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All Podcasts Alexa, Do I Have COVID? (with John Halamka)

Alexa, Do I Have COVID? (with John Halamka)

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Description

Dr. Bob talks with John Halamka, President of Mayo Clinic Platform, about how COVID has forced medicine to embrace technology at a blistering pace. They discuss what changed, what will stick around post-COVID, and why a computer will never be able to fully replace your doctor. But, are we close to having Alexa diagnose your illnesses?

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s Twitter account @inthebubblepod.

 

John Halamka is on Twitter @jhalamka.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Dr. Bob Wachter & Dr. John Halamka

Dr. John Halamka  00:00

So imagine this, I walk up, you know, it’s like, oh god, I got this fever, cough, night sweats, you know, hey, Alexa. (coughs) To which it says, aha, well, there’s a 68% chance that you actually may have this disease, let’s get you this test or a referral to that specialist.

Dr. Bob Wachter 

Welcome to IN THE BUBBLE. I’m your host, Dr. Bob Wachter. Well, that was Dr. John Halamka, coughing into your ear. John is one of the world’s experts on the digital transformation of medicine. And you’ll hear more on what that’s about as we get into the episode. But suffice it to say that the ways we diagnose and treat illnesses are going to be changing a lot as we as we move on with the digital transformation of medicine. And that whole process has been enormously accelerated by COVID. So we’ll get back to that in a second, let’s just spend a minute talking about where we are in the pandemic. Things in the United States are looking pretty good. We have moved from the plateau that we were at over the last few weeks to a mild decrease in overall cases.

Dr. Bob Wachter 

Even Michigan, which had its terrible spike a couple of weeks ago, is now moving downward pretty swiftly. And overall, things seem to be improving. It looks like in that race we’ve been talking about for several months of vaccines versus variants. The vaccines are winning in the United States, were still vaccinating 2 and a half to 3 million people a day. As I wrote recently, in an editorial in the Washington Post, I am a little bit worried because the world is really separating into the vaccinated and the unvaccinated and all things are getting tremendously safer for vaccinated people.

Dr. Bob Wachter

We’re starting to see more and more unvaccinated people get COVID, get sick, and go to the hospital. And so please, when you have a chance to be vaccinated, please take that chance. And if you’re not vaccinated, be careful, because all of the opening is terrific. But it mostly because numbers are getting better because people are getting vaccinated. Obviously, we can’t help but notice what’s going on in India. And it’s a massive tragedy. You know, we’re sort of used to tragedies like this, from what we saw in China, and then Italy, and then New York, and then thinking about Wisconsin and Los Angeles. But this may turn out to be the biggest one of all, with the greatest case toll, the greatest death toll. And just makes clear the point that Nicki Laurie made on Monday that until everyone is safe, and everyone is vaccinated, there will be tragedies around the world.

Dr. Bob Wachter  02:48

And in fact, none of us is completely safe. Because as the massive numbers of cases is being spread in India, there are also going to be new variants that are coming out of that. So, the United States has just announced that we’re going to be sending a boatload of vaccines to India, as well as raw materials. And that is terrific feels like a really important thing for us to do. We’re also moving forward in the United States on some of the guidelines, and we’re hearing about changes and some of the rules about what you can and can’t do outside. So mostly a fairly sunny picture in the US and a little bit dismal when we look at India, but even other parts of the world are doing okay, so as usual, split screen as we look at where we are with COVID.

Dr. Bob Wachter 

But today’s topic is a little bit different. We wanted to spend some time and do something we haven’t done in the last several months, which is to look at how COVID is changing the world of health and healthcare. And we’ve talked about disparities and how that has come out from COVID. But the biggest change and probably the biggest change by far will be the degree to which COVID has accelerated the digital transformation in medicine. Think about the way you shop, think about the way you consume, and purchase entertainment. Think about the way you plan a trip. All of these things have been completely remade by digital transformation.

Dr. Bob Wachter  04:11

You can argue in some cases for worse, but mostly, mostly for better made it easier and cheaper and more customer facing and consumer centric. Healthcare is pretty late to that dance. But we were going along a slow path of digital transformation that probably would have taken another 10 years and as you’ll hear from our guests, that 10-year journey has been bundled into about a year because of COVID. And it’s exciting, it is dizzying. It’s fascinating to watch. And the person who in the United States, the person who is most in the middle of it is our guest whose name is John Halamka. John is an emergency medicine physician by training but also an informatics digital expert. He spent most of his career at Harvard where he was the Chief Information Officer of Harvard Medical School, he ran all of the digital systems at Beth Israel Deaconess Medical Center, one of Harvard’s main teaching hospitals.

