Tech Brew Ride Home - (Bonus) Stanford's Medical School Dean Lloyd Minor On The Promise of Precision Health

Episode Date: February 23, 2020

I am honored to be speaking today to Lloyd Minor, the Dean of the Stanford University School of Medicine. He has a new book out called Discovering Precision Health, and if you are interested in health tech at all, ESPECIALLY if you are interested in trying your hand at a health tech startup? This is required reading. And for the rest of us, it’s also a great primer on how tech is about to transform health, and what we can (hopefully) look forward to as tech finally (again, hopefully) disrupts the health care space… in a positive sense! Sponsors: TinyCapital.com Learn more about your ad choices. Visit megaphone.fm/adchoices

On April 4th, 2023, around 2 in the morning, a man was found stabbed multiple times on a sidewalk in downtown San Francisco. Hey, who did this to you? What happened next turned the story into a political firestorm. Reports have identified the victim as Bob Lee, the founder of Cash App. From Bloomberg Podcasts, this is Foundering, the Killing of Bob Lee, beginning April 16. Welcome to another weekend bonus episode of the Tech Meme Right Home. I'm Brian McCullough. I am honored to be speaking today to Lloyd Minor, the dean of the Stanford University School of Medicine. Dean Minor has a new book out called Discovering Precision Health. And if you are interested in health tech at all, especially if you are interested in trying your hand at a health tech startup, this is required reading. And for the rest of us, it's also a great primer on how tech is about to transform health and what we can hopefully look forward to as tech finally, again, hopefully disrupts the healthcare space in a positive way.

Lloyd, thank you so much for coming on the podcast today. Because of the nature of what we talk about on this show every day, we're going to talk a lot about health tech and disruption in the healthcare space. But before we do that, I wonder if you could just outline the basic thesis of your book. The book, we'll talk about it again at the end, but it's discovering precision health. So what is precision health and why do you think we should be on the cusp of seeing it brought to fruition? Thank you, Brian.

It's a pleasure to be with you today. Precision health is about keeping us healthy. When we're sick, when we have cancer or heart disease, we want precision medicine. We want the very best sick care individualized to us. But shouldn't we really be trying to keep ourselves healthier, for a longer period of time. So precision health is about predicting, preventing, and curing disease precisely. In particular, it's about placing a lot more emphasis on the science and on the implementation of prediction and prevention. Because if we're able to predict disease through more

accurate diagnostic and screening testing, if we're able to prevent disease through changing our behaviors to looking at our risk factors and then modifying what we do to maintain our health based on our risk factors, we're able to do those things. The need for the ultra-acute care, which for so long has characterized our delivery system in the United States, that need should be reduced over time, and we'll all be healthier because of it, and we'll be able to deliver more effective health care. And you're obviously emphasizing that word precision. In your book, you talk about a lot of health care right now is one-size-fits-all.

So tell me more about how being precise is key to all of this as well. Certainly. I mean, a great example of precision is the approach today to treating breast cancer. Breast cancer is not a one-size-fits-all disease. The receptor status of the tumor, the age of the patient of the time of diagnosis, There are a host of different factors that go into determining the most effective treatment for a patient with breast cancer. And as a result of that individualization of treatment, the result of being able to tailor treatment based upon a lot of different characteristics of the disease and the patient, the result is that our outcomes are much better than they were.

when we just had a one-size-fits-all of doing the mastectomy and then giving radiation, maybe with and without chemotherapy, that's a great example of how precision has helped to achieve better outcomes. Let's move on to talking about technology's role in achieving this. You describe how the most sophisticated piece of technology in most doctor's offices, even today, is the fax machine, which obviously is something that a lot of the world has moved on from, so why has health care do you think, not medicine itself, but health care and health delivery, the practice of health care, why has it been such a difficult nut for technology

