Computers Are Eating Healthcare, Part 2

This post was originally featured on HIStalk.

This is the second in a series of posts that outlines how computers are eating the world. Check out Part 1.

Humans do three things and only three things: process information, store information, and share information. Everything in life, both virtual and physical (firing neurons drive physical movement), can be understand in these terms. Humans never can and never will do anything else.

Computers do three things and only three things: process information, store information, and share information. Computers never can and never will do anything else.

Unlike humans, computers excel at jobs that are intrinsically repetitive across all three dimensions of performance: processing, storing, and sharing information. Computers process, store, and share at infinite scale.

Because computers excel at these repetitive functions, they’ve dismantled most repetitive administrative and information distribution jobs that aren’t propped up by politics or regulations. Computers were the empowering tool that led to the dismantling of Blockbuster, the travel agency industry, the newspaper industry, and many others.

Healthcare is intrinsically repetitive. Will computers eat healthcare too? If so, how?

In the first post of this series, I argued that computers will eat radiology first. Radiologists look for patterns in images and cross-reference the EMR. The job requires almost no patient interaction. Occasionally radiologists query the PCP. Computers can perform those functions better, cheaper, and faster than radiologists ever could. Radiologists are slowly acknowledging that fact. This explains one of the themes of the most recent RSNA conference: interact with patients. Computers are still years if not decades away from naturally conversing with patients and providers. Radiologists want to interact with patients after decades of avoiding patients to avoid being eaten by computers.

Sedasys has built a new anesthesia monitor with a unique twist. It intelligently and automatically administers anesthesia during surgical procedures. Anesthesia, like all other forms of medicine, is intrinsically repetitive. Intra-operative anesthesia is at its core a negative feedback loop. Computers can automate that process.

IBM’s Watson is attempting to do the same thing with diagnostics. We are probably a decade away from that, though. Automated diagnostics are extremely difficult for a number of obvious reasons: conversing with the patient and understanding context, asking the right questions, natural language processing, processing enormous amounts of data, and many others.

Airplanes have been flying themselves for over two decades. With airplane black boxes, airlines have second-by-second records of millions flights spanning every conceivable weather condition in every conceivable geography. Planes automatically adjust flight paths based on what they’ve learned from every flight since the inception of black boxes.

And yet we still have pilots. Why? Regulation, and to respond in case the computer fails. Although I can’t find data to back this up, it seems reasonable that pilots boost safety metrics from 6 sigma to 7 sigma. Computers are responsible for the first 6 sigmas.

Computers will eat providers just as they’ve eaten pilots. Providers should look to the airline industry to understand what that means. The airline industry is medicine’s harbinger in a computer-eaten world.

In the future, providers will monitor computers, just as pilots monitor planes. This begs the question: will providers tell a computer what to do, or will providers be told by a computer what to do?

The Pristine Story: Heads Down Through the Holidays

Pristine is growing into a bonafide company. We're now actively executing, refining, and strategizing across most common business fronts: piloting at UC Irvine Medical Center, managing a substantial sales pipeline, executing on a marketing and PR plan, raising capital, refining the products, and establishing internal infrastructure and processes as the team grows. Speaking of which...
 
...Our team continues to grow. We have 9 full time employees now, and a few part timers. Buzz began full time on November 1st as our VP of Sales. In his prior life, Buzz built the nation's largest non-state based health information exchange spanning more than 300 hospitals and 14,000 doctors. We've also hired two more full time developers - Derrick Hinkle and Devin Fee. Derrick has a strong background in real time web communications and experience with our technology stack. Devin is one of the most talented dev ops guys in Austin, and brings a healthy dose of entrepreneurial experience to the team. He founded and ran a startup for a year prior to joining Pristine.
 
Although we're not actively hiring developers today, we continue to passively search for them. If any exceptional developers find us, we'll figure out a way to make it work. Devin actually joined this way. If you or any friends are interested, feel free to apply at careers.pristine.io.
 
We're also looking for qualified candidates who can lead a wave of upcoming Pristine deployments. Since we don't have the scale to segment job functions to different people, we're looking for someone who's well rounded that is reasonably technical, that can train, and that can support our early clients.
 