Dr. Bob Wachter

But right as the pandemic was starting, and before he knew about the pandemic, John changed jobs, and moved at least his work to the Mayo Clinic. Although he continues to live and run a working farm, outside of Boston, John took a job as the president of what’s called Mayo Clinic platform. And that is a fancy way of saying John is really in charge of Mayo’s efforts to not only digitally transform how the Mayo Clinic does its work. But ultimately, they are not short of ambition, ultimately, to transform the way healthcare works. And as you’ll hear, that is everything from how you see a doctor or a nurse practitioner or anyone else, to how you figure out whether you’re sick in the first place, and how you get your care. And if you get hospitalized in the future, it might be in your bedroom, there will be all sorts of changes in the way we think about monitoring people, how we get information and make recommendations about health and health care.

Dr. Bob Wachter  06:11

So it is very exciting, a lot of change, and really important and why are we talking about it on IN THE BUBBLE? Because it is a field that would have taken this would have taken 10 years. And it’s happened in a year because of COVID. And you’ll also hear there are certain things that relate to COVID. Probably the most prominent one is we think about the vaccine passports that we’ve talked about that, of course becomes a digital problem if we’re trying to authenticate someone’s vaccination status or someone’s COVID status. So we’ll get into that as well. So a lot to talk about really exciting and rapidly moving part of the healthcare landscape. And so let us bring on Dr. John Halamka.

Dr. Bob Wachter 

John, you look good. You look very Mayo-ish. You got a haircut. You got the tie on. It’s a good look.

Dr. John Halamka 

This is my Midwest compatible look.

Dr. Bob Wachter 

Yeah, I think it’s you. So we’re going to talk about digital transformation in the context of COVID. We’ll start with COVID. But I’m sure we’ll end up talking more broadly about where the world is and where it’s going. So let’s start with COVID. What do you think the biggest, digitally transformative thing has happened during COVID? And has that thing surprised you?

Dr. John Halamka 

So do I only get one choice? Or can I have two? I’m gonna have two. So the first thing is the remarkable trust and collaboration we’ve seen across the industry. So when you look at something like contact tracing, contact tracing require that Google, Apple and Microsoft work together seamlessly for the benefit of all and had Gemini of none. Would you have seen that two years ago?

Dr. Bob Wachter 

No way.

Dr. John Halamka

No way. Right? So this collaboration and coalition formation has been extraordinary. The other thing that’s changed is culture. So when you ask, let’s just take my 80-year-old mother, so mom, if you look at the last year of your outpatient care, how did it go? Well, I did my visits on my iPad, it was very convenient. I got what I needed. My medications were delivered to my home. Okay, mom, so you want to go back to driving 40 minutes paying $20 for parking, sitting in a waiting room with people coughing on you. And she goes, well, no. I mean, this thing over the last year, it’s worked flawlessly. Why would I change? Culture and expectation has changed.

Dr. Bob Wachter  08:36

Interesting. So you did not give the standard answer, which is the growth of telemedicine. It sounds like telemedicine is an element of a broader change, you think, which is people’s expectation about how they interact with the healthcare system, and how they manage their own health. That’s the big change with telemedicine, maybe be just being a thing? Is that the way you see it?

Dr. John Halamka

So my father died seven years ago, and my mother did not touch a keyboard while my father was alive. And today, she has an iPad, she has an iPhone, she has a Google Home, she is doing all of this virtual interaction because at the time of COVID, it became a necessity. So it wasn’t a she called me and said, you know what, I really want, telemedicine, she didn’t say that. What she says, what I want is care. And now I have all these appliances around my house that at a time of isolation, deliver the care, and that’s what I’m embracing.

Dr. Bob Wachter 

Yeah. She’s not teaching you how to code yet though, that she hasn’t gone that far?

Dr. John Halamka 

Not so much.

Dr. Bob Wachter 

So when COVID ends, let’s hope and assume it will at some point. What is it about the culture that doesn’t go back to the old way? I mean, you mentioned that she’s gotten a taste of it. And maybe she doesn’t want to park and all the other hassles, but you might argue that this was a forced bit of isolation. And when you know that at least many physicians think people want to come in and see us. And it’s useful for us to lay on hand. So what prevents the world from snapping back into position?

Dr. John Halamka  10:16

So of course, there will be those who wants to travel. And those who find the physical examination itself therapeutic, there is somebody who is laying on hands and is caring for me. But people are also discovering that we’re now entering a world of new sensors. You may have seen that Mayo Clinic launched a new company last week to take lead, 1/6 lead in 12 lead ECG’s. And use, we have about 14 algorithms in the world of cardiology, and do not only diagnosis but predictive diagnosis on diseases you don’t have yet. And so what you’re starting to see as well, wait a minute, you know, I learned this virtual care works okay. Oh, but now I have these devices, and all of use these sensors, oh, wow, I can actually get something I never got before in the world of on prem care.

