healthcare and the single most troublesome is the the Medicare pricing methodology which and I've got a piece coming out on that maybe I'd already know I think that I think I already mentioned that I think it's in writing already saying that without being ideological or exaggerating Medicare is basically soviet-style pricing it and it corrupts everything private we call our insurance private insurance but basically it's Medicare with a few tweaks so you're gonna have to do Medicare if you don't do that you're never gonna get get this Medicare is driving EHRs Medicare is driving all sorts of things in the wrong directions secondly the FDA you can look and I've written some of my articles have this European Union which I'm not a huge fan of has a much better drug and device approval system than we do it's competitive it's private-sector it moves faster it moves cheaper and it's one place we ought to start looking I've mentioned all the state regulations hospitals that's been talked about a lot here hospitals are sacrosanct it's while I'm lost Bill's been around here since my granddaddy's days and it's the biggest employer in town so no we don't want someone else coming into town with a better Hospital and the fifth one which i think is really critical and some of my colleagues i've been talking it up in in fortress and frontier and elsewhere and i think we're gonna end up doing some research on it the whole structure of medical education is a 1910 model that is if you look into the history of it it was absolute progressive era centralized command and control every medical school ought to have an identical curriculum every student who comes to a medicine medical school should have the same background you should do you know two years of lab and then two years of practicum whatever and what it what we have done is we have robbed it of the variety that could exist and that does exist elsewhere in the world the caribbean schools which started off as sort of low on the totem pole decades ago or actually making some significant strides in alternative curriculum models we are getting a few year Harvard just changed its curriculum last year's one of the final acts of Jeff flyer it's Dean and I recently met the director of one of the rare one of the first I think is the the first dual program in medicine and design at at Jefferson in Philadelphia so if you want to go there and become a doctor and design medical devices you do your training in a dual dual manner between the two so I think those are the big ones it's a great point and I actually quite agree with you and think of it this way what these technologies are doing are they are eliminating two things that are the demon I actually have just written a paper it's not out yet co-authored with Eric Topol whom some of you may have read on the history of paternalism in medicine and two things from the time of Hippocrates till now have really driven paternalism which is fixed costs and learning curves heretofore it has been a very expensive procedure for let's say a primary care physician to actually get to know who you are and what your physiology is and what your mentality is what your needs are there's a big learning curve and it's expensive to do it so when you shift doctors that doctor is rock-bottom and has to rebuild that process what I'm talking about is a way of taking squeezing down reducing the fixed costs and the learning curves so that yes if I move from Alexandria Virginia to wherever it is you live and I want you as my doctor bang I can bring you up to speed and I'll give you just an analogy a couple months ago I got picked up by an uber in Washington and I always talked to the diverse they're kind of interesting stories so this was a young kid and I said you know which part of town do you live in he said I live in Chicago I said well this is Washington so what are you doing here he said my parents live here and I'm visiting them this week and they're out today and I didn't feel like sitting around their apartment so I figured I'll just go make some money and so he said I just turned on the device and I'm driving what that means is he didn't have to go through the process of learning how to navigate around Washington which is a tough place to navigate and suddenly he and I could have a very personal relationship he'd get me where I wanted without any problems and I think the same thing will ultimately happen with these technologies that will make it possible for you bhang to be up to speed on my needs really quickly as opposed to the old way where it's going to take you years of really getting to know doctor and patient so yeah I think there's complete consistency between being more personal and yet in some way less dependent don't buy tongue we love that we live on controversy a halfway disagree in half we agree I don't want to to be an automat on in it no I don't I think the doctor has a legitimate use and I think what you're going to find even the people in this room are going to find that a sizable percentage of what you do in life is rote routine that distracts you from the cognitive brilliance that you carry in your brains you're typing on charts you're filling out things you're getting to know you're getting to know you're spending it on the road and what we have is the opportunity to take those rote tasks and let you do what you really what cannot be automated we've seen this in other fields this was the whole course from the Industrial Revolution on fields where people thought you cannot automate this it's a very personal task we found ways to do it I want to unleash you and I want you to be able to be personal but without the struggle of getting up to speed and acquiring information and maintaining the information your head we are a very mobile society now people move people travel I'm on the road a lot I might get sick somewhere else I would like the doctor that I see when I get sick on the road to be in a lot better shape to look at me than they would be normally I adore my primary care physician she's very important to me she knows me and I don't ever want that to change but actually we have lots of discussions on this and she's in a very forward practice that again has allows shares the electronic health record at least a portion of it with patients and I can contribute to it and I can discuss it and I think it's going to be much more of a back-and-forth process between patients and providers some of the speakers were referring to that earlier so I don't come in and say you know your whole world is gone it's going to go away but I do think it's going to change significantly and I think it's going to change significantly for the better as long as we allow it to also I have no problem with people as you said deciding what sort of practice do I want to go to do I want an intensely personal one with direct primary care or some other model I think that's great what we have now is a forced homogeneity largely from the federal government but also from the state governments to say we're going to set the standards that patients and providers have to live with and that means you've got to fill in these forms you've got to do meaningful use you've got to use the kind of EHRs that we want I would love to let all sorts of models flourish I happen to be a big fan of that with of yours which is why I'm here but I do want to see competition between different schools of thought and I'd like to see them tweak and progress and not stay in a sort of a stasis as to a large extent a lot of medical practice and medical training has been since the Flexner report of 1910 I'd like to let you have more leeway not less with that thanks I really want to thank dr. great boys from coming and spending the time with us he's been with us for a couple days now and I really appreciate his insights you know one of the important things about conferences like this is not necessarily to to stand up here and and have an echo chamber of people telling us things that we like and agree with it's to share ideas to to inspire thoughts to encourage thoughtful debate and so it's always nice to hear different perspectives on things so I really appreciate the thoughtful questions we've had throughout the entire day today again I appreciate dr. gray voice coming out thank you everybody for a wonderful day we will see you all tomorrow morning and I believe dr. gray boys be more than happy to entertain a little a couple questions I'll be upfront sure I'll be there or if we can go out to Zach's reception and I'll just say is the last thing you'll have this you'll have my email and you or anyone else please write with criticisms and compliments and ideas and suggestions i'm co-authoring this with a physician who's one of the most humane Oh bee gees I've ever met and let's see where it goes but I do want your input [Applause]

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