How To Go Viral with Healthcare Innovation — Homero Rivas, MD

[00:00] Milton:
Terrific… Thank you for listening to Telehealth Failures and Secrets to Success video podcast. I’m really excited having Professor Homero to the show. I think most of you guys probably know him. He’s extremely famous professor at Stanford, wrote a book, give so many talks, seems like everywhere, and done so many interesting projects. Before we start, people can read your official bio, can you tell more about yourself which people cannot read from your official bio.

[00:43] Homero:
No, I think I have a very different profile when it comes to medicine. Because I take care of people who either eat too much, or people who cannot eat, but that’s very different. That what brings me here. I’m a strong advocate of mobile health and telemedicine, and that’s based on the fact that we just have this tremendously long clinics, that they’re very repetitive. And that made me just see something that this great promising thing in information and communication technologies where you implement them in health care now. More than that I’m just a regular guy.

[01:26] Milton:
Sounds good. For people who tune in, I apologize for the quality of my videos is very poor. I’m in Qatar this week, and unfortunately the hotel network not as nice as it could. I really apologize for this. But next week I’ll be back at home. Homero, may be you could start by sharing your slides and your thoughts in there. Then after that, we just open up. On personal level, I’ve been looking forward to your presentation because I’ve been doing digital health for about 10 years now. There’s always a frustration things are so slow. I think everyone in the audience, I think they’ll experience that same things. We all eager to see your insight how to make things go faster.

[02:56] Homero:
In medicine, things go at a very different pace than in technology and in science, and that could be for many reasons. But if you think about it, there’s been physician for thousands of years in many different ways. And I think for the rest of humanity, there’s still gonna be physicians. We will practice in many different ways, but there will be effect. But one of the things that we see here in the US, we spend almost 20% of the gdp, is spend in healthcare and still, we have lots of inefficiency, and you would wonder why is that. I was telling you about how we have had medicine for a long, long time, but the business model that we have doesn’t really changed for that matter, why?

Because our practice is really not scalable. If you think about right now, it’s a great thing that we can reach out like pretty much anywhere throughout the world with this system, you yourself, you’re in Qatar, I’m in California, but people could be in South America or other places. And it’s something that is highly scalable.

Medicine itself is not scalable. After so many years of training and so many years of stories and practice, I was this week yesterday, in the operating room, I took care of only 4 people, and I arrived home at 9 PM after working all day in the operating room, it’s just not scalable. It’s just you cannot just bring it to masses. And that’s one of the things that can be very frustrating.

So yes, with digital health, like implementing information and communication technologies, we certainly can do this. But let’s talk a little bit why I think that it can be very challenging for physicians to innovate and why it takes so long, and that’s just because of it’s not really the DNA, but it’s just the way that we are brought up for that matter.

If you think about successful innovators for the most part, I’m not saying everyone. Because there’s a lot of controversy. If people really have high tolerance for failure, if they really take lots of risks or not, but most people, most entrepreneur takes more risks than physicians will take. Physicians are very risk averse. We go very cautiously about it. Successful innovators on the other hand, they are very opportunistic, they’re very social, they fail a few times and then they keep working on the same thing.

[06:04]
But on the other hand, as physicians from day one, we are told that we have to be very focus oriented to never never fail. So we always are trying to follow this predictable risk that usually is gonna be very small and very low. So by nature, if you don’t risk, if you don’t look for new things or different things, if you always follow dogmas, saying you have to do it this way and that’s it. You never question, well, then the innovation will go out a very low pace. And yes, we medicine and places like Stanford we innovate many things, but for the most part. But one thing is to be creative, execute, innovate, but then to implement that innovation here in the US, it can be quite challenging, especially at places where there’s a lot of liability involved.

So good or bad, We first go and try in some other places. Like as I mentioned, you could be in south america to be africa could be in asia, could be europe, whatever that may be, but probably we’re the last ones to implement that innovation. It can be sad because it’s somewhat hypocritical, but it’s the reality.

And the other thing, all the things, all the culture that falls in surgeon or physician like this, it’ll also create that mindset that we’re gonna be just based on this. And a lot of that is based on once again on the education that we receive. If you evaluate the medical school curriculum that most medical schools have, of course, you’re gonna see that you’re gonna have subjects that have basic sciences, you’re see subjects that have things so anatomy, if you see a pharmacology, psychology, all those things. And then as you start taking care of patients, how to talk to patients, how to treat patients and all different specialties.

but still very, very few medical schools or nursing schools, or schools for healthcare extenders will actually include things such as mobile health or digital health or telemedicine. So therefore, once you have those physicians who are more certified and they’re starting to practice, that never really goes through their mind, and so you have a bit more of a difficult time trying to persuade them that those would be actually very good ways how they can transfer care with the use of different technologies.

