Digital Healing

People, Information, Healthcare

Marc Ringel

• Publisher: Productivity Press
• Year: 2018
• Print ISBN: 9781032095110
• eBook ISBN: 9781351631556
• Topic: Business
• Subtopic: Business generale
• Index: Business

Medical practice and research are inconceivable today without electronic computing and communication tools. Digital machines do many tasks orders-of-magnitude better, faster and more accurately than humans.

Still, there are functions critical to the healthcare endeavor that people do much better than machines, things like: understanding and using natural language; perceiving what is unexpressed; taking into account values, culture, ethics, and human relationships; touching and healing. For the foreseeable future, the "smartest" computers will be no match for human beings when it comes to performing these most anthropic functions.

American healthcare is at a critical juncture. Providers and patients are increasingly frustrated by degradation of the human relationships that lie at the core of the medical practice. Technologies, such as the computerized medical record, get much of the blame for intrusion into the patient-provider relationship. However, it is not technology itself that is to blame. The fault lies with how systems are conceived, designed, and deployed.

This book analyzes how to organize the work of healthcare in a way that uses machines to do what they do best, thereby freeing humans to do what we do best. Smart use of electronic technology is crucial to the success of any bid to fulfill the Institute for Healthcare Improvement's triple aim to make healthcare more effective, efficient, and humane.

Chapter 1

Logical Conclusions: How Modern Medicine Fits into Western Culture

Science is the tool of the Western mind and with it more doors can be opened than with bare hands. It is part and parcel of our knowledge and obscures our insight only when it holds that the understanding given by it is the only kind there is.

—Karl Jung¹

The discoverer of an art is not the best judge of the good or harm which will accrue to those who practice it.

—Plato (Phaedrus)²

I chose philosophy as my college major because I was interested in most everything: science, math, literature and philosophy. A little later I added music and art. My natural inclination is to come at any topic, especially this one, from the widest perspective possible, which is what I will endeavor to do in this work.

By any measure—health indicators, number of uninsured, total cost, per capita cost, consumer bankruptcies, political inertia—the United States is at a crisis point in healthcare. Rather than just continue tinkering with valves and relays to keep this obsolete engine limping along, it behooves us to step back from the machine for a bit and seek the wider perspective we need in order to make some smart decisions and to take some smart actions that could really fix things.

Sometimes I think it would be best if we could just blow up this damn jury-rigged healthcare non-system and build a new one that gets people what they really need, and does it efficiently. That may or may not happen in my lifetime.

When I was a medical student in the early ‘70’s, my comrades and I did expect the economic and political system to collapse, possibly led by what we perceived, even back then, to be a remarkably inefficient and unjust healthcare system. I actually had a friend who had switched careers from social work to nursing in order to acquire the skills she imagined would be needed to care for the wounded on the Revolution’s barricades. At that time, the healthcare sector accounted for 6% of the GNP. Today it stands at 18% and is likely to be more by the time you read this.

Sooner or later our unsustainable healthcare non-system must reach an inflection point, where things really do collapse and reorganize in a radically different way. The cost curve cannot go up forever, nor can citizens’ discontent with the healthcare they’re getting (and not getting); nor health professionals’ unhappiness with the meaning and quality of their all-important work. Over the course of my career, I’ve predicted four of the last zero healthcare system collapses. Which leaves me with the question, what should be done in the meantime?

I hope, with this book, to contribute to a deeper understanding of how healthcare works, the first step toward making smart strategic decisions about which subsystems of this oh-so-complicated machine most merit our attention and energy. I will make the case that one subsystem that touches all the others, and consequently has huge potential leverage to shift the direction of healthcare at least a few degrees shy of straight over the brink, is information technology.

An Ultra-Wide Angle View

Let’s start our journey of understanding with views from an ultra-wide-angle (hopefully not fisheye) lens. I’ll begin with a little philosophy.

The ancient Greeks started Western philosophy and culture down the path toward understanding the world by observation and mathematization at least six centuries before the birth of Christ. These two approaches were melded during the Renaissance to become the scientific method. Francis Bacon, English scientist, philosopher, statesman and jurist (the world used to be full of generalists) first codified the principles of this way of understanding the world. His method for discovering what is true boils down to a cycle of observing, modeling, predicting and observing. (I beg forgiveness of my philosophy professors for compressing more than two millennia of intellectual history into a single paragraph.)