Dr. John Halamka 

So I just see it a whole new layer of customer demand for remote diagnostics, and ultimately, even remote therapies. And that what do I even mean by a remote therapy? Well, if I can do a lab test in your home, which now there is you’ve seen the EUA’s, right? You can. Should not be able to deliver some therapeutic interventions in the home too. And Mayo’s launched a business to do that. So I just look at these next couple of quarters as the sort of amazing expansion of the model of care delivery, but it was catalyzed by the COVID change, and it will be normal in the post COVID era.

Dr. Bob Wachter 

I’m guessing you would say that many of these things would have happened anyway, they’re really part of the inexorable progression of technological transformation and intermediation and people having tools that allow them to do things themselves that they couldn’t do in other walks of life that we’ve seen with financial services and with, you know, managing your travel and other things. How much do you think COVID accelerated things? So, you know, if there hadn’t been COVID, we would have gotten to 2022 by 2027, 2030. What do you think?

Dr. John Halamka  12:21

So I’ll be blunt. You know, I joined Mayo Clinic, January 1 of 2020. And it was handed the Bold Forward 2030 Plan. Do you know that in 2020, we finished the 2030 plan. And so that is I would tell you COVID accelerated 10 years, into 10 months.

Dr. Bob Wachter 

Wow. Wow. And do you think that is going to be generally true for the entire healthcare industry? Or is? I mean, I’ve answered my own question. Mayo is a unique place. But do you think that Mayo is in a position financially and in a position in terms of scope and scale to be thinking around, you know, around the curves more than anyone else? Do you know, how different is mail going to be then the average mom and pop practice or the average community hospital in a suburb somewhere?

Dr. John Halamka

So here’s what I would argue, you know, that I’m now the President of Mayo Clinic platform. And of course, the notion is, the platform isn’t for Mayo, the platform is for the world. And so that is if you’re in a critical access hospital in a rural area, and you need specialty consultation and intervention, that the platform componentry should be able to deliver it to you. So you know, you’re certainly correct about William Gibson saying the future is here. It’s just unevenly distributed. But the intent of the work that I’m doing is to now more evenly distributed. And let me give you one more case example. Mayo has just finished doing the development of an algorithm for radiation oncology, auto contouring of head neck tumors.

Dr. John Halamka 

So that means that we can take a CT or MRI from any place in the world and produce a radiation therapy out of contouring profile, avoiding your carotid artery and the nervous system and all the things that might be destroyed by radiation in a matter of an hour or two. Humans augmented by an algorithm. But you may not know because you know, you’re an expert in interoperability, but every Linear Accelerator on the planet has the same API. We can actually program every Linear Accelerator in every location in the world using the same API. So you could imagine this, wow, we’ve yeah, sure, fine. Mayo proved and validated the algorithm. But now if you’ve got a linear accelerator in Montana, we can actually program it remotely with the same care you would have received in a more urban setting.

Dr. Bob Wachter  14:48

And just to explain to folks what an API so you know, maybe either in terms of the app store these days I’m thinking about API is like spike proteins embedding in people’s noses. What does that mean when you say everything has the same API?

Dr. John Halamka 

Yeah, sorry for the term of art for the application program interface. I’m talking to Bob Wachter. So you know, he lives the same acronyms I do. But the idea of an API is that I can interoperate, I can send and receive data from an external party using a very common approach. Think of it more like how does a web browser get a web page? And the answer is we had this thing called HTML and HTTP that allowed us to pull data off of servers and display it on a computer or a phone, and API’s to interoperate medical data or control linear accelerators, very similar idea.

Dr. Bob Wachter 

So let’s go back into telemedicine for a second and then we’ll widen the lens, again into the broader trends, but talk about the transformation, specifically with telemedicine, you know, why did that happen so quickly? And as we come out of COVID, where will we be left in terms of telemedicine as a way that people interact with the healthcare system?

Dr. John Halamka  16:17

So I’ll give you some numbers from Mayo. But then more broadly talk about the United States experience. In January of 2020, 3% of Mayo Clinic’s visits were virtual. In April, 95% were virtual. And now here we are, you know, in 2021, and it’s about 20%. Are virtual. So, but still, I would argue this, how many times and your experience in digital healthcare, have you seen anyone for anything go from 3% to 20%? In a one-year period, right? Doesn’t happen.  20%, that’s still a pretty good run rate on telemedicine. But there’s some more interesting data. As part of this work I’ve done on the COVID-19 healthcare coalition. We ran a nationwide telemedicine survey of the nation’s experience from a patient and a provider perspective over the course of this COVID era.