[09:11] Homero:
Interestingly, the first ones to the best advocates for the health technologies would be the patients themselves, because they’re the ones who worry about themselves being taken care. So I would say the biggest biggest horror with no question of many different technologies is really no technological is not the battery, It’s not a cost. It’s not a weight to the system. It’s not the resolution is not any of those things, but usually it’s the mindset of those involving care. That would be biggest challenge.

Some of the things that we have done here at stanford, in my experience, it’s been probably five years for very since a seed grant that we had from the vice provost office of an online education, we’re able to develop a a course on mobile health, which pretty much it was directed to the design and use of mobile phones to create strategies that would implement a health care for that matter. If it’s only informational if it’s to aid with education, if it’s actually to help with the telemedicine or with the public health strategies, usually basic things.

But actually it was a great success for us because we were able to see that there was a lot of interest throughout the world to learn more about the use of this telemedicine platforms. And that evolve into a course that we actually started last year. I was mentioning as well that most of the medical schools do not have a curriculum, how to teach about our medicine. And we have a number of experts or pioneer in the field in many different ways that we have at Stanford, and this was offered to undergrads and also to medical students throughout the fall, where they could actually learn more about those different technologies.

At the same time, I’m very involved with other medical schools, and this university in dubai, where actually I will be practicing this summer. I will be moving out of stanford and mvoing to this medical school, and it’s very exciting because they are truly innovators and here we’re trying to implement, not only digital health technologies, but all the innovative platforms, such as science thinking and a number of different ones.

Very early on since a year one for med school, you can mold, you can create that mindset in new practitioners. So when they go into the practice and taking care of patients, they actually do not have that challenging in change of mindset, and it’s already something that they believe and they can implement these things. All the way we have been able to do things, We have this so call alab, which is the emmerging innovative, global health technology lab, and that’s just a collaboration with different schools and also with different expertise for that matter, not just a decisions, but it’s also a number of computer scientists, students, entrepreneurs, trying to work with things from, as I said, mobile health to the use of drones, to the deliver healthcare, to other things, such as the use of telemedicine, etc. But it’s just… I think that the question here is really not to just produce the same type of physicians that we’ve been producing for the last 100 years or more. It’s not the number of decisions where we actually need, but it’s just to find new mindsets, as I said innovative mindset, that adapt to the 21st century, because the education that we have in many ways to do not adapt to that, and hopefully that would be a reality that we can see in the next, I don’t know, 10 years or so. But anyway, that’s just a very small brief presentations. I can actually insight some of the conversation that we could have more than anything, because we could talk about things like this all day.

[14:35] Milton:
That’s really great. Really appreciate that. I guess in some sense do you find all these innovation from alab is little bit of self slighting. What I mean by this, the physician who are really innovative put a big challenge who like the people in status quo who have never join the innovation, do you have some idea how do you get that group of people getting them to do something different?

[15:07] Homero:
Yeah. You’re correct. A lot of that is gonna be, what’s the status quo, what the computer scientist or the engineer or the physician they have a passion for. But I would say you certainly have to go with low hanging fruit, things that makes sense. I think the key with no question is just to go beyond that, Just go to the very mindset in trying to create things.

It’s interesting how, for example, for social media, social media and medicine, it’s a fact that we go into clinic and every single patient has interacted with consult patients through social media. And that’s almost something like it took us by… It’s natural, it’s normal, but we never really truly talk about it in medicine. Should we pay attention to that? And I think it’s something that we as physicians can learn so much from it that. Unfortunately up to this point I its under-utilize the use of telemedicine for that matter. There’s so many patients who go into our office and they some secretively and so not, but they say, hey, can we share this conversation with my such and such over the phone. Over the phone is not the best thing. Sometimes they said secretive, Sometimes it’s not, but there’s so many different technologies that we have nowadays, it should be something more more formal. I think some of the challenges that we have had is, for example, physicians, I think that there’s always the worry about liability because we worry about being sued and like, oh my god, they gonna be very hard, and this and that. And I think if anything, it improves, the quality care that you have for patients, it is quality control, if you can video record and I think it should be done.