Lord Kelvin, the 19th Century Scot best known for his formulation of the first and second laws of thermodynamics, said, “When you can measure what you are speaking about, and express it in numbers, you know something about it, [sic.] when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts advanced to the stage of science.” A century or so later Peter Drucker, the renowned American business guru, intoned his version, “If you can’t measure it you can’t improve it.” The people who run American healthcare today appear to have taken both Kelvin and Drucker at their word.

The modern intellectual revolution was initially led by sixteenth century astronomers like Galileo, Brahe and Kepler. But it didn’t take long for the scientific method to be applied to understanding biology and medicine. De Motu Cordis, published in 1628 by English physician William Harvey, was world-changing, as much for its methods as for its conclusions. Harvey proved via unassailable experimental evidence that blood circulates in the body.

Medical scientists, aided by an ever-longer list of measuring devices, including microscope, thermometer, barometer, and most importantly, by close observation, rapidly expanded the scope of understanding of how the human body works in health and in disease.

Once the Dutch spectacle makers, Zacharias and Hans Janssen, opened an unseen world to the human eye and mind with their invention of the compound lens microscope in the 1590s, the world would never be the same.^* Three centuries later, Robert Koch, a German microbiologist, building on the work of his predecessor, Louis Pasteur, the Frenchman who founded microbiology, published his four postulates. Fulfilling these four conditions, Koch reasoned, was proof that a specific organism caused a particular disease.

1. The microorganism must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.
2. The microorganism must be isolated from a diseased organism and grown in pure culture.
3. The cultured microorganism should cause disease when introduced into a healthy organism.
4. The microorganism must be re-isolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.³

Research guided by Koch’s Postulates brought understanding of pathogenic bacteria, parasites and later, of viruses, leading to antibiotics and huge improvement in individual and population health.^†

Thanks to the successes of the last century-and-a-half in addressing infectious diseases, the ghost of Koch’s Postulates still holds sway over the medical mind, even though we doctors know better than to expect to find a single infectious agent at the root of most of chronic afflictions, like coronary artery disease, cancer and stroke.^*

It would be lovely if there were a cure or prevention for every disease that worked as reliably as antibiotics do for H. pylori; vaccine does for HPV; and penicillin still does for strep throat 75 years after it was added to the medical armamentarium by Alexander Fleming.

We don’t even bother to vaccinate for smallpox any more. Thanks to the smallpox vaccine, introduced by Edward Jenner over 200 years ago, the disease and the virus that causes it have been wiped from the face of the earth (except in a few repositories, in case the pathogen is “needed” as a biological weapon).

We are not going to find a single infectious culprit for most of what afflicts us today. Koch’s Postulates don’t apply to these complicated maladies caused by multiple factors. As they stand, the Postulates are just too simple to capture even large parts of the reality of infectious disease.

Consider the host. Every human being is biologically unique. This even holds for identical twins who start out with the same genes that come to be expressed more or less differently as a result of each individual’s life experience. In the course of learning its job of distinguishing every person from everything else in the world and every good cell in the body from every bad one, the immune system “constructs” a unique biological identity for every human host, defending it against infection and malignancy.

Over a lifetime, the nervous system, conscious and unconscious, also participates in the process of identity-building. Medical science is constantly uncovering ways in which the nervous system and the immune system are intertwined.^†

It should be obvious that the concept of an average host who mounts an average response to a single infectious agent is useful only up to a point. We have learned a ton of physiology, pathology, immunology and biochemistry since the time of Herr Professor Koch. Researchers know to cast a much wider net than for a single organism and a unitary host response when investigating most maladies.

Multiply the uniqueness of individuals with the complications of aggregating them into families, cohabiting groups, workplaces, cities and societies. Smallpox was eradicated not just because of the vaccine that primed individual immune systems to recognize and fight off the culprit virus, but because, for two centuries, public health workers, who depended for their success on understanding each society and culture in which the disease appeared, kept after disease occurrences and unvaccinated populations.

As a metaphor, these wonderfully simple four Postulates still exert a great deal of influence on medical reasoning. By comparison, Euclid’s Geometry, that most elegant deductive reasoning system that we cut our wisdom teeth on in high school, starts with five postulates.

Searching for simple answers to complex problems is a fundamental impetus of medical science, and of science in general. Reductionism lies at the heart of the scientific method. Control as many variables as you can, while you manipulate just one variable at a time, and observe the outcome. This is a way to learn what each factor does. Then combine the factors into a model that makes predictions and test it experimentally.

