Digitization, democratization and the future of healthcare

An interview with Dr. Eric Topol

As a firm believer that healthcare is due for a patient-driven revolution, Dr. Eric Topol is one of the most outspoken digital health pioneers of our time. Determined to help accelerate transformation, he has proven time and time again that he is willing to challenge the orthodoxies of his profession. He is widely credited for the Cleveland Clinic's status as the premier center for heart care in the United States and was voted “Most Influential Physician Executive” in the U.S. in a 2012 poll conducted by Modern Healthcare. Today, he serves as Director of the Scripps Translational Science Institute, Professor of Molecular Medicine at the Scripps Research Institute, To educate and empower both practitioners and patients, he not only serves as Editor-in-Chief of the online medical resource Medscape, but also authored bestselling books, including 'The Patient Will See You Now' and 'The Creative Destruction of Medicine'. Nikolas Spindler from KPMG Germany sat down to talk with Dr. Topol about the future of healthcare and discuss why it is going to be exciting.

Q: Dr. Topol, you're one of the few doctors to have played a prominent role in the old-fashioned structures of medicine - with overwhelming success - while at the same time being one of the most outspoken critics of that same exact healthcare system. Why do you demand a creative destruction of medicine and how come more incremental progress won't suffice?

ET: I think it's pretty clear that medicine is broken. Many aspects of it are unacceptable, the costs have gone through the roof and continue to rise. The level of patient satisfaction with the doctor - the relationship - has eroded. In many respects, the outcomes are far from optimal. So we keep putting in more financial capital, more human capital and personnel, and we still get poor outcomes. That's a very bad model. So we have to rethink what is the right approach and there are many aspects to be considered, not just in terms of digitization of healthcare, but also in terms of democratization, giving the patients more “charge” if they are willing to accept it, now that they can generate their own data and have algorithmic support and have tele-medicine and all these other digital tools. Beyond that, we are going to keep building on those first two Ds, the digitization and the democratization themes and that's part of what I consider the creative destruction of healthcare.

Q: In recent years, we have witnessed how digitization has turned our worlds upside down - few aspects of our lives have remained untouched by digital transformation. This makes it all the more surprising that healthcare is lagging behind and appears - as you once called it “sclerotic” - especially given its otherwise high-tech nature. How would you explain healthcare's resistance to change?

ET: Well I think there are multiple reasons. Here is perhaps the most fundamental one. For more than two millennia, doctors have been in charge, they have had the control over patients. They have been the conveyers of knowledge. Losing that control can be very threatening. The charge is being transferred more to patients, now that they can obviously look things up. Soon enough they will be looking at their own data - the already are - and make health decisions with support that doesn't necessarily involve doctors. So control is one thing, the second part of this whole issue with the resistance - if you will - is related to the financial reimbursement. Any of the models that challenge healthcare as we know it today, especially in the U.S., are very poorly received because they reduce reimbursements, which of course is not very appreciated because there has already been a reduction of reimbursements. And then the final part of what I consider the tripartite explanation is education and training. Consider many of the aspects of the new medicine like genomics and artificial intelligence, biosensors, telemedicine - many of these are not part of the way doctors have been trained, as most doctors in the US are over the age of 50, many of them are closer to 65, and are not very excited about going back to training to learn how to do smartphone ultrasound or how to understand the genomic sequence of an individual. That is a big issue as well.

Q: The call for reform is not new, but in many ways, results have often remained meager - E-Health for example is an en vogue term, but so far has remained a buzzword in many places. Why is now the time for a true paradigm shifts, to follow through on the promises and to walk the walk so to speak?

ET: Well, I think now, change has become increasingly unavoidable. We are just getting further and further away from what is remotely sustainable. So it's out of economic desperation, but also the tools are just newly available. All the devices and technologies I have just referred to have only now emerged - like the ability to perform inexpensive genome sequencing and use wearable biosensors that track any physiological system in the body. Deep learning, artificial intelligence, all these things are relatively new. So if you watch other sectors beyond healthcare, you will see how they are transforming, becoming more efficient and productive and there is no reason why we wouldn't extend that to the practice of medicine.

Q: My next question consists of two parts and revolves around how you envision the actual healthcare landscape in the future. 1) What exactly do you see as the new, big-impact frontiers in medicine? 2) How will the actual provision of care change in the future, that is how and where will people get taken care of?

ET: Well, one of the biggest impacts - but this is a little bit longer-term - is the lack of use of regular hospital rooms. Not that we would forego the need of acute care, intensive care beds, operating rooms and emergency rooms, but the regular hospital room is going to become less and less important. Just as we move from inpatient to outpatient, we will move from inpatient hospital rooms and outpatient to home, because we can exquisitely, remotely monitor people today. The work that's needed to actualize that at scale has not yet been done, but it can be done. And with the support of monitoring equipment comparable to that of an intensive care unit, people can live in the comfort of their own home, with all the benefits and economic savings - that is going to be one of the big changes of how care will be administered. Many things can be increasingly diagnosed through algorithms, whether it's a child's ear infection or sleep apnea using one's own smartphone or applying reusable sensors for the monitoring of heart arrhythmia. So we will see a lot more real-time diagnosis that is already reasonably assured, but then confirmed with doctors when the data are reviewed. That's a fundamental way in which care will change.

Q: One of your books is entitled “The Patient Will See You Now”, alluding that the patients will drive medical revolution. For healthcare providers and companies alike, these shifts in the dynamics can be viewed as either challenge or opportunity. How do you think players in the healthcare market will have to change the way they run their businesses to not only cater to the patient of the future, but to do so in an economically viable and sustainable way?