[17:44] Milton:
Yeah, my observation. And in general, this might be going back to the days I was undergrad. People who are pre-med, these are very smart to smart, these people usually the top of the class, people who get insanely high grade.They become doctor, if I were to observe, I feel like the underlying brain power of the physicians are the top eschelon of society. So they are more than enough to be innovative. But something you struck at the beginning, the medicine has very poor business model, you almost feel like the incentive structure, you don’t get rewarded by innovative. You really are the fee for service.

[18:29] Homero:
Because many of this, most of the video conferencing that there is. Doesn’t really get reimburse as it should. There’s those on challenges. And so that’s just another one extra, but your are right. Innovation itself, people just do it because passion about or because they have to. But incentive, should be better designed when it comes to innovation with no question.

[19:11] Milton:
Yeah. I almost feel like if you had a proper incentive aligned in there, then I think you can get physician most innovative, proposition in line.

[19:22] Homero:
No, but I think things are getting a lot better. It just takes time. And as I mentioned before, I think this will be a generational change because young physicians, my daughter, she’s five, she grabs the phone and she just even new software. She’s just figure it out. When she’s a teenager or an adult, she will oppose go inline and wait hours to see someone. She’ll be like I have to see them online, that’s the fact. And by then, there’s gonna be all this artificial intelligence that you are saying, and you will get suggestions as a patient without even seeing a doctor yet. So that’ll be a generational change with or without the incentives is gonna happen because it’s the convenience fact.

[20:29] Milton:
That make sense. For audience member, feel free to type in your questtion. So that is in terms of poor business model, is there a better business model for medicine. Not just in US context, like in global context that makes more sense.

[21:00] Homero:
But I think the best business model, its very controversial, of course, in many ways. But the best thing would be to make people stay healthy, because usually we spend 80% of our resources, in 20-10% people in the last year of their lives. And so when they’re super old and super sick and we try to keep them alive, that’s always been a so money and it’s okay, of course. Well, one, I love ones to last longer and better, but I think we need to find ways how, usually 1 percent of the healthcare budget is spent in prevention, we should be able to spend more money on prevention, that gets incentivise. I said, we as physicians get more for maintaining our patients healthy and probably maybe also patients. There’s been some interesting examples, like one of those is in the UAE, people were being paid to play golf to lose weight or to stay. I’m saying, I’m not… We don’t have to go to extremes, but if I make some ways that we can make people stay healthy, that will be the best way because that how you invest your money more wisely.

[22:41] Milton:
That makes a lot of sense. In fact, under this american doc, we’re cooking some new way to think about insurance, the way we model it, its actuallly cheaper if we pay people to be healthier. This model work a lot better.

[23:05] Homero:
Yeah, and some people maybe if you pay premiums or if you make them much bigger, then people will try to stay healthier, but I think it’s a challenge. It’s a challenge that our leaders in healthcare have to somehow figure it out. But I think we’re in a much better place now that we have all these different technologies, and I think we have to be able to find ways how to implement them better.

[23:50] Milton:
Homero do you have from your years of looking all the examples both US as well as globally, have you seen examples where innovation adoption was really quick, is there any insight from those case studies, where everyone should use that as best practice.

[24:08] Homero:
I think, well, it is not easy we have here in the US, it’s 300 million people is all these different states and authorities, everyone wants to say something, but clearly when you have a much smaller place where you have singapore, for example, you have just a single authority that is gonna say, this is gonna be done this way. Well, probably is gonna be more easier to innovate in many ways, and that is just by means of the nature of the system and the stakeholders and all that. That’s what I think. But I think it… No question is like in your family values, if you install them since very early, that would be good chances that those values are gonna being instill… We have to allocate our physicians when it comes to health, about course containment about the technologies about all these things, so we can hopefully change that mindset to a better what.

Question [David]:
How’s the level of cost of getting different level of physicians and experts and specialist being address. If there’s telemedicine vs no telemdicine, does that change any of the cost.

[26:30] Homero:
The cost itself, I think what they’re trying to say is there’s gonna be the same way that you have some specialties. You’re gonna have more specialist of a given thing than all this. There’s gonna be some people that are gonna be more in the bad. I’m not so sure. For example. I think there’s a short for primary care physicians. And one of the reasons for that is because they are not being paid enough, they should actually be paid more. That’s an incentive for them to be more. Whereas probably, I don’t know, someone who also fancy thing. They may get paid more, but I think the decisions themselves, we should value the need that we have for them so they can get paid more as far as with the telemedicine. I think that it allows you to actually be more marketable because you’re virtual. You can be pretty much anywhere. I think what we need to do is find ways for your licence can be a national licence, not only just a given states.

