Intelligent Primary Care
Last week I had the pleasure of hearing Daniel Kraft, MD speak at a monthly medical society meeting. Dr. Kraft has an impressive medical pedigree, graduating from Stanford medical school and finishing a Med-Peds residency at Harvard followed by a hematology/oncology fellowship back at Stanford. He also has a well earned reputation as a “futurist” from his work with XPRIZE, Singularity University, and Exponential Medicine. Before attending his talk, I got myself up to speed by reading and watching his public work including his 2011 TED Talk, his recent outlook on the future, and his incredible Digital.Health index. Since then, I have been thinking more about a couple of his favorite concepts.
EPISODIC TO CONTINUOUS CARE
Fitbit launched its first product in 2009 and began a wearable revolution, from Apple joining the fray in 2014 to all the products today including smart rings and “underwearables.” About a fifth of Americans just before the pandemic had some sort of wearable. In his 2011 TED Talk, Dr. Kraft introduced the idea of a “quantifiable self” and envisioned a future where wearables would integrate and provide continuous, actionable data for us and our doctors. On stage last week he was wearing two smart rings, a smart watch, and made an inference to several other devices on his person all of which provided a continuous stream of various biometric data to his phone. Data gathering has come a long way since wearables have gotten popular and the potential is huge for primary care, potentially even redefining the field.
Currently, the traditional way of chronic disease screening is still the arguably useless annual physical visit. The doctor has 15 minutes to do a comprehensive physical exam and review of the medical record on the off chance they catch something. Anyone who currently has a wearable knows vitals, like heart rate, vary with activity and over time. Episodic screening misses plenty of preventable or treatable illnesses such as paroxysmal atrial fibrillation (a fib), which can increase risk of stroke. There is even a subtype of blood pressure called masked hypertension which is defined as chronic hypertension missed in the office setting, and has real-life ramifications for patients. And those are just the problems for those who can get in to see a doctor. Those who can’t even get a physical exam due to cost or doctor availability, who skip decades of preventive treatment, tend to show up in the emergency department with preventable end-organ damage from treatable chronic disease. Smart devices can shift disease screening to early disease detection.
Apple has been researching the ability of the Apple Watch to detect a fib. As the technology improves in sensitivity and specificity, by having continuous monitoring, the Apple Watch may do a better job at catching paroxysmal a fib than any 15 minute doctor visit (where 30 seconds tops is spent listening to the heart) or 10 second EKG. A comprehensive, continuous device or devices could potentially catch all chronic diseases at the start and allow for lifestyle or medical intervention before the disease develops sequelae. And with the rise of continuous glucose monitors (CGM), the mind doesn’t have to go far to envision a world where a small device can sit on our skin and continuously check for abnormalities in the bloodstream. Once chronic disease is diagnosed and addressed, continuous wearable data can also replace episodic check-ins. For example, the CGM may reasonably soon replace the episodic hemoglobin A1c checks which often miss acute hyper or hypoglycemic episodes. Identifying adverse triggers in real time and learning to avoid those will easily beat seeing an average of events over the course of months and giving generic advice about eating better and exercising more.
Right now the doctor’s office is still detached from these monitoring devices. Dr. Kraft talks about “prescribing wearables,” which is a cool and interesting idea, but instead of having burned out, tradition-loving primary care physicians integrate new technology into their practices, imagine the wearable companies incorporating physician services. Imagine the Apple Watch offering a televisit on your iPhone when the a fib alert goes off, or Dexcom offering a subscription to Livongo or Virta when your blood sugar remains elevated for a period of time (after offering you nutrition and exercise programs, of course). These scenarios improve access to necessary services and allow for earlier intervention. Instead of the annual exam clogging up to 10% of any given primary care office, time can instead be used to see complicated and urgent issues. Consumer devices are the perfect vehicle to drive the future of early disease detection while leveraging the physicians time and transitioning episodic sick care to continuous well care.