to crack up until now? I think there are a variety of reasons, and some of them are appropriate and you can understand them. We absolutely have to ensure privacy and security of both related data. However, the financial services industry has figured out how to do that and other aspects of the economy as well have developed secure systems for exchanging and holding information. We should be able to do the same thing in health care. There are also some significant challenges and problems with the electronic health record systems that are being widely used across the United States today. They're based upon technology platforms that were developed in many cases

in the 1970s, and they were also initially designed to be billing systems, not systems that help physicians deliver better care and that help patients interact with their care and with their providers in more informative ways. Those issues come together to create an environment in which technology has not had the same sort of transformative effects that it's had in virtually every aspect of our lives, you know, other than health care. For example, today, the way you and I order goods and services. The way you perform financial transactions, that's radically different than it was a decade ago. Yet today, most of us still pick up the phone and place a call to an office of a doctor or other health care provider if we want to make an appointment. We still bring out paper records

with us or we have them faxed to the doctor's office in advance. We haven't seen that same sort of disruption that has occurred in every other sector of the economy. It does seem, though, I mean, it seems like every day I'm doing another story about a new health tech startup or somebody that's raised around or whatever. And in the book, actually, you have the actual data. You pointed out then in 2018, $8.1 billion was invested in digital health startups. That's up from the $5.7 billion the year before and up from just 1.1 billion about a decade ago. I'm curious, what do you think has changed that has suddenly made health care a fertile ground for investment and new companies? Several things have changed.

One is that we're seeing some really bright, energetic entrepreneurs get very interested in health and health care delivery. That's a good thing, because they bring with them enormous knowledge and tremendous amount of passion and dedication to really having impact in ways that perhaps those same entrepreneurs would be attracted to other sectors of technology in the past, but now they're migrating to health care. And the entrepreneurs that I interact with and the venture capitalists that are providing the support for those entrepreneurs, I believe that today there's a real enthusiasm for having impact. There's an enthusiasm for bringing the same sort of transformative disruptions

that have occurred in other aspects of technology, where technology has been applied to other activities. They're taking that passion and that entrepreneurship and applying it to issues we have in health and health care. I think that's the fundamental difference. We're starting to see some exits that are favorable from digital health companies. It's early on to know when not that's going to last and whether or not those companies will continue to thrive as they have either gone through IPO or gone into the later rounds of their funding. But I think they're encouraging results from activities in companies like Foundation Medicine, Flatiron, other companies like Omada and Lubongo.

I mean, these companies are thriving in terms of their businesses, and they're also showing real impact in health. So that's obviously what we want to see. We want to see the companies have the technologies embraced by and produced by the companies having an impact on health and healthcare, and obviously if they're going to succeed, they have to do well from a business point of view. And I believe there's some examples of that occurring, where both the companies are having

impact and they're doing well in terms of their businesses. Yeah, that's one of the things that I liked about the book is that you, there's many, many examples like real-time, real-world examples of companies that are finding success. There's also, there's a section in the book where you talk about what it takes for a startup to succeed in the healthcare sector. And you sort of describe the situation where there's kind of no overlap between two different worlds where, like, the people that are already in the healthcare system who know the system, understand how it works, you know, the healthcare practitioners who should be the natural

entrepreneurs to maybe rise up and disrupt the system, they're so caught up in the day-to-day of the health care system and delivery of it that it's hard for them to make the time to start a company. Meanwhile, you have, you know, people outside healthcare that want to come in and think the way to disrupt the system is maybe to just bypass it, and they fail often because they don't understand how the system works, you know, and maybe has to function. So how do you, is there a way to square that where these two kind of ways of creating a company don't quite overlap? I think there's several ways. One is to get more healthcare providers interacted with, engaged with entrepreneurs and technology experts. And the companies that have been successful

have done exactly that. And, but we need to see more. that. In our medical school, for example, I'm pleased that many of our medical students get involved with startups during their medical school experience or shortly thereafter. Our medical students are overwhelmingly attracted to going into medicine because they want to have an impact in the lives of people and in delivering patient care. But I think increasingly there's a larger number of students that are recognizing they can have that impact for sure in direct interacting with patients and we want them to do that. First and foremost, we train outstanding physicians in our MD programs. And we also want a cohort from that group of outstanding

