June 22, 2016

In a presentation titled “Digital Dystopia” at the American Medical Association’s 2016 Annual Meeting in Chicago the associations Executive VP and CEO James L Madara MD shares his thoughts on “the emerging digital environment” and calls out Eric Topol’s books and mHealth apps as ‘snake oil’.

mHealth Insights

I think James L Madara MD has made a careless mistake here and shown that the American Medical Association is out of touch with the opportunity to adopt the tools of our time. He’s clearly reading a script and I get the feeling he hasn’t written it so perhaps it’s not too late to hire in a Mobile Industry guru to run a mobile training camp for the team there at the AMA and then build on this with mHealth training for all AMA members before launching some progressive initiatives that show real leadership eg. a mandate requiring members use smartphones (that are loaded with high quality clinical content and up to date reference texts) when practicing, etc, etc.

“But today, I’d like to provide thoughts on the emerging digital environment we find ourselves in: and what we might do to move toward digital tools that lead to professional satisfaction and improvements to care, rather than to further practice disruption”

I think it’s critical that we are very clear: the work Doctors do today would be completely impossible to achieve without mobile technology:


“Our AMA predecessors engaged the very heavy lifts of stamping out quackery, creating standards for medical education, and developing the first code of medical ethics. Simply put, the AMA stopped the flow of the snake oil remedies of that time”

I think James L Madara MD‘s referral to how the AMA stamped out the snake oil industry quackery is an interesting nod to where the organisation is struggling with the new landscape. The business model for the AMA used to be in providing the seal of approval for medical products and as they’ve had their eye off the ball for so long they’ve lost this first to the internet giants (Google was practically seed funded by all-too-often-illegal adverts for medications) and now to the mobile giants (the app store owners Google and Apple).

“But you know something, appearing in disguise among these positive products are other digital so-called advancements that don’t have an appropriate evidence base, or that just don’t work that well—or that actually impede care, confuse patients and waste our time. From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality. This is the digital snake oil of the early 21st century”

I think there’s an intentional attempt here to ignore the obvious difference. These apps of mixed quality automatically come with an obvious clear rating score. Instead of thinking there’s some point to beating up on junk cookie cutter apps that no Patient would ever even think of using, I think the AMA would find it much more productive having a productive conversation with Apple and Google to add something like “AMA member ratings” to the medical app sections of their app stores so that Patients and Carers can better compare and contrast these when looking for and evaluating apps they are considering using.

“Even those digital products that might be helpful often lack a way of enriching the relationship between the physician and the patient. It’s like trying to squeeze a 10-gallon product idea into a 2-gallon health care knowledge base. More and more we’re seeing digital tools in medicine that, unlike digital tools in other industries, make the provision of care less, not more, efficient. And these digital tools often don’t connect with each other—interoperability remains a dream. We were told that interoperability was the future; we didn’t expect that it would always be in the future. The age of digital snake oil”

This is a common feeling among Doctors who are jaded by the successive failures of digital technologies that initially promised so much. It’s important to appreciate that in 2016 things have moved on and it should be obvious that the mobile industry has fixed interoperability issues eg. I can text some money via mPesa to a worker in a rural village in Kenya and they could use it to sms or place a call to the President of the United States.

In 2016 the AMA should not be whining about the lack of interoperability but using it’s immense power to back progressive things that are available to fix the lack of interoperability that results in poor outcomes for Patients eg. backing the International Diabetes Federation’s call to make mHealth an embedded compulsory part of how we provide care to Patients with chronic conditions and ending the nonsense we have today where expensive consultants waste everyone’s time fanning their faces with the diaries that Patients are diligently completing.

“Energizing this rush of new products we find popular books predicting a future of digital health care, that in the near future, will bypass physicians altogether—where patients can largely look after themselves. These extravagant claims did achieve their primary goal: Lots of books were sold. These claims also drew the attention of the lay press and private sector, two groups that couldn’t have known any better. One highly praised book touted how patients could order their own blood tests by the hundreds—do it today!—then follow algorithms to essentially self-treat. Snake Oil Stanley would be so proud! Anyone been reading the papers of late? Been following the many evolving investigations and apparent fraud of such touted new pathways? … That hallucination didn’t turn out so well, did it? As one of our presidential candidates might tweet: “DUMB!”

I think it’s clear that the book(s) being referred to here are Eric Topol MD’s brilliant “The Patient Will See You Now” and “The Creative Destruction of Medicine”. I can’t see Eric being harmed by this (sales will probably spike again with inquisitive Doctors wanting to find out what he is actually predicting – click here to order your copy of “The Doctor will see you now” on Amazon) but I think it’s very unfair to  label a book in which a Cardiologist shares his thoughts on a possible future of medicine by comparing it to the outright scam of Theranos that put Patients lives at risk eg. writing that Patients will be able to order their own high quality blood test and actually giving someone a blood test result that you know is inaccurate and unverified are two totally different things.