Question:
So Prevention is the key, so we don’t really have a healthcare, we have a sickcare, how do we get the healthcare system to keep people healthy.

[28:39] Homero:
well, this, there’s some different models, for example, model of concierge medicine for that matter where people pay a given amount like but I don’t know, 10000, 20000 whatever, and so I get access to my given doctor anytime througout all the year. Well, that doctor has a huge incentive to maintain their patients healthy, so they don’t bother him. So, If we can find ways how we truly get doctors engaged that they care. Even high risk patients stay as healthy as possible. That’ll be great. Sometimes those incentives have to be created outside the national health system, the medicare medicaid, outside, as I said with the entrepreneurial systems like concierge. But the same employers, it’s on their best interest if their patients are not going to the hospital all the time. So organizations like Stanford, they actually pay you to exercise and stuff like that. Maybe it’s a waste of money, I don’t know. But it’s just trying to find different ways how to keep people healthy.

[30:37] Milton:
I was thinking like basic premise, despite all the capital, majority of healthcare still fee for service. Fee for service as the dominant economic engine, then the incentive structure is not rewarding.

Homero:
I think if you keep someone without getting sick you get a bonus.

Question (Jane):
How do you view digital health in supporting urgent care situation better for routine follow up care.

[31:35] Homero:
I think you can tap into whichever field you can imagine, for example, with urgent care, I can only met this overcrowding overcrowding of ERs and urgent case. And most of them, it’s because of people that they actually don’t need to even be there. So I think at some point, the first thing, you will have artificial intelligent engines that will go through a screening and I will say, listen, maybe you shouldn’t even worry about it, or you should just call this number. And that would be one way to you get rid of a few, and then maybe all the things you can document way in advance through pictures, video, conferencing, something, and so they already tell you, just be reassure, you don’t need to come here, It’s not like emergency stuff like that. So I think there’s a great benefit.

[32:47] Milton:
That makes sense. It’s interesting. Maybe I just keep on going back to the business incentives. We have a bunch of conversations VSee will be focus a lot on ER diversion. Having patients show up it actually increase revenue, so when you do the true ER diversion, you have a huge impact. In this case, it’s one of these things where you wanna do the right thing for everyone. But in the end, they have to pay the bills too.

[33:28] Homero:
It’s like, well, but that’s one of those things because we are in medicine because of our passion to help people. It shouldn’t be because I am going to make so much more money if I do it or not. I think yes, One of the things that you want is to find as many ways as possible not to have as many people in your hospital. Of course, to finance people, they’re gonna say, well, we’re losing the patients. But you should be able to, as I said, to also have incentives by avoiding people to come to your emergency room.

Question (John):
The VA seems to be the leader in telemedicine, why is more emphasis for people just put in the best practice in VA using, people just adopt those commercial market.

[34:35] Homero:
I think that it’s true what john says. I think it’s been 20 years. I remember being in training and seeing that the telemedicine being used at the VA, and that’s because of the needs, because they haven’t… Sometimes you don’t have providers, and then you have this patients who don’t have great access their veterans, they have problems with the legs, whatever that may be. And so it’s a phenomenal way how to do that. Now, the VA, it’s a fellout institution, and it’s like the government itself. It’s impossible to translate that business model to a for profit business model that you may have at a center in the city. But I think it’s a great sample to see how for many things it can work well. And of course, they have many deficiencies as well. And there’s things that they may not do as well as as probably they could. But no, I think they’ve very successful with that.

Question:
We talk about reimbursement for telemedicine, and barrier with the this business model. So other than that, what some other changes do you see that blocking telemedicine from widely adopt.

[36:21] Homero:
No, I think one of the things is we set the payment, the reimbursement. But one thing that I mentioned in my brief talk is the mindset that we have. I think among physicians, there’s a mindset of liability. That I am liable in the sense that someone can record my conversation, and then that can be used against me if something happens because they have evidence. And so that’s a more of that, believe it or not, that physicians worry about it. I think on the other hand, if you explicitly, in a professional way, explain everything that you have to explain to the patient and they have it well documented, even if its recorded, I think you have a much better chance of being well protected. But I think that’s one of the other things. I think nowadays any computer, anyone who has a smartphone for that matter, can engage into a telemedicine consultation, and that would be great. As a doctor you might not like it much better. But as a patient, if you are in Qatar, you get sick and then you wanna talk to your doctor, you’ll be very happy.