physicians to be engaged in transforming the way medicine's practiced and the way health care is delivered. And that intersection between someone who is very well trained in a science and in the compassion and in the practice of medicine and someone who can have an intelligent dialogue with a technologist and really help that technologist to understand the day-to-day issues that physicians and patients deal with, that interaction is something we want to foster here at Stanford. You wrote that the keys to succeeding as a healthcare startup are to, number one, solve a truly hard problem, which, you know, that's what every start. up wants to do in theory, also deliver a delightful user experience that results in sustained

user engagement and behavioral change, which again, okay, you want the product to be useful and delightful. But also, an entrepreneur in the space needs to be a great enterprise entrepreneur to know how to navigate the health ecosystem as well. Like, for example, you talk about how such a large portion of the health care system right now in the U.S. is non-profit. So as an example, you would need to know to understand how selling into that market is functionally different. Exactly. And that oftentimes is the hang up. If you're a chief information officer of a healthcare delivery system, what you think about day in and day out is making sure that the systems are working, that they're working accurately, that there's no downtime.

there's huge consequences of even seconds to minutes of having downtime and information systems that are running hospitals and delivery systems. But you're inherently conservative because you need to be. Your first responsibility is to the people in your organization that are delivering care and the people who come to your organization to receive care. And therefore, you're going to be inherently skeptical about someone who says, oh, I can completely change your world. I can make everything work so much better and more efficiently

and you'll deliver better care. You'll have a better patient experience. You know, there's a pretty high bar to overcome the understandable skepticism. And I think the most successful entrepreneurs and businesses figure out how to navigate that. Maybe it starts small. Maybe rather than designing apps and technology, that are marketed to and interface directly with delivery systems.

Maybe they interface directly with employers. That's been a model employed by companies like the Bongo, Ombata, and many others. So there has to be some creativity in understanding that healthcare delivery is a highly regulated industry. It has a very, very high bar for failure. and that means that you have to plan your products accordingly. You know, I think it was version four of the iPhone when it came out. There was some problem with the antenna and it dropped calls. Antenna, yes.

Right, and Steve Jobs made a wonderful speech. It's classic about how, look, I understand the stopping calls, other smartphones drop calls to, we're going to get this right and stick with us because we have an amazing product and you'll get it right and you won't be disappointed that you stick with us. I can do it much more eloquently than I just summarized. But, you know, dropping a call is a nuisance. It's frustrating. But by and large, it does not kill people. If you have an app that misrepresents something or that delays a patient from getting care or any number of other things that interferes with the delivery of health care, it can really cause harm to people. So the bar for making

sure that the technology works at the time it's introduced is much higher, I think, than it is in traditional consumer-facing tech, if that makes sense. Indeed, actually. And that actually kind of, again, I report on a lot of these consumer-focused devices that are coming to market now. Like, you know, I guess it's just the high penetration of mobile devices in all of our lives now is driving a lot of this. And is that, I mean, this is coming back to the thesis of the book. Like, being proactive and not reactive, is this a key area of the moment right now? You know, you even talk about, like, the Apple Watch Heart study that I've reported on the

idea of your Amazon Alexa listening in to hear if you're coughing or, you know, this is a lot of, is a lot of the revolution that's coming about having this data of doing precision monitoring and stuff like that? Yes, I think it's about empowering us as individuals to understand and have impact over our health in ways that we couldn't in the past. There's been this curious dichotomy, particularly in, I think in American society, that we accept responsibility for our finances. We accept responsibility for, you know, making sure that our roof doesn't leak in the house and a host of other things. But we've had this curious disconnect with our health. I think we have, and this is obviously a generalization, but many of us have just

assumed, well, you know, if I get sick, I'll go to the doctor, I'll take some medicine, and it'll be fine. We haven't focused nearly as much attention on understanding what are the determinants of our health. How can we engage in behaviors, plan our lifestyle in ways that ensures we're doing the most to maintain our health? And part of the reason why that is existed is that we haven't furnished information about health in an actual way to people. in ways that we furnish information about other things going on in our lives. And I think that's one thing the technology, one benefit that technology offers. Every time you and I fly on a plane, those jet engines are being monitored hundreds, thousands of times a minute.