Since DEMO, we've raised an additional few hundred thousand dollars from a host of angels. If you or anyone you know would like to invest, please contact me privately.
 
We've been trying to maintain a steady presence with the media. I was recently on with news anchor Taylor Baldwin in San Diego, and another segment on KEYE in Austin (we're in the 3rd segment in this link). We've also been working with some major national publications and analysts to help educate them about the opportunities for Glass in the OR and healthcare more broadly. We'll continue to pepper the media for the foreseeable future.
 
We attended FutureMed in San Diego, which was quite possibly the best conference I've ever been to. I wrote about it on HIStalk. We also just got back from the Digital Health Conference in NYC. And I just finished pitching at Hatch Patch in Houston, where Pristine won. Looking forwards, I'll be attending the mHealth Summit in Washington, DC Dec 8th - 11th (please let me know if you'll be there and we can catch up), and Buzz and I will be travelling to medical centers all over the country throughout December.
 
We're working on a couple of strategic partnerships that we're planning to announce by the end of the year. Although we can't go into any details yet, we believe that these deals will really accelerate our growth going into 2014. Stay tuned.
 
And to wrap things up, here are some blog posts for your enjoyment. I was recently picked up by Svbtle, an online magazine that provides industry experts an avenue to publicly discuss their respective industries. Buzz and I are working on some deep analytical dives into the state of health IT and health delivery. We can't wait to share those with everyone when they're ready.
 
PS, I'm going to be reducing the frequency of the Pristine Story to once every 4 - 6 weeks. As the company grows, it will be more pertinent to space things out.

What Does The Future Of Medical Process Control Look Like Through Google Glass?

This post was originally written for the HATCHpitch TechStreet Houston contest, where Pristine won.

Google Glass and other eyeware computers will provide a foundation to deliver the ultimate process control in medicine. As doctor Atul Gawande has written, checklists are the simplest and most effective form of process control.

Broadly speaking, checklists should be implemented when the following conditions are true:

1. There's a repeatable process that must be followed
2. The cost of being wrong is high

There are an enormous number of areas throughout hospitals in which these conditions are true. Some examples:

Endoscopic scope processing

• Preparation of complex drugs in pharmacies
• Patient preparation for many diagnostic imaging studies
• Wound care

Although checklists are commonly implemented in perioperative environments today - where the cost of being wrong is astronomically high - checklists can and should be implemented in every environment in which the conditions above are met. Too many patients are seriously injured or die every year from simple, preventable mistakes. If implemented correctly, checklists can save thousands of lives.

If the process of implementing checklists introduces too much friction into a given workflow, it's unlikely that checklists will be successfully implemented in that context. Although we've seen ORs implement checklists pre-op, the methodology is generally quite poor. Most ORs today simply have a poster on the wall. Paper checklists, although a step in the right direction, provide no guarantees, no checks, and no audit records that checklists were actually adhered to. Google Glass and eyeware computers more broadly present the ideal form factor to implement checklists into sensitive clinical environments. Using eyeware computers, providers can work through checklists hands-free, and can even incorporate rich media such as audio, images, and videos into checklists.

Our mission at Pristine is to shape a future such that in 5 years, we'll look back and wonder how medical providers performed their jobs without Glass.

What Does The Future Of Medical Communication Look Like Through Google Glass?

This post was originally written for the HATCHpitch Tech Street Houston contest, where Pristine won.

Healthcare delivery is an increasingly collaborative effort: there are virtually no environments today in which a single person provides all of the care for a given patient. Healthcare providers are working in cross-functional, cross-disciplinary teams more than ever before.

Increasingly large care teams lead to more opportunities for miscommunication. Medical professionals need the right tools to communicate seamlessly in real time at the point of care. At the same time, providers are doing their best to keep their hands sanitary. They're struggling as they frequently touch dirty devices such as their phones, pagers, and other walkie-talkie like solutions.