Question:
In terms of telemedicine, you cannot do physical examination. When you don’t have physical examination in a telemedicine, how much does that influence a physician confidence in making a diagnosis.

[38:16] Homero:
that’s a very good question, and I would say it depends on the specialty, but the specialties that close to 100%. Like the radiologist, maybe I may be exaggerating, but most radiologist don’t need to examine their patients. So most of the things that I consult with patients, and I don’t want you to have a wrong impression, but I don’t have to rely on the physical exam because if I talk about a difficulty with eating or someone who on the other hand eat excessively and we talk about different things, there’s really no need for that with no question. The physical exam is something that it’s quiessentially something that’s super important.

But we have more and more different technologies that we can rely even in a much better way than the physical examines. We have ways so you can get an ultra-sound and then transmit that directly. We have ways so we can get the EKG monitor and we have ways that you can listen to sounds, we have much more sophisticated ways of taking pictures of skin lesion that can be at some point, be evaluated, looking at the ear, looking at the eye, looking at the mouth, so many things. Yes, yes. Ideally, you will wanna have someone, but I’m not saying it’s not a panacea. It’s something that… It’s just another way of leveraging in what you have and what you know to make medicine and the practice of medicine better. That’s it.

[40:14]
How far are we from the technology of star trek, it’s a little fancy, where you don’t need to touch to examine the patient

[40:28] Homero:
I don’t have a much free time, but I always like to watch sci-fi movies. And last night I was watching Aliens and aliens, and I was in 79, 86, and it’s crazy how they have all these things, still we don’t really travel to space as extensive as we have in those movies. But it’s gonna happen. I would say within 10 years, the way we practiced medicine is gonna be so different and this telemedicine thing is gonna be very common. I am very optimistic about it. I still be doing surgery and still be complaining, and we’ll have lots of challenges. But I wanna say that with no question in 20 years is very, very, very different. It’s already very different than it was 20 years ago.

Question:
What about in term of quantum care test. We know in Silicon Valley we have notoriously a bad examples. Impact in terms of adoption of telemedicine

[[42:05] Homero:
No, I don’t think it’s going to be at the terran for it. I think there’s gonna be good and bad examples of successes and failures. But if we just keep punishing ourselves with things that have failed, we will never innovate. I actually admire the leadership in the company how they persuade. I can’t still believe it baffles me, but at some point, you’ll be able to get those diagnosis with your phone and a number of thing. And I think that’s great and it won’t be a diagnosis. It will be just a way how we can get more information. I was just thinking to just this moment about, you get your genetic code now, whereas before, that’s like science fiction and now you can learn so much about yourself. It’s crazy.

[43:25] Milton
As we wrap up the session, if I could do a rapid fire, ask you three quick questions. Just a single answer. The first one is you sure have a lot of insight in there, if the audience just learn one thing for you today, what would you have the audience to learn from you.

[43:45] Homero:
Stay possible and be open to new things in healthcare. It will be safe.

[43:58] Milton
What do you believe in that the rest of the world don’t be it digital health or innovation

[44:10] Homero
The thing that we’re just gonna be observers, doctors. Artificial intelligence is gonna help us do so much and we’ll just check. yes, that’s looks great.

[44:30] Homero:
If you can whisper just one idea to President Trump, what is that one thing you want him to build in regards to healthcare

[44:42] Homero
Well, I would say it’s something impossible. No, I don’t wanna say, but I would say the primary physicians, they need to be better paid, probably to be top batch. And telemedicine needs to be reimbursed and pretty much mandatory in all practices.

[Announcement] Milton:
We’re pretty excited we’re getting out American Telemedicine Association 2018, we actually have the biggest booth this year. We have a lot of exciting talk from Amazon, Optum to UCSF, and a bunch of interesting talk happens inside our booth. We also have a bunch of interesting companies co-exhibiting with us. We have joint marketing program, its pretty exciting for our eco-system where we help each other, share sales lead in there. Contact becky@vsee.com if you are interested.

We have a competition in South East Asia for this motorcycle backpack design competition for telemedicine, digital health, send gem@vsee.com an email if you’re interested to be a sponsor or judge.

We’re making a lot of progress on writing up our blueprint how to decrease the cost of healthcare.