Dr. John Halamka 

What you saw was numbers like this, 73% of patients said, well, all my needs were met with telecare. 80% said, I engaged my physician in a meaningful way with telecare. You know, again, high 70s people saying, oh, I actually believe that this is the new normal, and that’s fine. So what you started to see, as you’re sure not only do we go from 3 to 95 to 20. But the patients are an asset. It was good enough. I felt rapport, I want to continue doing this. And then the providers similarly felt that this was a way where they could reach their patients, especially in this time of COVID who would have not been reached in any other way.

Dr. Bob Wachter  18:02

So it seemed to me that the three enablers of the growth in telecare were fear on the part of both patients and providers. They didn’t want to come into the same air cloud as each other. The relaxation of some of the regulatory barriers and payment parity that a doctor would get paid the same for a tele visit as an in person visit. Fear probably will begin going away at some point, what do you think’s gonna happen to the regulatory barriers? And what do you think’s gonna happen to the payments?

Dr. John Halamka 

So you and I chat with many of the same people. And so as I talk to people at HHS, CMS and many other agencies, everyone is telling me the same thing. It’s not going to roll back. That is we’re going to sustain the gains, because we’ve been able to achieve quality safety in many cases, lower cost, so that these regulatory waivers and rollbacks are likely to be moving forward. I don’t see reversals. Now the reimbursement issue is going to be interesting. And that is, if you were to ask the question, what does it cost to deliver a high acuity serious and complex treatment in someone’s living room? Versus in a […] Medical Center? Answer is we’ve done this right over this course of the COVID period I’m sure your callings have, too.

Dr. John Halamka 

And in fact, a hospitalist, your area of expertise can deliver care at about half the cost in the home. Because just the basic overhead of operating in a home is far less. So therefore should the reimbursement be half? Well, wait a minute, we’ve got a lot of startup costs. We got a lot of you know, new staffing, new training, new technologies to deploy. So we’re near parity now and that is actually as you pointed out, made all these things possible. Probably the reimbursement will eventually get a little right sized to the cost. But that’s going to require like any industry that we achieve some scale first.

Dr. Bob Wachter  20:13

Talk about AI for a second, because if you’d asked me in January 2020, all right, there’s going to be a pandemic and its pandemics will tend to accelerate the both technological and cultural changes that might be in store anyway, you might have said telemedicine and virtual care would be accelerated, you might have also said that artificial intelligence is ready for primetime kind of hype right now. But it’s going to be a shining moment. I guess from my perspective, I haven’t seen that much of artificial intelligence, sort of hitting its tipping point, but maybe I’m missing something. What do you think?

Dr. Bob Wachter 

So and Michael is the person who runs the Center for Digital Health Innovation at UCSF, so has sort of analogous job to John’s at Mayo, although Mayo has a far larger scale.

Dr. John Halamka 

We’re on the trajectory. And let me just point out some of the challenges and problems as you might guess I collaborate extensively with Michael Bloom. And so we’re both thinking through these issues.

Dr. John Halamka

So imagine this, I have taken 1 million Scandinavian Lutherans and I have developed the most incredible algorithm that you’ve ever seen. And I’m going to take that algorithm and I’m going to run it at UCSF. It’s gonna work, maybe? Do we know?

Dr. Bob Wachter

We don’t, right.

Dr. John Halamka

Too little care? Too much care? False positives? False negatives? We don’t know. So what we’re seeing is people are now recognizing and Fei-Fei Li from Stanford gave Grand Rounds three weeks ago at Mayo. And I asked Fei Fei, I said, well, is there a definition of data that is heterogeneous and good enough? And she said, there’s no such definition, right? This includes short people, tall people, thin people, fat people, you know, and etc. It’s like no such definition. I asked her, is there a standard labeling process for AI?

Dr. John Halamka  22:11

So when you lift a product off the shelf, you’ll know it actually work in San Francisco. And she said, no such labeling process exists. And FDA, you know, through its software as a medical device approach certainly has the capacity to say it’s safe. But that doesn’t necessarily mean it’s effective. And so to your point, where we are His algorithms are being developed that are surprisingly good, this EKG stuff for the radiation therapy stuff I described. But we don’t yet have the appropriate packaging, the appropriate system that allows you to find the thing that is going to help you right now for the patient in front of you. And that’s what we’re all working on together.