THE COST OF INNOVATION
Dr. Kraft mentions Moore’s Law in most of his talks and articles as a way to set the stage for the newest innovations he presents. He also likes to recount the story of visiting Mass General for a reunion weekend and noticing how not much had changed in the decades since he was a resident, notably how the fax machine was still in the same place. There exists a disconnect between the technological innovations available and their actual use in the average doctor’s office or hospital. Also, as medical technology advances exponentially and the cost of tech overall decreases, healthcare costs in the US continue to rise. This occurs because the evolution of medicine and medical technology has far outpaced the evolution of our payment model.
Modern day American health insurance began in 1929 with a group of teachers partnering with Baylor University Hospital to help pay for hospitalizations. This time period was only a year after the discovery of penicillin, just over a decade after the Flexner Report radically changed US medical schools from snake oil academies to pinnacles of scientific discovery in modern medicine, and a full two decades before the Framingham trial even started. At the inception of modern US health insurance, health care was catastrophic sick care because the knowledge and technology hadn’t advanced to produce anything better, so using insurance to pay for health care made sense. Today, however, the polio vaccine has replaced the iron lung, we've learned how to prevent heart attack and stroke rather than simply react to them, and national screening guidelines help catch devastating diseases such as cancer before they cause severe dysfunction. These advancements in medicine have drastically reduced the burden of disease and cost to the system, yet we still choose to pay for these relatively cheap services through a vector designed for catastrophic care, and that has led not only to rising costs, but also has impeded the implementation of technology in the average doctor’s office.
When the Butterfly iQ ultrasound came out, I got one as soon as I could because I had some ultrasound training in medical school and the idea of having a full spectrum probe in my pocket at all times sounded incredible. This was during residency and as I discussed the device with my colleagues and faculty, the question of “can we bill for it?” came up recurrently. The answer was “maybe” and it would take a lot of effort to document properly in order to attempt billing for it in a primary care setting. Bedside ultrasounds were predicted to replace the stethoscope over a decade ago, and yet today, very few primary care clinicians even know these devices exist. Reactions from my colleagues to my newly acquired piece of technology, which could improve patient outcomes, illustrates how the current payment model inhibits all sorts of common sense technology implementations. Everyone’s waiting for affordable innovations that can also “bill well.”
COVID-19 significantly advanced the use of telemedicine which opened access to underserved populations and changed how we interact with the healthcare system. These changes occurred only because the “payors” finally decided to pay for it. Telemedicine technology existed ubiquitously and affordably over a decade ago, but its use took a global pandemic to convince insurance companies to value the service. Having a few major corporations determine what technologies or services are allowable stifles innovation, especially in the primary care space.
Two primary care movements have removed themselves from reliance on old school insurance payments and lead technologic innovation by embracing payment innovation: direct primary care (DPC) and direct-to-consumer services (DTC). DPC practices receive a direct payment from patients, usually in monthly installments. Most DPC practices, including my own, focus on providing the most cost-effective, comprehensive care for their patients and will embrace new technology to help do so. For example, I learned about the Butterfly iQ and SkinIO from DPC physicians who saw the benefit of these technologies for their patients and did not care about billing more for implementation of the technology. DTC companies use affordable technology to provide services outside of the traditional doctor’s office. Dr. Kraft sits on the board of one such company which allows diagnosing and treating urinary tract infections from home among other direct services. Many DTC companies in the US offer single issue services at affordable costs and have the potential of even consolidating to replace how we deliver primary care by leveraging low-cost technology and sidestepping archaic insurance payment models. As Moore’s Law continues to play out in healthcare, utilizing low-cost, high-tech solutions requires an equally innovative, likely insurance-free, payment model.
Dr. Kraft describes technology not as Artificial Intelligence, but as Intelligence Augmentation. From screening to chronic care management, the technology already exists to build a fully technology-enabled primary care office. The right team bringing together the right tech could quickly and soon make our current primary care system look like Kodak or Blockbuster. Primary care physicians need to practice “exponential thinking” in this discovery process now more than ever. X marks the spot for primary care of the future, and we’re solving for X.