It’s quite bizarre that the AMA CEO has gone on record in 2016 stating that it’s somehow unbelievable that we might arrive at a time in the future when Patients will be able to ‘look after themselves’. Isn’t that what they’re already doing in the thousands of hours they have in-between office visits? Isn’t that what every diabetic has been doing since glucometers were introduced and they no longer needed to go to a Doctors office to test their blood glucose?

We practice medicine, new evidence comes to light, we debate it, we adopt it. We should not label the progressive smart Doctors who are brave enough to lead the debates as snake oil peddlers. Where was the AMA’s statement and advice to members on Theranos (before the WSJ expose)?

“Fortunately, more sober analysis of the current state can be found elsewhere, as in Bob Wachter’s wonderful book, The Digital Doctor. A more promising digital future can be envisioned that enhances the physician-patient relationship, produces better and more efficient care, and allows more time for physician-patient interactions—the type of outcome that has been so falsely promised by much of the current digital snake oil”

I think it’s more than a little naive to be thinking that the future is just more of the same especially as there is absolutely no evidence whatsoever to suggest that technology is being used by the big healthcare companies to increase the amount of time a Doctor spends with Patients.

In fairness to Eric Topol’s books they make a powerful case for the important role Patients/Carers need to play to influence this direction and for Patients to do more to manage their health and ensure that the time they have with Doctors is better spent.

“But Wachter provides no false illusions as to the current state, and well describes the present. Something I’d call our digital dystopia: from direct-to-consumer digital health devices—which, only in the fine print say “for entertainment purposes only”—to our clunky electronic records, to ICU’s that sound like primitive swamps abuzz with a cacophony of bells, alarms, and whistles”

I think this statement is revealing because it suggests that Dr Bob Wachter’s book is okay because it discusses a familiar easy to understand gradual change that’s happening whereas Eric Topol MD has crossed a line because he sees the healthcare model being transformed not by tweaking a Doctor’s clunky EHR but by handing over ownership of the healthcare record to Patients.

Because (as William Gibson famously stated) “The future is already here – it’s just not evenly distributed”I think the AMA would be able to better build on it’s leadership by highlighting the good work of Doctors who have moved beyond the comfortable and embraced new ways of working rather than knocking 15 year old app developers who are just trying to share their ideas and showcase their talent. Good examples might be the GPs in the UK’s NHS who are using what are essentially early Mobile First Electronic Record systems, the Intensive Care Units in the NHS that have for some years now taken a mobile first approach to design and eliminated unreliable error-prone labour intensive paper based processes and replaced the alarms/buzzes/whistles with personalised mobile messaging systems, etc.

“Just as in the mid-19th Century when we separated the useful anti-toxins and compounds like aspirin from Stanley’s snake oil remedy, today we’re tasked with separating the digital snake oil from the useful ­­—and potentially magnificent—digital tools. The future is not about eliminating physicians, it’s about leveraging physicians”

If in 2016 you feel like James L Madara MD please order and read Communities Dominate Brands by Tomi Ahonen and Alan Moore now. It was published over ten years ago but the teachings in it will still be life changing for you.

“Leveraging you by providing digital and other tools that work like they do in virtually all other industries—making our environments more supportive, providing the data we actually need in an organized, efficient way, and saving time so we can spend more of it with our patients. A new AMA study analyzed a variety of settings and type of practices: 50 percent of physician time was devoted to the keyboard—50 percent! Only a third of their time was free to interact with patients.”

If the AMA can’t get American Doctors using anything better than clunky inefficient and super  expensive EHRs why do they think they’re in a position to influence and provide the quality control on mHealth apps that Patients will want to use?

“To compound this, physicians also spent two hours each evening on the keyboard finishing the data entry from the day… evening hours that used to be spent reading JAMA or decompressing with family. Our current state? American physicians have become the most expensive data entry workforce on the face of the planet. What a waste. How frustrating”

In what world is the solution to this the wholesale write off the idea of Patients using apps? (some of which we know are proven to save Doctors from the very administrivia he’s complaining about!).

“Let’s face this 21st century digital snake oil the way our predecessors confronted their task in the 19th century: by inserting ourselves into the processes from which digital tools emanate. So, how do we do this? What are we working on? To begin with, we’re intensively working with vendors and manufacturers as well as the federal agencies that regulate them. You’ll later hear from CMS’ Acting Administrator Andy Slavitt on enhanced federal pressure for interoperability and efficiency in our health records. For EHR 3.0, not 1.0”

Oh dear… the AMA thinks it’ll be able tackle what it deems to be ‘snake oil’ with unimaginative and meaningless buzzwords like “EHR 3.0”. Most Patients in the USA can’t even view their EHR!

“In retrospect, one might argue that our field was insufficiently embedded in the creation of the first wave of digital products. The result: defective products not informed by physicians”

I think the opposite happened and the healthcare industry is today littered with defective products that are not informed by the very Patients and Carers that need to use them and make absolutely no sense to the BornMobile generation eg. the implanted cardiac devices that don’t inform Patients if they’re on/off/defective, the expensive unconnected medical devices that we prescribe to children that are so dumb Parents are pressurised into DIY hacking efforts, the millions of unconnected ostomy bags that Medics have neglected to even think about even bothering to connect, etc.

