https:\/\/vimeo.com\/169280480<\/p>\n
I’ve known Eric Dishman for about five years, because we’re both kidney cancer patients. I’ve known that he’s a really sharp thinker, and a high-ranking executive at Intel, deeply interested in and involved in their work in healthcare.<\/p>\n
May 3 was his last day at Intel, and he gave what may be the most mind-expanding reality-popping speech I’ve heard, and I’ve heard a thousand. (Really, I was fixated, and at one point my jaw dropped.)<\/p>\n
Where’s he going from Intel? He’s going to head up the “million person cohort”<\/a> project at the National Institutes of Health. An Intel guy heading up a huge NIH project?? When you listen you’ll hear why.<\/p>\n The occasion was the annual meeting of NEHI, the Network for Excellence in Health Innovation, where I had my patient engagement fellowship<\/a> last year. Their new President and CEO is Susan Dentzer, former editor-in-chief of\u00a0Health Affairs<\/em>, and boy do things look interesting there.<\/p>\n Minute one of this video is Susan’s introduction; 32 minutes are Eric’s speech; the balance is Q&A.<\/p>\n I can pretty much promise that this video will contain things you’ve never heard before – things that are very new but quite real. Yet you’ll also hear things that are very familiar to students of this blog:<\/p>\n Below is the transcript of his speech, so you can text-search it. But it has much much more impact hearing his voice, so I hope you’ll listen.<\/p>\n It is an honor to be here. For a long time I have wanted to speak to NEHI so I literally did do it on my last day at Intel: “Wait, I am going to add a couple of more days and stay on.” My Intel email address doesn\u2019t work anymore so don\u2019t send me anything there. I don\u2019t know what my NIH one is yet, so don\u2019t send anything there, I can\u2019t access it, I am in this betwixt and between state.<\/p>\n But I wanted to be here, because you are exactly the kind of audience that I want to talk about ecosystems with, because you are<\/em> an ecosystem and you are forming an ecosystem, as Susan just said, of combining people from different parts of the sector and outside of the sector \u2013 and that\u2019s <\/em>what it\u2019s going to take.<\/p>\n I call this \u201cJourney to personal health for all,\u201d I changed the name a little bit. And I\u2019m just going to share with you some of my both professional journey and my personal journey in that regard.<\/p>\n I want to start by saying 29 years ago I was in a Duke University hospital, I\u2019d already had cancer, I had been diagnosed with cancer for about a year. I was 19 when I was diagnosed at Chapel Hill. And I met this woman named Verna who taught me to be a patient advocate, taught me not to be just a sort of automaton as a patient walking around and letting them do unto me whatever they wanted to do. She had two things that she would say constantly to me. The first was \u201cKnowledge is survival,\u201d and the second is, \u201cYou<\/em> must have the most knowledge on the \u2018team.\u2019\u201d And she would use the word team sarcastically, because at that point the notion of a health team was sort of more of a vision than something that was actually happening.<\/p>\n It\u2019s in that regard that if I think about what I have been doing at Intel for 17 years \u2013 and I think about what I am about to do with the Federal government, they really have the same mission, I\u2019m just wearing a different hat \u2013 that is trying to drive what Intel has called personal health, but NIH and the government are calling Precision Health for All. Really from an Intel perspective, we were trying to build the data infrastructure that facilitates the notion that knowledge is survival.<\/p>\n And at the same time, as I think about what I am going into with the PMI cohort, we are going to build the world\u2019s largest, most diverse cohort of humans ever and collect the most data, most diverse data types that have ever happened, with a very participant focused model \u2013 we don\u2019t call them subjects, we call them participants.<\/p>\n So really, from an Intel perspective and from a PMI perspective, both of these are about accelerating the knowledge. Accelerating from data to knowledge to clinical and medical breakthrough and just revving up that innovation engine is what the essence of my job has been and is going to be going forward.<\/p>\n So as I think about this and I think about my history at Intel, it\u2019s been incredibly rich and it might be surprising for you to know that for more than 15 years we have had a focused group on health and life sciences. And we have actually done field work globally in more than 50 countries studying everything from the front line of those delivering care to the patients and the family members around them who are trying to actually support them as they go through the \u201csystem.\u201d And grounded in that, we have seen and been a part of, as a company, driving things like electronic health record adoption.<\/p>\n The very first study \u2013 and there is a picture of me up here actually on the slide, the top right of the slide, that\u2019s like my first day of field work at Intel and I am studying a hospital that\u2019s startin\u2019, to fixin\u2019, to get ready, to think about, movin\u2019 to maybe sort of a kind of electronic health record, right? And so from the early days \u2013 I mean we did the studies with Kaiser when they were just starting to roll out EHRs and then starting to use mobile devices.<\/p>\n So from EHRs to starting to use the early laptops which eventually became tablets and now phones, so that you have a mobile workflow, now to the buildout of cloud and a lot of those environments around the world, those who are trying to figure out how do we automate the quality metrics and actually capture quality metrics, so that you\u2019re not delivering even worse quality care by having people spend more of their time filling out the quality paperwork as opposed to actually delivering care with the patient.<\/p>\n Patient centered medical home, payment for results, all of these transformations Intel has been both trying \u2013 a part of from a policy perspective as well as from a business perspective trying to figure out how are we going to build the IT infrastructure that facilitate these new kinds of care models and economic models.