Dr. Bob Wachter 

So take us forward to 2030. AI has passed its hype point; it’s now fully integrated into the world of healthcare. Tell me about the life of a patient and a doctor as it relates to all these spiffy things that AI is now doing that it can’t do today? What’s going to feel and be different?

Dr. John Halamka 

So let me give you a couple of examples. So I’m going to ask you a completely rhetorical question, which is, do you find that you have colleagues, family members or friends that say, hey, Bob, you know, I woke up this morning, and I have this sign and symptom, where should I go? And what should I do?

Dr. Bob Wachter 

Constantly, yes. I tell people that my job is I’m a witch doctor. I tell them witch doctor, they should say.

Dr. John Halamka 

Exactly. Now, would you agree that and I have many colleagues working on these problems. So I know that it shouldn’t we have ways for healthcare, right, Waze figures out how you should drive.

Dr. Bob Wachter 

Waze, so for people that are listening, so that the app that allows you to navigate traffic better.

Dr. John Halamka  24:03

And how does it do that and figures out well, I looked at 10,000 cars who did the same thing, and they went this way. Shouldn’t you say, well, I was in San Francisco on January 3rd, and I woke up with a headache at this address. And it was just like, oh, well, surprisingly, actually, people in that building all have headaches today. It’s carbon monoxide. Or, gee, you know, it turns out there are a whole bunch of fires going on in San Francisco, and everybody in San Francisco has a headache, or no, that’s pretty weird. Have you been to Wuhan lately?

Dr. John Halamka 

You know, anyway, point being that you should have care navigation that is provided by tooling and not calling Bob Wachter. They’ll still call Bob but I made the point being the tooling will now be more generally available to help you get to the right doctor for the right treatment at the right time, that’s going to be different. But there’s also going to be new kinds of data available. So let me just give you a quick example. So I’ve done a lot of work with the Bill and Melinda Gates Foundation over the years, and two of my colleagues were traveling with me in India and Africa, started recording the sounds of people’s coughing.

Dr. John Halamka 

And they developed the world’s largest data set of cough sounds. And they then have used AI algorithms. They now with an AUC. Well, so high sensitivity specificity of .85.

Dr. Bob Wachter 

Okay, meaning very, very accurate.

Dr. John Halamka 

Yeah, it’s very accurate. They can diagnose tuberculosis from the sound of the cough you make.

Dr. Bob Wachter 

That’s crazy.

Dr. John Halamka 

Right? And so we’re right, but you get a big enough data set. Right, and you train an algorithm, right? I know, it sounds a little creepy, but I mean, it’s been validated. So imagine this, I walk up, you know, it’s like, Oh, God, I got this fever, cough, night sweats. You know, hey, Alexa. (coughs) To which it says, aha, well, there’s a 68% chance that you actually may have this disease, let’s get you this test, or a referral to that specialist. So I use this as an exemplar, because right we’re going to have heart recordings, sounds, telemetry, coughing, all these new things, from the phones, we carry the devices, we wear, the devices in our homes, which are going to help narrow down our diagnostic possibilities.

Dr. Bob Wachter  26:38

All right, I want to tell you a story that I hear all the time, and it is from Digital Utopians. And it goes like this, the world is going to be a wonderful place because all of the patients are going to be home. And they are going to have a watch that’s monitoring their heart rate and their EKG and they’re going to be coughing into their iPhone, and their toilet will be wired. So it will know that their urine has changed and their digital scale will send off signals.

Dr. Bob Wachter 

And all of that data are going to flow seamlessly to their primary care doctor, who’s going to say how wonderful it is that I can know all of this about my 2000 patients. Now, when I hear that, I can tell you that every primary care doctor that works at UCSF, will quit by 5 o’clock this afternoon. And if any of that happens, so tell me how much of that will happen? And how exactly are we going to manage it?

Dr. John Halamka 

Right. So you are completely correct. And let me just give you a story from Mayo Clinic about what we’ve done. And why I think there are solutions to the problem you’ve posed. I mentioned that we have a series of algorithms that evaluate EKGs. Those algorithms predict a fib in the future, measure your ejection fraction, your heart pump strength, measures certain diseases like pulmonary hypertension. Now, those are printed on the EKG itself. So that is the doctor hasn’t changed workflow. The doctor isn’t getting alerts, reminders, nothing is changed. Just when they look at the ECG paper or digital. It happens to have in addition to the usual interpretation, normal sinus rhythm, it also says 18% ejection fraction.

