2025: 20% doctor included?
an exercise in technology
speculation & musings
vinod khosla
vk@khoslaventures.com
twitter: @vkhosla
10% to 20% of cases:
delayed, missed, and incorrect diagnosis
2
graber, et al., jama, 2005
40,000+ patients in u.s. icus
may die with a misdiagnosis annually
3
winters, et al., bmj quality & safety, 2012
50% of MDs are below-average
4
math
human doctors
cognitive limitations
cognitive biases
5
a study of one hundred cases of diagnostic
error involving internists found…
6
Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642
…system-related factors contributed to the
diagnostic error in 65% of the cases and
cognitive factors in 74%...
7
Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642
…premature closure was
the single most common cause
8
Article: http://archinte.jamanetwork.com/article.aspx?articleid=486642
the value of second opinions
cleveland clinic doctors’ review of initial diagnosis
disagree with initial diagnosis
find need for further testing
recommend major changes to treatment
plan
11%
15%
18%
recommend moderate changes to
treatment plan
recommend minor changes to treatment
plan
9
26%
22%
Source: http://www.businessinsurance.com/article/20111204/NEWS05/312049987?tags=|74|305|339|342
the American College of Cardiology and the
American Heart Association made 7,196
recommendations leading to 53 practice
guidelines on 22 topics…
…48% have level C evidence (the worst kind)…
…11% have level A evidence (the best kind)…
…and only 19% of recommendations in class I
guidelines had level A evidence
10
Source: www.ncbi.nlm.nih.gov/pubmed/19244190
surgeons were given detailed diagnoses
& asked if patients should get surgery …
half said yes … the other half said no …
when asked again two years later,
40% of the docs gave a different answer
11
Source: http://jama.jamanetwork.com/article.aspx?articleid=380215
four cardiologists were asked to diagnose
stenosis in patients
using high-quality angiograms …
… they disagreed 60% of the time
…and disagreed with themselves (on rereads) 8-37% of the time
12
fifty-eight experts’ estimates of the chance of an
outcome of an important procedure
0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3% 3% 4%
5% 5% 5% 5% 5% 5% 5% 6% 6% 6% 8% 10% 10%
10% 10% 13% 13% 15% 15% 18% 20% 20% 20%
25% 25% 25% 30% 30% 40% 50% 50% 50% 62%
70% 73% 75 75% 75% 75% 80% 80% 80% 80%
80% 80% 100%
what does a consensus of a group whose perceptions
might vary from 0% to 100% even mean?
13
wide ranges of uncertainty
seventeen experts’ estimates of
the effect of screening on colon cancer deaths
0%
25%
50%
75%
100%
proportion of colon cancer deaths prevented
= one expert’s response
14
Source: http://jama.jamanetwork.com/article.aspx?articleid=380215
conventional wisdom and the “tradition of medicine”
should fever be reduced in critically ill patients?
“there were seven deaths in people getting standard treatment
and only one in those allowed to have fever”
“the team felt compelled to call a halt, feeling it would be
unethical to allow any more patients to get standard treatment”
15
Source: http://www.newscientist.com/article/mg20727711.400-fever-friend-or-foe.html
nearly half of all american adults
have difficulty understanding and acting upon
health information
institute of medicine of the national academies, 2004
http://www.nap.edu/openbook.php?record_id=10883&page=1
16
there is good reason
to challenge the assumption
that every individual practitioner's decision
is necessarily correct
17
eddy, et al., jama, 1990
for most study designs and settings,
it is more likely for a research claim
to be false than true
18
ioannidis, plos med, 2005
inescapable conflicts of interest…
…most physicians are
motivated to deliver
quality care…
…but the typical
physician response also
includes a desire to
protect high salaries…
19
http://online.wsj.com/article/SB10001424052702303983904579093252573814132.html
entrepreneurs will ask
the naïve questions that uncover
hidden assumptions…
…and move us to
the grey zone of “speculations”
20
in the future,
patients will have the data & analysis to
become the CEO of your own health
21
peter diamandis
80% of what MDs do can be replaced
(with better care than the average MD)…
…but not every MD function will be
replaced
22
the “human” element of care can be
provided by the most “humane” humans
(and MDs can be humane)
23
machines are better at integrative medicine…
…across “all symptoms”, demeanor, patient history,
phone activity, 1000s of data points, genomics,
population management guidelines, …
…and machines won’t have to win
every time…
…they’ll just be better overall
24
Lifecom CHAMP in acute care
I …distributed care with medical assistants
were 91% accurate
without labs, imaging, or exams
II …“safe triage” with 75% physician bypass
rate for acute care encounters
25
isabel II
matched expert diagnoses
91-95% of the time
26
dr. algorithm
v0
27
the transition will start with
“toddler MDs” and digital first-aid kits
28
Cellscope: ENT+ derm images…
Eyenetra: auto-optometrist
Alivecor: frequent EKG+ analysis
Quanttus: physiological metrics (HR, BP, SV, CO, RR, T, …)
Ginger.io: mental health
Adamant: breath analysis
Medgle: graph of medicine
Kyron: practice based evidence
Healthtap, Crowdmed: crowdsourced answers
Jawbone, Misfit: wellness wearables
29
don’t wait days
to take your daughter to the
hospital…
…check her ear infection
as soon as it hurts
CellScope
30
*a khosla ventures investment
don’t go to the hospital and
get connected
to a bunch of electrodes…
…take your own ecg
for less than a buck…
…and know you have heart disease
before you have an attack!