<\/p>\n And now we\u2019re facing this disruptive shift towards bringing big data the biggest of the big data, or what I think of as big knowledge, because if we have a bunch of data but it doesn\u2019t turn into knowledge that\u2019s not terribly helpful for driving personal health for all to healthcare.<\/p>\n As I reflect back on my years at Intel, there has been two fundamental lessons learned. I mean so many I can\u2019t even sort of imagine them all, but two at the highest level:<\/p>\n And I am going to just harp on this issue of ecosystems with you today because I think NEHI has been and has the potential to be a disruptive player by bringing together an ecosystem that works in a unified way towards driving disruptions in the healthcare world.<\/p>\n Now one of the things I learned about building ecosystems at Intel, I could give you a 10 hour talk on how to build ecosystems at a level of detail. What Intel does when we imagine \u201cOkay, we want to go here over the next 15 years, and we literally map out an ecosystem of industries and players and those that are going to be resistant to it and then we try to figure out how do we get them to change their business model so that they\u2019re no longer resistant to it \u2013 I\u2019m going to give you the really quick version of this, but step one when we build these ecosystems is, if we want to transform, we set an audacious goal.<\/p>\n If you think back to the PC industry, when it was a radical notion to say, \u201cHey we want a PC on any\/every desktop\u201d \u2026 I mean how far we have come since then\u2026 that was a radical, audacious goal \u2013 that was a multiyear effort. At Intel, we started working to try to figure out \u2013<\/p>\n And now as we think about, you know, our new audacious goals of \u201canytime, anywhere, any device\u201d computing, we\u2019re doing that same set of activities to think through who that is. And there are four main dimensions to it every time we look at it.<\/p>\n The first time I built a telehealth startup was for [Microsoft’s] Paul Allen 27 years ago, and it technically<\/em> worked, but the workforce, workflow and policy and standards were not there. Great technology without covering all of that circle means you\u2019re really in trouble very, very quickly. So if you think back to the multimedia era of PCs \u2013 you may not know this, but Intel lined up hundreds of other organizations to make it commonplace to where you suddenly could use a computer for multimedia. We developed the codecs and then spun off a lot of the software companies that would use those to be able to use, do video on a PC in the invention of CD-ROMs and the hardware equipment, and there\u2019s that ecosystem that needs to go bring the cost down on that \u2026 what could you get Microsoft to put into the operating system at that point? Investing in and creating a whole bunch of software vendors and software developers; and a lot of times that meant teaching new curricula to these software developers because they had never programmed anything like this before. That\u2019s an example of bringing together an ecosystem.<\/p>\n And what I challenge you to do as NEHI thinks about the transformations that you want to help unleash in the world is, think through these four dimensions and think through who you need to begin to do that.<\/p>\n This is exactly what we want to do if we want to enable personal health for all. If we are going to achieve that then we\u2019ve got to take an ecosystem approach because of the audaciousness of it.<\/p>\n So first, set an audacious goal \u2013 personal health for all \u2013 and I will share you some of the others that we\u2019re actually walking through, at Intel.<\/p>\n This really means \u2013 personal health for all \u2013 an individual, at the center, of a collaborative, data driven, or knowledge driven, team. And there are so many pieces of that we have to put together:<\/p>\n When we do this, we\u2019re going to have a range of types of data that are analyzed to produce a holistic \u2013 not one-disease view of you \u2013 a holistic view of the individual with dynamic knowledge. I am going to talk about genomics in a little bit.<\/p>\n If we were doing it right today and genomics were affordable and scalable, we would likely be doing genomic sequences of cancer patients every time they come in for chemo. The body responds, tumors morph, right? And you\u2019ve got to sort of see as a dynamic ongoing individual how you can set that up.<\/p>\n Our data infrastructure today is not designed for holism or dynamism, right? These are challenges that we are going to have to do going forward. And what this would mean in the end, for all of us, is a prevention plan and a treatment plan for your<\/em> needs, your body, your social situation. Because all of those come into play, in terms of the health outcomes that you are going to carry forward.<\/p>\n Now if we are going to leave behind today\u2019s paradigm of a reactive kind of mainframe-centric healthcare paradigm \u2013 and it\u2019s really designed for the non-existent average of all of us. When I was first diagnosed and they walked me in and said \u201cYou\u2019re going to die in 9 months,\u201d thank God Verna, the woman that I met, was an actuary. And she took me in and said, let\u2019s look at all of the research that\u2019s behind their proclamations about your 9 month death sentence. And sure enough you come to find out that most of the studies had been done with 85 and 90 year olds. And the recommendations, for somebody at age 19 with this cancer that they had never seen before, just didn\u2019t apply.<\/p>\n And even for those 85 or 90 year olds these clinical trials washed out individual difference and said, \u201cYou are the average of all of those who have been studied.\u201d The problem is, none of us are that average. We do the best that we can to extrapolate from averages to individuals, and we kill people and we cost an enormous amount of money as we go do that. And to be fair, we never had the tools to do it any other way prior to now.<\/p>\n So what are the elements of personal health? I have used a version of this slide for I think 15 years, it gets prettier \u2013 you know I finally got people with better graphics skills than I had to be able to render it.