Dr. John Halamka  28:24

And so at Mayo Clinic, people say, oh, wow, it says it’s a totally normal EKG. Oh, but look on it. It also tells me there’s something I should think about. So that idea of no change in workflow no change in cognitive burden. But giving you something of value back has really helped, so that’s answer one. Answer two is, I believe we’re going to need just like you invented hospitalists, we’re going to have virtualists, we’re going to have care traffic controllers, I suspect, right, which would be those individuals who ensure that this noise, this massive amount of digital noise, if there is a signal to be found, if there is an alert or reminder or an event gets routed, it cannot be just another burden for that primary care physician. That’s just not going to work.

Dr. Bob Wachter 

Yeah. But even your first scenario, which is it doesn’t do anything more intrusive to my workflow than print out. Helpful message on the EKG. If I’m a doctor or health system, I’m kind of worried that if that happened a month ago, and I didn’t know it and react to it, is something bad going to happen to my patient and I’m going to get sued? So you sort of need your care traffic controller layer to be built to be monitoring this in real time. And we know from other digital signals like being in the ICU, that the false alarms are manifold, they’re all over the place. And that’s in a highly monitored, highly technological setting. That’s not someone forgot to take their watch off when they went into the shower. It screwed up the signal. So I’m still head scratching about how this all works out.

Dr. John Halamka  30:08

Yeah, well, so there is an element to this, which is the medical legal issue, which we don’t have an answer for, which is what is malpractice? Is malpractice a bad outcome? No, it’s substantial deviation from the community standard of care. So what’s the community standard for the application of AI algorithms to look at real time body telemetry signals and take action? Oh, there is no community standard. And so what you will guess, this is just a guess, that as society goes forward, what we will recognize is that there will be a expectation for certain kinds of tools having certain kinds of accuracy, which potentially could result in certain kinds of action, but it will not be 100%. And it would just be a question of was the community standard as it evolves followed even if that community standard is based on automation.

Dr. Bob Wachter 

Yeah. Yeah. And it gets into the as we think about the driverless car, a self-driving car, it can be terrific, it can be safe. And then there’s one accident that sets it back years. And you can make the perfectly rational argument that net, it’s safer, it’s actually safer than humans driving cars, because it doesn’t fall asleep. It doesn’t drink it. You know, all the things that humans sometimes do when they’re driving, or get distracted. And yet the single problem becomes iconic. How does that not happen? As we begin giving more and more authority and agency to the digital monitors, the digital reminders, and more and more of them live in the patient’s world? You sort of the first thing that goes wrong, of course, that becomes a story on 60 minutes, doesn’t it?

Dr. John Halamka 

Well, you know, and so you’re exactly right, it gets back to this culture question. And let’s just from a data perspective, let’s talk about thrombo embolic events and the administration of COVID-19 Vaccines? So we gave 7 million doses and six people got a disease. Okay. Well, I’ll just tell you, because a number of colleagues and I have just submitted a paper, we actually looked at every vaccine, not only COVID vaccines, but all the other vaccines. And we looked at pre and post rates of these kinds of events. And you know, we cannot find any signal, any indication that any vaccine of any type causes these events at a level that is beyond the baseline you’d see in an unvaccinated person.

Dr. John Halamka  32:45

So this is the challenge to your point is that if I told you 100 people would die, but now we put in a digital intervention, and one person will die. And how does society react to that? Is that a good thing? Or is that an acceptable thing? Because it’s really hard in any digital intervention to get to 100% perfection. And so it’s something that as a society, our ethicists will have to say, well, was that one person that died? Omission? commission? Was it you know; the algorithm was flawed? Or was it this the background that you know, humans are complicated in this happens, and this society says, okay, we accept this low level where things don’t work out perfectly.

Dr. Bob Wachter 

You mentioned COVID vaccine. So we should spend a minute talking about vaccination passports or authentication, which strikes me as a knotty issue that ethically policy wise, but also, digitally at this moment, if somebody is insisting on me showing that I was vaccinated, when I tried to get into the San Francisco Giants game tonight, I will show my little card that I apparently can buy online for five or 10 bucks. So seems like there needs to be a better solution. Is the answer to that digital? And if so, what would that look like?

Dr. John Halamka  34:19

And so as you say, this is a complicated issue. So this isn’t about saying you must get vaccinated. This isn’t about reducing an individual’s choice, freedom, civil liberties, it’s also not requiring them to buy a phone, right? Some people don’t want a phone. What it is, is asking, can you come up with a standard? A digital standard that enables a person who would want to show their information for some circumstance, either on their phone or a piece of paper in such a way that it is verifiable? And so what I’ve worked on with colleagues over these last couple of months, is what I would call verifiable clinical information.