“Today, we’re active in pursuits toward correcting this—toward having physician knowledge embedded in the development of new products. Here are a few examples: First, we’re conveying to manufacturers what physicians actually need. Digital tools that add layers onto our day are not helpful—those are digital snake oil, we hate them—hate, hate, hate them. In contrast, digital tools that would simplify and better organize our lives, and also adapt to the natural variations in our practices—those that would free more time for patient interactions—that’s what we want. Tools like that we’d love—love, love, love. There are too few of these today.”

I think this sentence highlights how obsessed the AMA is with measuring a Doctors time and how challenging it finds attempts to move beyond the office visit model where the only thing that’s being measured is the Doctors time.

“Second, we’re forming interactions with the emerging companies that produce health-related goods and services—for example, working with MATTER, a Chicago-based incubator for emerging health care companies. More than 120 companies are now located in MATTER, as well as our AMA interaction space. There, we inform entrepreneurs of the exact needs of physicians at the creation of innovative ideas. Some of you have participated in this—and for that I thank you.”

I think the AMA need to be careful in taking shots at app developers because what if one of these 120+ startups turns out to be a lemon (or worse still a fraud) what’s the forfeit that the AMA is going to make for backing them with their support and vouching for their credibility when it’s been so quick to call ‘snake oil’ on the established companies that are already operating in this area?

“We do much better if new products and services are deeply informed by our actual problems and needs, rather than flying on an entrepreneur’s incomplete views. We bring the granular understanding of the physician-patient environment. That’s difficult to discern from the outside”

I remember hearing similar comments out of motor industry execs when they heard about Elon Musk‘s crack pot ideas for electric cars ten years ago…

“Third, in January we launched an innovation studio in Silicon Valley, Health 2047. Health 2047—(the 2047 in recognition of our 200th anniversary)—will take many of the problems identified by AMA studies and apply rapid prototyping and design to achieve tools based on physician need. Emerging prototypes will be iterated with physicians until the tool gets it right. This effort is attracting high-level talent in Silicon Valley. Talent that’ll be directed to the problems faced by physicians”

In this paragraph is everything you need to explain why this plan has no chance of working. It’s a strategy that would be like Elon Musk moving to Wolfsburg or Stuttgart and iterating his prototypes with petrochemical and combustion engine experts until they got things right!

As the old saying goes: an expert is someone who can tell you every reason why a new approach won’t work…

“Fourth, while shaping this future, we also need to address the current state. That’s why we’re identifying workflow and practice adjustments that can produce higher practice satisfaction today. These digital modules, which we call Steps Forward™, are available to all physicians and can be accessed through our website. I announced Steps Forward last year at this meeting; and since then more than 70,000 users have accessed these tools to improve practice”

It’s interesting that while the AMA see’s the value in physically moving to Silicon Valley it’s not adopting the silicon valley startup mentality to adding new products. Instead of buying an already operational business that excels in this area and will bring proven talent the AMA has gone and built it’s own new business unit. It’ll be interesting to see how this approach works, until then it gives the impression the organisation isn’t confident that the silicon valley approach is an effective way to develop new business units.

“We’re now fully engaged on many fronts—engaging not only the important aspect of legislation and regulation, but also directly engaging those who produce the products and services that’ll feed our practices … pipeline products that are now being informed from the start—with the knowledge of what physicians actually need”

Perhaps it’s just me but I think the AMA would have more success if it focused on new products that Patients and Carers need rather than “what physicians actually need”.

“I’ll end with something from Bob Wachter’s book: quote —”Even when that wonderful day arrives when we have finally coaxed the machines into doing all the things we want them to do, and none of the things we don’t, we will still be left with one human being seeking help at a time of great need and overwhelming anxiety.”—end quote. That relationship between the physician and the patient isn’t a transactional one—but it’s one that requires time; time that should be made available by helpful digital tools; tools that work effectively as they do in virtually every other field, but ours. We need that…..and we need to be directly involved to make it happen. What we don’t need, is more digital snake oil”

I get the feeling from this choice of quote that the AMA needs to move beyond the idea that the Physician Patient relationship is always about high intensity diagnostic moments that are spent in the clinic. We need to be clear that in 2016 the vast majority of Doctor consultations involve Patients who have already  been diagnosed and are managing long term conditions, before any of the major opportunities for tech to enhance the Doctor/Patient relationship will become apparent.

It’s also key to appreciate that in virtually every other field the digital disruption that happened because companies wentmobile first was never initiated by the association that represents that industry eg. Apple Computers wasn’t a member of the GSMA when it launched the iPhone, Amazon wasn’t a member of the various retailer associations, Uber wasn’t a member of the New York City Taxi & Limousine Commission, AirBnB wasn’t a member of the American Hotel and Lodging Association, Facebook wasn’t a member of the any established media associations, etc, etc.


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