2025: 20% doctor included?

an exercise in technology speculation & musings

vinod khoslavk@khoslaventures.com

twitter: @vkhosla

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10% to 20% of cases: delayed, missed, and incorrect diagnosis

graber, et al., jama, 2005

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40,000+ patients in u.s. icus may die with a misdiagnosis annually

winters, et al., bmj quality & safety, 2012

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50% of MDs are below-averagemath

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human doctors

cognitive limitations

cognitive biases

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a study of one hundred cases of diagnostic error involving internists found…

Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642

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…system-related factors contributed to the diagnostic error in 65% of the cases and

cognitive factors in 74%...

Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642

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…premature closure was the single most common cause

Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642

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the value of second opinions

Source: http://www.businessinsurance.com/article/20111204/NEWS05/312049987?tags=|74|305|339|342

cleveland clinic doctors’ review of initial diagnosis

recommend minor changes to treatment plan

recommend moderate changes to treatment plan

recommend major changes to treatment plan

find need for further testing

disagree with initial diagnosis

22%

26%

18%

15%

11%

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the American College of Cardiology and the American Heart Association made 7,196 recommendations leading to 53 practice guidelines on 22 topics…

…48% have level C evidence (the worst kind)…

…11% have level A evidence (the best kind)…

…and only 19% of recommendations in class I guidelines had level A evidence

Source: www.ncbi.nlm.nih.gov/pubmed/19244190

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surgeons were given detailed diagnoses & asked if patients should get surgery …

half said yes … the other half said no …

when asked again two years later, 40% of the docs gave a different answer

Source: http://jama.jamanetwork.com/article.aspx?articleid=380215

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four cardiologists were asked to diagnose stenosis in patients

using high-quality angiograms …

… they disagreed 60% of the time…and disagreed with themselves (on re-

reads) 8-37% of the time

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fifty-eight experts’ estimates of the chance of an outcome of an important procedure

0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3% 3% 4% 5% 5% 5% 5% 5% 5% 5% 6% 6% 6% 8% 10% 10% 10% 10% 13% 13% 15% 15% 18% 20% 20% 20% 25% 25% 25% 30% 30% 40% 50% 50% 50% 62% 70% 73% 75 75% 75% 75% 80% 80% 80% 80%

80% 80% 100%

what does a consensus of a group whose perceptions might vary from 0% to 100% even mean?

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wide ranges of uncertainty

Source: http://jama.jamanetwork.com/article.aspx?articleid=380215

seventeen experts’ estimates of the effect of screening on colon cancer deaths

0% 25% 50% 75% 100%

proportion of colon cancer deaths prevented

= one expert’s response

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conventional wisdom and the “tradition of medicine”

Source: http://www.newscientist.com/article/mg20727711.400-fever-friend-or-foe.html

should fever be reduced in critically ill patients?

“there were seven deaths in people getting standard treatment and only one in those allowed to have fever”

“the team felt compelled to call a halt, feeling it would be unethical to allow any more patients to get standard treatment”

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nearly half of all american adults have difficulty understanding and acting upon

health informationinstitute of medicine of the national academies, 2004

http://www.nap.edu/openbook.php?record_id=10883&page=1

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there is good reason to challenge the assumption

that every individual practitioner's decision is necessarily correct

eddy, et al., jama, 1990

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for most study designs and settings,it is more likely for a research claim

to be false than trueioannidis, plos med, 2005

http://online.wsj.com/article/SB10001424052702303983904579093252573814132.html19

inescapable conflicts of interest…

…most physicians are motivated to deliver quality care…

…but the typical physician response also includes a desire to protect high salaries…

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entrepreneurs will ask the naïve questions that uncover

hidden assumptions…

…and move us to the grey zone of “speculations”

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in the future,patients will have the data & analysis to

become the CEO of your own healthpeter diamandis

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80% of what MDs do can be replaced (with better care than the average MD)…

…but not every MD function will be replaced

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the “human” element of care can be provided by the most “humane” humans

(and MDs can be humane)

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machines are better at integrative medicine…

…across “all symptoms”, demeanor, patient history, phone activity, 1000s of data points, genomics, population

management guidelines, …

…and machines won’t have to win every time…

…they’ll just be better overall

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Lifecom CHAMP in acute care

I …distributed care with medical assistants were 91% accurate

without labs, imaging, or exams

II …“safe triage” with 75% physician bypass rate for acute care encounters

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isabel II

matched expert diagnoses 91-95% of the time

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dr. algorithm

v0

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the transition will start with “toddler MDs” and digital first-aid kits

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Cellscope: ENT+ derm images…

Adamant: breath analysis

Eyenetra: auto-optometrist

Ginger.io: mental health

Alivecor: frequent EKG+ analysis

Quanttus: physiological metrics (HR, BP, SV, CO, RR, T, …)

Medgle: graph of medicine

Healthtap, Crowdmed: crowdsourced answers

Kyron: practice based evidence

Jawbone, Misfit: wellness wearables

don’t wait days to take your daughter to the hospital…

…check her ear infection as soon as it hurts

30 *a khosla ventures investmentCellScope

don’t go to the hospital and get connected to a bunch of electrodes…

…take your own ecg for less than a buck…

…and know you have heart disease before you have an attack!