Dr. John Halamka 

Now that could be a vaccination, or it could be a PCR test for COVID. Or it could be a doctor’s at a station that you had active disease and you are recovered. I mean, right? It could be all kinds of things. But we would use it’s a public key infrastructure digitally signed at a station in effect that says, oh, Bob at UCSF, did my test, and it was negative. Okay, so to validate that digitally, whether that’s shown on your phone, or a QR code on a piece of paper that you carry, we go back to UCSF and say, I have in front of me this credential, this piece of information. Was it in fact, issued by UCSF by Bob, on this day for this person? And the answer comes back, yes, that is real.

Dr. John Halamka 

And so therefore, if you bought it on eBay, not gonna work. Now, there is one element to that, that is not solved yet. Obviously, in the United States, we don’t have a universal person identifier. So when I go to a Giants game, and I say, My name is Bob Wachter, and here is my QR code. Is that up to the Giants to decide, well, how do they validate that I’m actually John Halamka? Not Bob Walker? Credential doesn’t do that for you. It’s just proving it was issued by UCSF for a person on a date.

Dr. Bob Wachter  36:26

And as you’re thinking about this credential, is there a model out there that you’re using have other types of similar credentials.

Dr. John Halamka 

And so the standard that we have chosen is called the Smart Health Card. And this particular standard uses the fast healthcare interoperability resources or fire, which is a very universally accepted way of distributing clinical information in this country. And it uses the same kind of digital signatures that would be used by a payment app to validate that an individual was paying for something legitimately. So literally, all we’re doing is simply reassembling. Well known, already proven and well, use standards to verify clinical information.

Dr. Bob Wachter 

Okay. Just a couple more questions. The first 10 years of digital and healthcare, which I think is probably been the last 10 years hasn’t gone as well, as we would have hoped. I wrote a book about it. Lots of bumps along the way. As we look back on the next 10 years, when we look back, what will have gone wrong as you plan. I know you do you think hard about bumps in the road and curveballs. If we get this wrong, what do you think the factors will have been that caused us to get it wrong?

Dr. John Halamka 

Right? Well, so often what we see is technology for technology’s sake. And we have to avoid that temptation. Right? So we have to ask, well, what is the real problem? And how does technology help us get to the solution, you and I have advised many companies over the years, who decided, oh, we’re going to build this great website, and patients are going to type in their information, it’s all going to be great. And not a single person uses it, because it provides no value. And so that’s the key. It’s let’s provide patients something of value. Along the way, as we’ve talked about, let’s make sure we don’t create more bias.

Dr. John Halamka  38:19

And whether that bias is a digital divide bias, or it’s a race, ethnicity, age, gender bias, because the last thing we want is an algorithm that fails or delivers the wrong diagnosis or treatment to a patient population based on demographics. And privacy is really a key question. Last week, Mayo Clinic ran a conference with 80 international leaders, asking about the ethical privacy protecting uses of data for research, drug discovery, the idea that we’re going to have new cures and treatments. And this is tricky, because as you know, I’m a medical altruist. So my genome is public. My medical record is public, my microbiome is public. But you may have totally different preferences.

Dr. John Halamka 

So as a society, we’re still working through this, how do I consent for potential secondary use of your data you so that I’m respecting whatever your preferences are. Because otherwise, we run into what we’ll call the Henrietta Lacks problem. A woman who donated tissue not knowing that it would become the most important human cell line. And suddenly, something she had no control over became a product across the world. We want to avoid that kind of lapse in our digital environment as well.

Dr. Bob Wachter 

Yeah. Maybe last question. I have a daughter who’s a fourth-year medical student, what would you tell her about the career that she’s going to have and would you advise her at all to go into certain specialties? Not go into certain specialties? Because she’s looking at a not a 5- or 10-year time horizon she’s looking at what will medicine be like 20 years from now, 25 years from now?

Dr. John Halamka  40:02

Yeah. So I wouldn’t be as bold to say, oh, don’t go into radiology because machines will do that, you know, I wouldn’t say anything like that. What I would say is when I was at UCSF, and you know that I’m a proud UCSF graduate, I’ve memorized everything in the textbook, because that’s what you had to do. I would argue that today, our medical students shouldn’t memorize a lot, they should understand knowledge, navigation, and discovery and data analysis. And in that way, they will do clinical trials of one. And that’s a skill set so different from my training. But your daughter is exactly the right age to embrace that idea that I’m going to have the data of the past, guide the patient, care the future.

Dr. Bob Wachter 

And can you reassure her and me who’s helping with the tuition that there will be doctors 30 years from now?