ET: I think the rise of consumers will have to be reckoned with, I mean we've been seeing consumerization as a major force - that is another inevitability. I think the patient knows best, it is their symptoms, their body and more and more also their payment. So there is going to be increased consumerization and consumer power and we've seen that in the current world where the smartphone has driven so much of the economy. We are used to getting the food or groceries delivered to your house. And now you can have a doctor come to your house, or use a phone app or you can have an immediate telemedicine counsel instead of waiting an average of over three weeks throughout the U.S. for a primary care appointment. So these things - the dysfunctionality, the costs, the convenience, the change of consumer power in a digital era - will all have to be accounted for in future business models.

Q: As a follow up: In what key areas do you feel traditional healthcare providers and companies have the biggest “backlog” and in which areas will they need the most help to successfully position themselves for the future?

ET: I think there is always resistance. These changes we talked about are clearly major changes. I view all of this just as an inevitability, it's just a matter of when. Medicine will have to change and adapt - the rest of the world is doing, obviously, and the two areas that are most resistant are healthcare and education. Both of them have serious problems that can be alleviated, in some ways rescued by making these changes.

Q: One of the biggest obstacles in today's healthcare system appears to be the misalignment of stakeholders' interests. Cynically speaking: What is best for the patient may not always be what is best for the hospital, let alone the insurance company. This is puzzling, given that teamwork is absolutely crucial in medicine, be it at the operating table or at bedside. So what role will collaboration play in the future of healthcare and how can true alignments between stakeholders be forged in the future?

ET: I don't think there is any question: The realignment - there are multiple forces to consider, we talked about the increasing consumer power, there are startups with a whole sea of innovation, and then there are the insurers, who will have to adapt as well - they need to cut costs of care, but also without any outcome reduction. So we have many moving parts, but the main thing that is different from the past - and that goes back to the creative destruction of your first question - is about the datafication, the data-driven aspect. And up until recent times, we didn't have a way to deal with all this data. But with machine-learning, and deep-learning, that's really transformative, and that's why we are seeing a very rapid increase in the number of FDA approvals of deep leaning algorithms for radiology and pathology and there will be many more going forward across every clinical field. The ability to deal with that data was also the great remaining step to holding up progress in collaboration, but hopefully that won't be the case for much longer.

Q: Along with changing expectations of what healthcare is supposed to be, doctors will have to adapt the way they provide care. What do you think are some of the key skills that healthcare professionals will need to cultivate in the future of healthcare? May doctors even become more and more obsolete - or how will their roles change?

ET: The role of doctors will have to change. The biggest deficiency now is the relative unwillingness to recognize the patient as an equal, sharing all of the data with patients, their notes for example. Not for all patients, of course, but for those that are willing to take on more responsibility. So let them generate data and let them use algorithmic support and have doctors provide more guidance. But the most important thing is to increase the bond to patients, which has been eroded over recent decades. And that requires time, and the big problem here is we need to get more time between patients and doctors - doctors will have to stand up for that and stop being squeezed. One of the important reasons today why the need for change is so desperate includes depression and burnout. More than half of doctors in the U.S. report that they suffer from symptoms of burnout, and a subset of those are depressed and we see a record number of suicides among physicians. Something has to alleviate that to improve both sides: The patients are unhappy with the limited time they get to see doctors. But we also want to get doctors back to what they want to do in the first place, which is care for patients and they can't do that in a matter of just 7 minutes of a visit.

Q: We have arrived at the last question and many people inside and outside of medicine claim that healthcare will be the defining theme of the 21st century. It is a growth market, on the one hand marked by a growing burden of chronic diseases, but also by a growing sense of health-consciousness and empowering technology. We know you are an optimist at heart, but we've also seen obstacles and backlash loom large. In closing, what makes you feel so confident for the future of healthcare?

ET: I'm mainly confident because health is such a precious thing that everybody looks at as the most important treasure in their lives - maintaining one's health is a priority. Eventually, we will rise to a far better model and a system where we respond to the charge, the ridiculous cost, the lack of personalization and of datafication - so all these things that have to be reckoned with. Having been a student of medicine for more than three decades, I know this will be an eventuality and healthcare will be great someday - I really feel that, it's just a matter of when. I hope it's sooner rather than later, I recognize it may take a while. It's not an on-off light switch sort of things, it's really a wave front. We are already seeing changes, we have already seen more adoption of sensors for diabetics and people monitoring their blood pressure or heart arrhythmias through their phones - telemedicine is on the rise. We are seeing evidence that these things are starting to take hold of more and more people than ever. More than 20 million people have had a consumer genomic assessment in the US - change will likely accelerate.

Dr. Eric Topol, a professor in the Department of Molecular Medicine, is an executive vice president at Scripps Research and the founder and director of Scripps Research Translational Institute (previously Scripps Translational Science Institute). His work melds genomics, big data, and both information technologies and digital health technologies to advance the promise of individualized medicine. Topol has published over 1,100 peer-reviewed articles, and his more than 230,000 citations place him among the top 10 most cited researchers in medicine as measured by Thomson Reuters' Institute for Scientific Information. Widely viewed as one of the most influential physician leaders in the country, Topol is the author of two bestselling books on the future of medicine: The Creative Destruction of Medicine and The Patient Will See You Now. His next book, Deep Medicine, focused on artificial intelligence, will be published in 2019.

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