Glass is ultimate communications tool because it:

1. Is always there
2. Wireless
3. Hands free
4. Supports audio, video, and text based communications

Medical professionals have never been able to share what they see in real-time. Now they can. This is a profound concept with uses throughout virtually every avenue of care. Just imagine:

• Surgeons will use Google Glass for remote consults, and for teaching and training.
• Anesthesiologists will use Google Glass to communicate with their CRNAs across ORs.
• Nurses will use Google Glass to collaborate and share patient information to expedite workflows and connect disparate parties.
• Residents and fellows will use Google Glass to receive consults and support from attendings.
• ICU nurses will use Google Glass instead of rolling around telemedicine carts.
• Emergency room (ER) nurses will use Google Glass to beam in physician consults instantly.
• Nurse practitioners and physician assistants will use Google Glass to beam in MD consults.
• Providers in the patient's home will use Google Glass to beam in consults without interrupting their workflow.

The opportunities to open new avenues of communication and collaboration are immense. We're just at the tip of the iceberg of what can be done.

Our mission at Pristine is to shape a future such that in 5 years, we'll look back and wonder how medical providers performed their jobs without Glass.

Understanding How Profits are Shifting Across the Computing Value Chain

This post was originally featured on TechZulu.

There’s a famous scene in Pirates of Silicon Valley (a movie that chronicles the origins of Microsoft and Apple) in which Bill Gates is meeting with IBM executives. The IBM executives agree to license software from Microsoft because “there’s no money in software anyways.”

The IBM executives weren’t stupid. They failed to recognize an inflection point in technological history in which profits would shift from hardware to software. They didn’t value the application layer because up until then, there weren’t any profits in the app layer. All profits had resided in the hardware and configuration layers.

Today, Google, and cloud computing companies more broadly, are doing to Microsoft what Microsoft did to IBM. Profits are moving up the value chain from on-device software to software-as-a-service in the cloud. This is manifesting as OS and software licensing revenues are shrinking as cloud-hosted SaaS apps are growing.

In the past few years, Microsoft has come to realize this, as reflected in Steve Ballmer’s repeated assertions that Microsoft is a “devices and services” company. Microsoft has acknowledged that their traditional profit layer of the value chain is evaporating. On-device software used to be an end – a valuable service that customers would pay for – but on-device software is evolving to be a means to a new end: cloud-host SaaS apps.

Although the profitability of the on-device software layer is eroding, on-device software is more important to profits than ever before. Software is more tightly coupled to the layers below and above it – hardware, and cloud services. Effectively, on-device software is becoming a fixed cost of the associated hardware and cloud service solutions.

Why have profits migrated away from on-device software and toward both the cloud and hardware?

Profits are moving up the value-chain because the benefits of delivering cloud apps outweigh the costs. The most significant costs of delivering apps through the cloud are performance and bandwidth requirements. Because of Moore’s Law, these costs are effectively trivial for most cloud apps. The benefits of moving apps to the cloud are enormous: always up to date, maintaining a single instance, opportunities for A/B testing, unlimited computing potential, and many more.

But why are profits simultaneously moving down the value chain to companies such as Apple, Samsung, Jawbone, FitBit, Pebble, Inevitables, littleBits, Looxcie, Parashoot, and robotics companies? During Microsoft’s peak, hardware standardized around a few form factors (ATX, mid-ATX, micro-ATX, laptops, etc). But in the modern mobile computing era, virtually no two computers share an identical form factor. As such, hardware is far less of a commodity today than it used to be. Perhaps more importantly, mobile devices present new opportunities to experiment with novel hardware functions that are closely bound to associated software functions. Microsoft’s traditional OS-licensing model simply doesn’t support a model in which hundreds of companies are creating novel hardware form factors.

Will profits shift again? If so, why?

Although I feel naive saying this, I don’t think profits will materially shift within the foreseeable future. Economics dictate that cloud computing is more power and cost efficient than local computing given sufficient connectivity. As systems-on-a-chip continue to shrink, we’re going to continue to see computers appear in all kinds of new places, particularly in the realm of wearable technology and smaller form factors. Local software is a stepping stone to the power of the cloud. In essence, local software is losing significance in the profit chain as it amplifies the layers of the value chain above and below it. Local software no longer dictates the price, nor plays a role in the device’s total value, but rather, is powering new hardware and connecting that hardware to the cloud.

The new hardware-to-cloud era is here.