31 *a khosla ventures investmentAliveCor

don’t go to the optometrist…

…get measured for glasses at home

32 *a khosla ventures investmentEyeNetra

don’t guess what’s going on inside your body…

…get vital intelligence

33 *a khosla ventures investmentQuanttus

Adamant Technologies

NOx: 40ppm

don’t wait for an asthma attack…

…know when it’s coming

34 *a khosla ventures investmentAdamant

forget kappas of 0.2 in the DSM-5…

…get reliable, consistent diagnoses

35 *a khosla ventures investmentGinger.io

graph the world of medicine…

…and see where you fit

36 *a khosla ventures investmentMEDgle

evidence-based medicine isn’t enough…

…think practice-based evidence

37 *a khosla ventures investmentKyron

… use data-mining to learn ethnicity-specific drug interactions(e.g. statins work differently in Indians)

thousands of physicians…

…no waiting room

38 *a khosla ventures investmentHealthTap

...and your innovation here (call us)

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healthcare service stations&

digital first aid kits

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keep people out of the doctor’s office…

…with point innovations in cardiology, dermatology, optometry, psychiatry,

internal medicine, …

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innocuous point innovations…

…will evolve into a wave and explode into a tsunami

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dr. algorithm

v0v1 – 2015v2 – 2017v3 – 2019v4 – 2021v5 – 2023v6 – 2025

…

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we’ll start with clumsy point innovations like alivecor, cellscope, adamant, ginger.io,

neurotrek, consumer physics, jawbone, misfit, …

…“insighted” by machine learning…

…leading us to discover things we never knew were right in front of us

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the best MDs will train systems over 10 years…

…systems will symbiotically provide “bionic assist” and “AMPLIFY” MDs

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dr. house+++ will be the trainer for dr. algorithm

…no manners required!…but manners learned!

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findings thanks to data

using statins for in-hospital stroke patients reduced the death rate by 40%!

kaiser permanente

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the practice of medicine

the science of medicine

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I will be wrong on the specifics but directionally right

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the shift to “computerization” has already happened in other areas…

…airline pilots, stock trading, car driving

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there aren’t enough rural doctors in india and few have access to

jama journals, mris, …

…the world of medicine is under-resourced globally

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20% doctor included?

vinod khoslavk@khoslaventures.com

twitter: @vkhosla

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better data for post-study studies

overcome ioannidis’ problem of regressions to the mean

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smart computers can be objective cost minimizers…

…while being care optimizers

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would a hospital cure you in half the time…

…if it meant cutting their business in half?

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would big pharma give you a better drug…

…if it meant losing subscription revenue?

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would most psychiatrists cure you…

…if it meant cutting off the recurring revenue visits?

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would a medical device manufacturer sell you a less-expensive sensor…

…if it meant cannibalizing sales of

the really expensive equipment?

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findings thanks to data

depression is a risk factor for diabetes

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devices

analytics

data

improved patient outcomes at lower cost

architecting healthcare

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social and technological forces are conspiring to make

the traditional role of the doctor irrelevantbryan vartabedian (attending, texas children's hospital)

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baseline systems models of patients

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computerized dialog managers

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innovation starts at the fringes

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hundreds of “experts” …28,000+ forecasts over 20+ years

results: “experts” are poorer forecasters than

dart-throwing monkeys

the folly of experts: tetlock study

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don’t prescribe pills …

… prescribe apps

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adverse drug events increase hospital costs by >$3000 per stay…

…and billions (estimates range from 110 - 180 B) in annual spending nationwide

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in a study of 3 hospitals, 40% of adverse events were medication-related

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the cost of drug-related morbidity and mortality exceeded $177.4 billion in 2000.

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nearly half of all american adults have difficulty understanding and acting upon

health informationinstitute of medicine of the national academies

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most [patients] preferred receiving their discharge information from

the [computer] agent compared to their doctors or nurses

in the hospitalbickmore, et al., interacting with computers

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virtually all of the current quality assurance and cost-containment mechanisms

assume that there is "accuracy in numbers."

why should we assume that the physician offering the second opinion knows the correct answer?

what does a consensus of a group whose perceptions might vary from 0% to 100% even mean?

eddy, et al., jama, 1990

get the answers to questions…

…you never knew to ask

80 *a khosla ventures investmentAyasdi

get second opinions…

…from everyone

81 *a khosla ventures investmentCrowdMed

track your life…

…all from your wrist

82 *a khosla ventures investmentJawbone

track your life…

…with a fashion statement

83 *a khosla ventures investmentMisfit