Experimental testing may be done in a laboratory, employing test tubes, culture dishes, or live animals. Clinical experiments often occur in healthcare settings. For example, a group of clinic patients is administered a drug while a comparable group gets a placebo. Treatment or placebo is assigned randomly and neither patients nor researchers know who’s gotten which. This sort of double-blind randomized experiment is considered the gold standard for sussing out all sorts of facts, including what effect a drug really has, in spite of what the patient or researcher may have expected.

An experiment may be observational, based in clinic or community, following a set of parameters in a population over time and calculating correlations. Or it may be done solely by mining medical and public health databases for clues to how things work. (See Chapter 12, “Research.”)

Science is a unique universe of knowledge. It depends on being able to test and retest every observation and every theory. Only those facts that stand up to the most intense public scrutiny are considered reliable building blocks upon which to construct the next advance in knowledge. “Public,” in this sense, does not mean the general citizenry. It is restricted to fellow experts.

Of course, the elite public of scientists is wrong sometimes. New theories must often swim against the stream of “established” expertise. For starters, consider the travails of Darwin, Einstein and Galileo in defending their earthshaking theories.

Facts and theories that are considered bedrock scientific truth one day may be overturned the next. That a brick can be removed from the scientific edifice because it has been falsified is as critical to the power and credibility of science as it is that new bricks of knowledge and understanding can be added.

The ever-advancing scientific frontier leaves in its wake a body of knowledge that grows exponentially, as well as a rubble heap of discredited facts and theories. For example, after I had spent three decades of my career nagging every woman over twenty to do a breast self-exam, I abruptly stopped. New studies had shown no improvement in disease course or survival of women who had discovered their malignancies as a result of self-exam. Rather, these patients had more procedures, worry, discomfort and expense than women whose tumors had been discovered by their health care provider, by mammogram, or noticed incidentally by themselves. This may seem counter-intuitive, based on the belief that it’s always better to catch tumors earlier; which illustrates why we cannot depend on common sense alone for making medical decisions. We always need good research. (Of course, anybody who does find a breast lump should still see a health professional about it right away. Ignoring a lump is never a good strategy.)

Couple science with technology and you have the synergy to transform every aspect of human life, including healthcare. If I were to try to name all the technology—from stethoscope to functional MRI; from petri dish to DNA sequencer; from punch card to supercomputer; from horse-and-buggy to remote activity monitor—that physicians have counted on to care for patients since the beginning of the modern age, I might never get to the end because things are being introduced today faster than I could list them.

The result has been world-changing. Our power to prevent, diagnose, treat, ameliorate and cure disease is many orders of magnitude more than it was in Sir William Harvey’s day. At least in the developed world, medical science has changed everything about life: how we are born, live and die; families; expectations; and our relationship to disease and suffering.

Reductionism

I would like to go back a few paragraphs and pick up the concept of reductionism. Breaking the world into smaller pieces (concepts), seeing how each piece works, then putting them back together in a model that makes testable predictions, is what science does. As time passes, we seem intent on examining smaller and smaller pieces that later we try to reassemble into a working whole. Modern physics—theorizing on scales that range from the quantum, Planck length 1.616199 × 10⁻³⁵ meters, to the cosmological, diameter of the visible universe 4.4 × 10²² meters—strives to unite it all under a Theory of Everything (ToE).

A ToE has eluded the best minds, including Einstein’s and Hawking’s, for over a century. It is supposed to combine relativity with quantum physics, that is, gravity with the other three forces of nature (electromagnetism, strong nuclear force and weak nuclear force).

Even without a ToE, it was hoped that quantum physics could eventually explain everything about chemistry, which would inform biochemistry, which would tell us all we need to know about biology. Continuing on up the building block scale, biology was supposed to explain psych...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• About the Author
• Introduction
• 1 Logical Conclusions: How Modern Medicine Fits into Western Culture
• 2 What Computers Do Better Than Humans
• 3 Technology
• 4 What Humans Do Better Than Computers
• 5 Data versus Story
• 6 Economics
• 7 Security and Privacy
• 8 Electronic Health Record
• 9 Patient Care
• 10 Telehealth
• 11 Public Health
• 12 Research
• 13 Education
• 14 The Connected World of Patients
• Coda
• Glossary
• References
• Suggested Reading
• Index