AliveCor
31
*a khosla ventures investment
don’t go to the optometrist…
…get measured for glasses at home
EyeNetra
32
*a khosla ventures investment
don’t guess what’s going on inside
your body…
…get vital intelligence
Quanttus
33
*a khosla ventures investment
don’t wait for an asthma attack…
…know when it’s coming
Adamant
34
*a khosla ventures investment
forget kappas of 0.2 in the DSM-5…
…get reliable, consistent diagnoses
Ginger.io
35
*a khosla ventures investment
graph the world of medicine…
…and see where you fit
MEDgle
36
*a khosla ventures investment
evidence-based medicine isn’t
enough…
…think practice-based evidence
… use data-mining to learn ethnicity-specific drug interactions
(e.g. statins work differently in Indians)
Kyron
37
*a khosla ventures investment
thousands of physicians…
…no waiting room
HealthTap
38
*a khosla ventures investment
...and your innovation here (call us)
39
healthcare service stations
&
digital first aid kits
40
keep people out of the doctor’s office…
…with point innovations in cardiology,
dermatology, optometry, psychiatry,
internal medicine, …
41
innocuous point innovations…
…will evolve into a wave and explode into a tsunami
42
dr. algorithm
v0
v1 – 2015
v2 – 2017
v3 – 2019
v4 – 2021
v5 – 2023
v6 – 2025
…
43
we’ll start with clumsy point innovations
like alivecor, cellscope, adamant, ginger.io,
neurotrek, consumer physics,
jawbone, misfit, …
…“insighted” by machine learning…
…leading us to discover things we never
knew were right in front of us
44
the best MDs will train systems
over 10 years…
…systems will symbiotically provide
“bionic assist” and “AMPLIFY” MDs
45
dr. house+++ will be
the trainer for dr. algorithm
…no manners required!
…but manners learned!
46
findings thanks to data
using statins for in-hospital stroke patients
reduced the death rate by 40%!
47
kaiser permanente
the practice of medicine
the science of medicine
48
I will be wrong on the specifics but
directionally right
49
the shift to “computerization” has already
happened in other areas…
…airline pilots, stock trading, car driving
50
there aren’t enough rural doctors in
india and few have access to
jama journals, mris, …
…the world of medicine
is under-resourced globally
51
20% doctor included?
vinod khosla
vk@khoslaventures.com
twitter: @vkhosla
52
53
better data for post-study studies
overcome ioannidis’ problem of
regressions to the mean
56
smart computers can be
objective cost minimizers…
…while being care optimizers
57
would
a hospital cure you
in half the time…
…if it meant
cutting their business in half?
59
would
big pharma
give you a better drug…
…if it meant
losing subscription revenue?
60
would most psychiatrists
cure you…
…if it meant cutting off the
recurring revenue visits?
61
would a medical device
manufacturer sell you a lessexpensive sensor…
…if it meant
cannibalizing sales of
the really expensive equipment?
62
findings thanks to data
depression is a risk factor for diabetes
63
architecting healthcare
devices
data
analytics
improved patient outcomes at lower cost
64
social and technological forces are
conspiring to make
the traditional role of the doctor irrelevant
65
bryan vartabedian (attending, texas children's hospital)
baseline systems models of patients
66
computerized dialog managers
67
innovation starts at the fringes
68
the folly of experts: tetlock study
hundreds of “experts” …
28,000+ forecasts over 20+ years
results: “experts” are poorer
forecasters than
dart-throwing monkeys
69
don’t prescribe pills …
… prescribe apps
70
adverse drug events increase hospital costs
by >$3000 per stay…
…and billions (estimates range from 110 180 B) in annual spending nationwide
71
in a study of 3 hospitals, 40% of adverse
events were medication-related
72
the cost of drug-related morbidity and
mortality exceeded $177.4 billion in 2000.
73
nearly half of all american adults
have difficulty understanding and acting upon
health information
74
institute of medicine of the national academies
most [patients] preferred
receiving their discharge information from
the [computer] agent
compared to their doctors or nurses
in the hospital
75
bickmore, et al., interacting with computers
virtually all of the current quality assurance and
cost-containment mechanisms
assume that there is "accuracy in numbers."
why should we assume that the physician offering
the second opinion knows the correct answer?
what does a consensus of a group
whose perceptions might vary
from 0% to 100% even mean?
76
eddy, et al., jama, 1990
get the answers to questions…
…you never knew to ask
Ayasdi
80
*a khosla ventures investment
get second opinions…
…from everyone
CrowdMed
81
*a khosla ventures investment
track your life…
…all from your wrist
Jawbone
82
*a khosla ventures investment
track your life…
…with a fashion statement
Misfit
83
*a khosla ventures investment