Healthcare of Tomorrow: Digital, Genomic, and Patient-Focused

VBCC - March 2013, Volume 4, No 3 - Health Policy
Caroline Helwick

New Orleans, LA—As a leader in the movement to modernize healthcare through the latest technology, Eric J. Topol, MD, the Gary and Mary West Endowed Chair of Innovative Med­icine, Professor of Genomics, Depart­ment of Molecular and Experimental Medicine,  Scripps Research Institute, La Jolla; Director of the Scripps Translational Science Institute, La Jolla; and Chief Academic Officer, Scripps Health, San Diego, CA, proposes creative and effective ways to treat patients that will also dramatically reduce the cost of care.

Dr Topol shared his observations in a keynote address at the 2013 Health Information and Management Systems Society annual conference.

Dr Topol addressed 3 themes—the “digitalization” of medicine, the genomics revolution, and patient engagement and empowerment. These areas are fast becoming a medical reality, although current practice still largely fits the description posed by Voltaire: an era in which “doctors prescribe medicines of which they know little to cure diseases about which they know less in human beings about which they know nothing.”

The lightning-fast pace of digital technology will soon change this. In 2003, the world’s cumulative generation of data was estimated at 1 billion gigabytes. Just 10 years later, it’s in the trillions—zettabytes. “The digital revolution is accelerating innovation, driving connectivity, and irreversibly transforming our world…except, so far, in medicine,” Dr Topol said. “But it will hit medicine as well, because the digital infrastructure we are building is extraordinary.”

Drilling Down to the Level of the Individual
The practice of medicine will shift from the “population level,” with general recommendations for all, to the level of the individual, thanks to tools that can help “define” who the individual is, he said. One benefit of this will be the avoidance of unnecessary harm and cost. Mass mammographic and prostate-specific antigen screenings cause harm to approximately 200 of 1000 screened persons and cost the United States $7 billion annually, plus another $33 billion for false-positive diagnoses and the harm associated with this, Dr Topol emphasized.

Treatment as well will become more targeted. Consider, he said, that atorvastatin—the highest-selling medication in history—reduces death and mortality by 36%, but in absolute terms it reduces the incidence of cardiovascular events from 3% to 2%. This means that for 99% of persons, a lifetime of statin medication results in nothing more than a better laboratory test.

“Can’t we do better than this?” Dr Topol asked. With the ability to make “Google maps” of each individual, and to employ omics, sensors, imaging, and the like, “we can get incredibly more precise,” he suggested.

Medical Apps: Coming Soon to Your Smartphone
An impressive array of medical apps for Smartphones will mean instantaneous access to medical information on a patient level. Apps can already:

  • Produce continuous blood pressure readings and cardiograms
  • Monitor glucose levels and oxygen saturation
  • Digitize one’s voice, helping to diagnose neurologic conditions
  • Test for pulmonary and thyroid function
  • Assess medication compliance.

“You can get all your vital signs right on your wrist,” according to Dr Topol, who demonstrated how his own Smartphone is equipped for this. “If you think that looking at your e-mail or browsing the internet is entertaining, how about looking at your vital signs.”

He predicted, “The Smartphone will evolve to become a ‘soul-mate’ device that knows your body better than you know yourself.”
Other handheld devices can produce images of the heart within minutes, can photograph the eardrum to help the diagnosis of otitis media, and can measure the eye’s refraction and thus eliminate the need for the optometrist. 

Will Doctors Become Obsolete?
These patient-based devices represent “ways to bypass seeing a physician,” Dr Topol added. “We don’t need doctors so much when we have remarkable, innovative technology. As medicine becomes more of an information science, many tasks can be taken on by patients.”

Certainly, removing the physician from the equation would be incredibly cost-saving. A recent study from Indiana University evaluated an artificial intelligence framework for simulating clinical decision-making in 6700 patients, and found the cost per unit of outcome to be $189, versus $497 for traditional care (Artificial Intelligence in Medicine; January 2, 2013). The computer prescribed better treatment than the physicians, resulting in a 40% improvement in outcomes and a 50% reduction in costs.

Using innovative technology can also help keep patients out of the hospital, thus saving $17 billion alone by the avoidance of hospital-related medical errors (Classen DC, et al. Health Aff [Millwood]. 2011;30:581-589). “Keeping patients in their homes for monitoring would be safer, convenient and less expensive,” he suggested. Hospitaliza­tion would be reserved for intensive care, surgery, and procedures.

“For that matter, when so much can be done remotely, why do we need office visits?” Dr Topol added. A recent study found that use of an “online clinic” for simple conditions delivered savings of $88 per episode, with high patient approval (Courneya PT, et al. Health Aff [Millwood]. 2013;32:385-392). The study was based on 4008 virtual visits and 17,678 regular visits, which costs $113 versus $208, respectively, per episode.

Scripps is undertaking a study of resource utilization and costs with “online care,” randomly assigning 200 patients with hypertension, diabetes, or atrial fibrillation—typically, high consumers of healthcare resources—to standard care or to care provided via Smartphone/apps/sensors.

“The idea of going to the doctor’s office is someday going to feel as foreign as going to the video store,” he predicted.

Genomics Will Change Care, Reduce Costs
The burgeoning genomics landscape is also intersecting with infor­mation technology, because genome sequencing can now be completed within hours using handheld devices. In addition, the cost of individual whole-genome sequencing has steadily plummeted, from nearly $100 million in 2001 to $28 million in 2004 to <$4000 today.

“No technology has ever matched this degree of progress in what it can do, accompanied by a reduction in cost,” Dr Topol observed.
Whole-genome sequencing is iden­tifying rare mutations in individuals with previously undiagnosed conditions, leading to treatments and, in some cases, cures, and is poised to greatly individualize cancer treatment based on mutation status. Last year, 11 newly approved oncology drugs each cost more than $100,000 for a course of treatment, emphasizing the importance of prescribing them only to patients who are likely to benefit. In addition, the use of pharmacogenomics to identify susceptibility to treatment-related toxicities will help guide treatment.

Power to the Patient
Finally, the medical practice of the future will allow patients more access to their personal health information. “Today’s doctor/patient relationship is based on asymmetry: the doctor has a lot more information while the patient has very little,” Dr Topol observed. “The concept of the superiority of the physician over the patient has got to go. We are moving the information across the board to produce parity.”

This change will be reflected by greater access to medical data by patients. In a 2012 survey by National Public Radio, 81% of respondents said they would want their genome sequenced, and 73% wished to have all of the information the test could provide. “We should not be suppressing direct-to-consumer access to data. It’s your DNA. You should be entitled to it,” he maintained.

The American Medical Association, on the other hand, disagrees, according to a February 2011 statement stating that genetic testing should be performed only under the guidance of a medical professional. “Talk about consumer engagement. This is antiengagement,” Dr Topol commented.

He stressed that physicians must also become more accepting of communication via e-mail, and must be more open to allowing patients access to physicians’ notes and to laboratory results. Some progressive healthcare systems are now changing their policies to allow such transparency.

The movement toward patient engagement can be summed up, Dr Topol said, in a mantra he proposed: “Nothing about me, without me.” He concluded, “In terms of real engagement and connectivity, this is where we want to be.”

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