Samuel Hoskins is a 52 year old man, recently diagnosed with Type II Diabetes. His story is not atypical for many in Western cultures. Over the years, his weight increased while his activity decreased. At first it was not noticeable, relaxed fit instead of slim cut, but now on this October night leaving his family doctor, Samuel is now a diabetic. His doctor, who had known him since his early 30’s, was knowledgeable and reassuring. Diabetes was manageable, with effort it could be controlled and complications avoided. The first step for Samuel was to start a new medication Metformin. His doctor was also concerned about his blood pressure and cholesterol. “If they don’t improve, we have meds that will help” – for Samuel this part was more ominous than reassuring.
In medical terms we would say that Samuel has diabetes, hypertension and borderline cholesterol and he is being treated by his primary care physician, but that does little to describe the actual work being done. To better understand we need to introduce a concept: “health jobs”. I’m not talking about employment, doctors, nurses, pharmacists, etc. When I use the term health jobs, I am referring to the specific tasks that are being done as part of the provision of care for a person. Health jobs are the tasks that patient’s need done. The health jobs themselves may or may not be specific to a disease or diagnosis; they may be done by health professionals for patients; or they may be done by patient’s themselves. They may be related to diagnosis and treatment, but also to prevention.
When looking at health jobs, it is useful to step back and examine the goals a particular patient may have. For Samuel and his diabetes, his goals are straightforward, and at this stage are all about avoiding the bad things that diabetes can bring:
Looked at from this perspective of goals, Samuel’s health jobs become simpler to understand. First and foremost, he needs to control his blood sugars as that has been definitively shown to reduce both microvascular and macrovascular complications as well as infections and co-morbidities. Secondarily, he needs to monitor and control his risks for these complications. And finally he will want to screen for and diagnose early any complication or co-morbidity so that it can be optimally managed. The table below outlines his specific health jobs, as well as whether these are jobs for Samuel or for his team of health professionals.
Type II Diabetes is of course a disease, and the goals and management are correspondingly healthcare oriented, yet within the array of jobs to be done to reach Samuel’s goals, many fall within his capacity and capabilities. Of the jobs performed by his health team, I see four underlying reasons why they are done by professionals and not by Samuel:
These four reasons are reasonable, broadly accepted and widely applicable across all health jobs. Given the potential adverse effects and interactions, most accept that healthcare professionals should be responsible for prescription medications as well as the administration of immunizations. Having healthcare professionals required to order screening, monitoring and diagnostic tests makes sense from a cost-control basis but also because of the expertise necessary to interpret the data from tests in the full context of a patient. Many diagnostic and therapeutic procedures require a level of technical ability only mastered after 15+ years of post-graduate training so it makes sense that consumers do not attempt these things at home. Finally, the role of trust and confidence cannot be underestimated when making important decisions about our health and wellness.
The emergence of the digital health stack promises to disrupt this logic directly by leveraging artificial intelligence to provide consumers with personalized insights allowing them to correctly interpret, and safely act upon information, at marginal costs that over time will approach zero.
For Samuel, one can imagine the application of the digital health stack for diabetes pharmacotherapy, providing a learning algorithm that uses a vast array of data relevant to him:
This algorithm would compare this information to the complete set of medical literature as well as vast datasets of outcomes from other diabetics along with Samuel’s previous data in order to make a therapeutic recommendation. This insight would be precise and personal and probably significantly safer than anything coming from a healthcare professional relying only on traditional means. With the emergence of 3D printing for medications, Samuel’s dosage could even be personalized with delivery to his home by drone. His response to the medication would be tracked immediately and fed back so that the algorithm could adjust and learn. Over time the efficacy of the algorithm will improve and the cost will come down.
The real promise for diabetes with the emerging digital health stack lies in leveraging learning algorithms to predict and prevent the initial onset of diabetes. In many ways this will be the path forward; shifting care from a healthcare, disease orientation into the wellness, betterment perspective of prevention and optimization. The same approach used for the pharmacotherapy of diabetes could be used to direct activity and lifestyle changes with the potential use of therapeutic nutrition and supplements.
Beyond diabetes one can see some common, broad categories for Health jobs:
From this list we can see that learning algorithms will play a key role in shifting health jobs from healthcare professionals to consumers because they will improve safety by having more complete information and built in feedback monitoring of any and all interventions. The technical ability required to perform health jobs will diminish as it becomes consumer grade with computation and machine intelligence providing better quality assurance and interpretation than any individual technician’s capability. The marginal cost of the underlying exponential technologies will approach zero. Finally, the measurement of health outcomes and the feedback loop necessary will allow consumers to trust and have confidence in learning algorithms over time.
For Samuel these technologies hold the promise that he will be fully in control in of his health. He will have the tools to understand, manage and change the course of his diabetes. To do this he will be willing to share his data with the applications, algorithms and services necessary to achieve his goals. When it comes to avoiding the complications of diabetes, privacy fears seem like remote risks.