Dr. John Halamka 

So here is, Warner Slack, who I think you probably knew, as one of my mentors, always said to me, if a computer can replace your doctor, a computer should replace your doctor. And what he meant by that was to say, why do we go into medicine, empathy, listening, being able to help patients and their families navigate very difficult decisions. And I think so many of those characteristics will never be replaced with any algorithm.

Dr. Bob Wachter 

Well, that’s a great note to end on. And I tend to agree with you. But I will see, you know, people have been willing to trade off the in person contact with the trusted professional with some digital solutions in other fields. You know, the role of the physician is going to change over time. And but I think there will always be a role for that, that human contact and that human being, and we’ll have to see how it plays out. Thank you, John, for your leadership. And thank you for explaining this future world to us. I really appreciate it.

Dr. John Halamka  42:03

Well, thanks so much.

Dr. Bob Wachter 

Well, I hope you found that as interesting as I did, it’s really breathtaking to think about what the world of health and healthcare is going to look like, in 10 years. People sometimes say to me, oh, you know, healthcare is going through such massive transformation. And I say, are you kidding me, you know, people still mostly have to come in and see a doctor and sit in the waiting room and read the Reader’s Digest. There are no unemployed doctors, there are no unemployed nurses, very few hospitals have closed.

Dr. Bob Wachter 

You know, my wife is a journalist, I’ve seen what transformation looks like, you know, talk to people who work in the taxicab business or in retail, I mean, the kinds of transformations that we’ve seen in other industries are coming to healthcare. And it’s scary, and it’s dizzying. But I think ultimately, it’s going to be for the best, I think patients are going to get better care closer to their home, often from their home. And I actually do believe that life for doctors and nurses will be better as well, because a lot of stuff that we do, that’s just silly, that really is a waste of time makes no sense. And it just we have to do it because there’s no other mechanism to do it. But I think if we get the digital piece, right, there will be a lot of things that patients can do themselves or just take out friction from the system.

Dr. Bob Wachter 

And it should enable patients to get better and safer and hopefully cheaper care. And when doctors are involved, it will be things that we’re uniquely good at. And so I think it’s a pretty exciting prospect over the next 10 years. We have a number of other terrific episodes coming up on IN THE BUBBLE, we’re going to talk equity, and the equity issues have changed over the last several months now we’re spending a lot of time thinking about vaccines, vaccine hesitancy as it plays out in different communities, particularly communities of color. And we have kind of a two-part episode as we talk about equity and particularly around vaccination. Rhea Boyd, who’s a physician who has focused a lot of her work on issues in the Black community. We’ll talk about that.

Dr. Bob Wachter  44:18

And the other part of the segment we’ll be talking about what has happened here in San Francisco in the Mission District, which is our heavily Latinx district, where a group of community workers and activists have partnered with some of my colleagues at UCSF to deliver just remarkable care to the underserved community, the Latinx community here in San Francisco. Our guest for that will be Jon Jacobo, who is a community leader in the Latinx community in San Francisco, and my colleague Diane Havlir, who’s a physician and the director of our HIV infectious disease division and also has been the leading light in setting up this partnership.

Dr. Bob Wachter 

We’ll have another episode where we talk about the future of work. I can tell you at my place, we’re trying to figure this out, does everybody come back? Has nobody come back? Is it a hybrid? If it’s a hybrid, does everybody come back on Tuesdays so we can all see each other? Or is that wasting too much space, if everybody’s in the same day, I think every business that I know of is trying to sort this out. And of course, nobody knows how to get it right, because we’ve never done this before. So we’ll have an episode where we think that through with you. And finally, one of the issues that everyone is struggling with is no matter what the guidelines say, getting back to normal is weird.

Dr. Bob Wachter 

We’re just not used to standing with other people, hugging them, taking our masks off, eating with them, all of that stuff. And as we try to get back to normal, it’s really too fast to say, just snap your fingers and it’s 2019 again, just doesn’t work that way the human brain doesn’t work that way. And so we have a couple of terrific guests to help us think that through. One is Craig Spencer, who is an emergency physician in New York, who has been writing really brilliantly about the experience in the front line, but has written a fair amount recently about the weirdness of trying to get back to normal. And Lucy McBride, who’s a physician in DC, who has I don’t actually coined the term, but she’s been writing about FONO, which is Fear Of Normal. And that is actually a fairly human instinct to be a little bit afraid of going back to normal and how we think about that, manage it, and ultimately, hopefully do get back to normal as we work our way through it. So it’ll be interesting talking to Craig and Lucy about that. Until then, please stay safe, get vaccinated, and we’ll speak to you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening

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