Medicine is on a profound journey, similar in scope to the transition made in the 1930’s and recounted in Lewis Thomas’ seminal work “The Youngest Science”.  At that time, physicians shed many of the horrific practices from the 19th century and embraced the scientific method.  Our understanding of physiology, began to match our knowledge of anatomy and modern medicine was born.  The discovery of antibiotics, notwithstanding the serendipitous nature of discovery  involving mold floating through an open lab window,  powered a sense that health, illness, life and death were now the realm of human understanding.  

At the turn of this century, the human genome was sequenced and a new journey began in earnest, albeit more slowly and involving more complexity than was imaginable.  This movement is progressing   to a complete molecular understanding of health, wellness, illness and disease.  The underlying mechanisms of human physiology are being illuminated and we are casting off the assumptions of the last century.  Drugs that we have thought of as “hypertension” drugs are simply drugs that work on particular biochemical pathways in the body; useful in hypertension but perhaps similarly so in other conditions or circumstances.  Diseases that in the 20th century were thought to be worlds apart, like coronary artery disease and pemphigus (a rare and severe dermatological condition) are found to be closely related at a genetic level.  Our division of specialities by anatomy, will look awfully quaint when we look back at the last hundred years.  For example, conditions treated by gastroenterologists concerning our gut, run that gamut from cancer, autoimmune, endocrinological, and now increasingly microbiological as we learn more and more about the effects and consequences of the 10 trillion bacterial residents of our microbiome.

What powers this transition in medicine, is a what I call the new digital health stack.  It starts with the digitization of everything:  

• Molecular:  genome, epigenome, transcriptome, proteome, metabolome. 
• Anatomical: Digital CT, MRI, Functional MRI, PET, Ultrasound
• Physiological: external biosensors capable of measuring every aspect of our physiology in real time at very low cost.  Developing internal biosensors capable of measuring both molecular and physiological.
• Lifestyle – sensors that track activity in all aspects – exercise, diet and even personal exposure to harmful substances
• Environment – sensors that monitor environmental changes in terms of pollution, air quality,  UV index, solar activity
• Clinical records – finally the linkage to traditional clinical outcomes from clinical records that have been digitized over the past 20-30 years

What follows this mass digitization will be data aggregation, putting together datasets that for the individual will provide a complete picture of what they experience and the interplay between all of these aspects of what determines our health and wellness.  This data aggregation will be powered by big data techniques and  will start with correlative discoveries that will ultimately need to be hardened by science.   The potential for this discovery, will lead to digital health platforms where patients seeking to fully understand their health will demand their data.  

Data aggregation will provide the substrate for artificial intelligence and the creation of predictive, diagnostic, therapeutic and prognostic algorithms.  The platform with the most users, with the most data will benefit from the most innovators building the most useful algorithms.  As in everything digital, this virtuous feedback loop will exert “winner take all” pressures to the market and accordingly there will be a very limited number of digital health platforms.

Algorithms will initially be supported by human expert workflow, initially as part of a virtual care encounter, but evolving from being a part of every encounter to more of a quality control role and eventually disappearing entirely.  These algorithms, once functioning autonomously will require compelling user interfaces, with profound understanding of human behavioral change built in to their design.

For many health and wellness needs, people will of course continue have the need to see doctors and health practitioners, but even these encounters will be strengthened and improved by the integration digital health stack.
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Finally the stack is driven by the complete capture of outcome information, fed back into the platform and available to improve the algorithms.

​This emerging digital health stack foretells a future in health care where a few digital health platforms emerge to disrupt, demonetize, dematerialize and ultimately democratize health care globally.  How long will this take?  It probably depends on where you live and the strength of  the counteracting forces (regulation, health care culture, entrenched interests…etc.) in your location.  In parts of the world that have not developed modern health care systems,  the shift to digital health may come first, in ways similar to the developing world’s adoption of cellular technology without first building land lines.

Over the next few months, I will continue to develop and expand this thesis, identifying, unpacking and validating the forces that will combine to determine the trajectory of digital health.

​In the past several weeks I have sat on two health care panels at multi-disciplinary conferences.  The dialogue has been interesting, informative and occasionally challenging and disruptive. But on both panels, and in both conferences I was struck by the absence of an important voice, that of the patient.  In healthcare we speak of being patient-centered, or encouraging patient engagement, but when we get together to talk about health and ideate about the future, patients are tellingly absent.  That we are missing this important perspective is not surprising given the provider centric nature of modern healthcare, but the time has come to change.
 
Advances in digital health, wellness and personalized medicine are putting information into the hands of individual patients in a way that we have not experienced previously.  Many patients already know more about the genes responsible for their metabolism and mental health than doctors do.  Blogs devoted to bio-hacking help individuals make sense of this information and make it actionable.  This information is outside the purview of regulation and traditional healthcare and some of it is provided by self-serving shills who are only interested in selling supplements.  But dismissing this movement of individuals who have empowered themselves to know and understand their own health is to miss a powerful trend in health.

From this an organization has arisen around the following charter:
Charter clauses:

1. Patients or caregivers with experience relevant to the conference’s central theme actively participate in the design and planning of the event, including the selection of themes, topics and speakers.
2. Patients or caregivers with experience of the issues addressed by the event participate in its delivery, and appear in its physical audience.
3. Travel and accommodation expenses for patients or carers participating in the advertised programme are paid in full, in advance. Scholarships are provided by the conference organisers to allow patients or carers affected by the relevant issues to attend as delegates.
4. The disability requirements of participants are accommodated.   All applicable sessions, breakouts, ancillary meetings, and other programme elements are open to patient delegates.
5. Access for virtual participants is facilitated, with free streaming video provided online wherever possible.

 
I am supportive of this approach and have begun to work with the organizations that I interact with to adopt this charter for programs delivered in Canada.  I encourage each of you to do the same.

Check it out: patientsincluded.org