The beaming information back down to Earth. And the routine maintenance on those engines is done based on that information being received. Now, most of that's completely out of the awareness of the pilots, unless there's a problem. in which case the pilots are made aware, we should be able to have comparable types of information available in an ongoing basis about our health so that we can intervene before there's a big disaster so that we know what our propensity for certain diseases is, and that we're able to take the preventative measures based upon those risk factors. And we're only starting to see that really get into our environment today. I think the next five to ten years we're going to see a rapid

acceleration in the pace of that information becoming available to we and to me. I'm so glad you brought up that analogy because I highlighted it. The idea that, you know, 40 years ago an airplane would be inspected every few months, whereas now like the health of a plane is being monitored while it's in the air, that's a perfect analogy for what, in theory, we should be able to achieve soon with this sort of monitoring technology. It's within our grasp. It's not trivial, but it is definitely within our grasp. Can I ask about, there's been some discussion recently about, you know, there's a lot of concern by people about their data and handing over their data and

especially now their health data. People are worried about the control of their own data, but you write that in the current health care system, there are these weird, perverse incentives to sort of hoard information and not share it. So, again, how should I square this? Like, people's fears of their data not being under their control versus maybe data isn't being shared enough, and thus the health care system is not as efficient as it could be? concerns about data sharing. I mean, we want to ensure the security of the data,

and we want to make sure that patients have control over where and how their data is being used. That being said, these perverse incentives that I write about in the book are related to the fact that for healthcare delivery systems, once a patient is enrolled in a delivery system, it's in the business interest of that system to keep the patient in the system. And one of the ways of doing that, of course, the best way of doing that is making sure that the system's offering outstanding care in a patient-centered way with monitoring of patient satisfaction and all the things that other businesses use to make sure the consumers stay

engaged with their services and their products. But another way to keep people in a system is to make it really difficult for their information to be transferred from one place or one system to the next. There's a lot of federal legislation that has been devoted to addressing those problems and making sure that they're regulatory guidelines that require systems to make data transportable and to really place the patient data in the hands and control of the patient when patients want to have that sort of access and control over their data. I'm optimistic, therefore, that data will be more portable in the future.

Certainly, we now have the technology needed to make data interchangeable in ways that it wasn't in the past. So it's not per se a technological barrier that's preventing data from one health system be transferred to the other, even if they're on different VHR systems. Those technology barriers are being lowered because of the sophistication in the technology. but there still are some economic and business-related barriers that I think the federal regulatory space is helping to address. Finally, you write about this precision health vision that you have is one of a high-touch environment, not just a high-tech environment. Like, precision health should be about strengthening the doctor-patient relationship, not replacing it. it, not taking the doctors, the humans out of the equation, right?

Exactly. That's absolutely essential. We've gone through a period for the past 15 to 20 years where I fear that technology has done more to separate health care providers from consumers, from patients, than it has been able to bring people together, to bring patients and providers together. We have to overcome that. And that's why I do talk about high-tech, enabling, high-touch. There's nothing more disappointing for a patient, or frankly, for a health care provider than when you're as a patient sitting in the exam room, the health care provider walks in, and the first thing they do is go to the computer terminal and start typing. Maybe they say hello, maybe they make eye contact briefly, but then they're looking at the screen and they're typing.

And maybe they're listening, hopefully, or maybe they're concentrating on what they have to type in order to complete their documentation requirements. And that just has to change. No one goes to a health care provider to be looking at the back of their head while they're typing into a computer terminal. And we can change that, and we just have to push forward and make sure that we do it. The book, again, is discovering precision health, predict, prevent, and cure to advance health and well-being. Dr. Minor, thank you so much for coming on the show to talk about this.

Thank you very much. It's a privilege being with you.