<\/p>\n But there are three fundamental elements that I talk about when we talk, we are moving to an era of personal and precision health.<\/p>\n Before I go through them you have to stop and think about that for a minute. If we say to the populace, and we say to the politicians, and we say to ourselves we\u2019re going to move to an era of personal health or precision health, then we have to admit<\/em> for a moment that we are now in an era of impersonal health, imprecision medicine, that\u2019s incredibly fragmented, incredibly data-poor and very institution centric in terms of how we deliver care.<\/p>\n That\u2019s going to be a careful message of my new job as we talk about trying to accelerate precision health or precision medicine for all: I would say well, wait a minute, what exactly are we doing to ourselves today, if we don\u2019t yet have precision and it\u2019s not yet designed for the person?<\/p>\n The three elements that we are trying to bring together \u2013 and this is true globally, I\u00a0mean Intel does this work in dozens of countries around the world \u2013 fundamentally, it\u2019s about collaborative care, distributed and personalized care. These are the three elements of what we call personal and precision health.<\/p>\n In collaborative care we do these exercises \u2013 I\u2019m a social scientist by training \u2013 as we study these people around the world, we\u2019ll have them do this exercise called a place map, and we will take an individual or a family sit down and talk to them and say, hey map out for us all the nodes of, all the places that you actually do care, or receive care, or are a part of your life and care. And they very quickly will draw like a hospital but they will draw all these other places around the community from their gym, to their pharmacist, to the particular person at the grocery store that helps them think through what they are going to bring home. Their map is like a DNA footprint in and of itself, of what they stitch together in their lives in the community.<\/p>\n If all of those parts of the personalized care system for that person or that family are not stitched together from a data sharing and from a \u201cIT\u201d perspective, and we don\u2019t connect them all, we are going to be in trouble.<\/p>\n We\u2019re doing some work in China, helping to stitch together elder care teams, and in China they are thinking through \u201cWe need whole new kinds of care workers to use the IT.\u201d So for example they are looking at things like, \u201cW\u2019re going to train a new category of person that has a combination of some IT training, some social work training and other sort of community health kinds of training,\u201d to facilitate the kind of IT of a very neighbor-driven care model for seniors as well as technologies that are tracking the quality of the care that the neighbors are actually delivering for one another? That\u2019s a collaborative care team stitched together in a very different way than we do today. And it\u2019s not all about technology, it\u2019s about workforce, workflow and other kinds of things along with that.<\/p>\n On the distributed care, right from a policy perspective I will share with you a goal that we have been actually trying to drive both as a large employer in our own ACO-like model but across about 12 countries working on health reform right now, is: setting quality metrics that are based on place of care. Was the care delivered in the safest, least restrictive, preferred setting of choice by the patient or by the consumer?<\/p>\n And if you start measuring for and paying for that question then the advent of things like using telehealth appropriately \u2026 right now at Intel we are working on some very aggressive hospital at home models with partners that we are quite confident can actually help treat things like sepsis and pneumonia and a whole list of other conditions that we do in a hospital in a home setting safely, effectively and at far lower cost than actually what\u2019s happening today, right.<\/p>\n So just the beginnings of telehealth that we have today \u2013 this ought to be a fundamental mixed mode care model and a clinician who has the right and the responsibility to choose what dangerous drug they are going to put you on, can make a damn decision about what\u2019s the right mode of care to follow-up with you on? Is it going to be phone calls? Is it going to be in-home? Is it going to need to be coming in into the institution, right? So distributing care in the significant way is a big part of making health personal.<\/p>\n And then the third is personalized, and this is not just genomics, people equate this with genomics and that certainly \u201comics\u201d in general are a big part of that, but this is n=1 care or n=1 medicine, based on a wide range of data types. We just finished a pilot at Intel called U24.7 with the combination of clinical and wearable data that was all made available to the individual themselves, including their EHR data from multiple EHRs, from different places and different times and different vendors.<\/p>\n And a fundamental premise of this was a lot about giving data back to that person. By the way, the million person cohort, we are going to do exactly the same thing. So personalized could mean as simple as some sensor information in context to where information from your smartphone is brought into help you know how to customize medication prompting for you as an individual. We have done studies on this for years at Intel. For some people having Oprah\u2019s voice, remind them to take their meds was the most effective strategy; for others it was blocking their television and the sports wouldn\u2019t play again, until you got up and took your meds.<\/p>\n The point is, even that is using data to personalize care in a deep way. And obviously when you start to add things like genomics, then you\u2019re talking about having a genetic map and baseline that helps to know how do we prevent or how do we customize drug treatments for you specifically. A broad set of things go into that.<\/p>\n At Intel we have been helping to build out the end-to-end infrastructure in multiple countries to deliver on these three pillars of personal health for years. But I\u2019ve managed to prototype it for myself and as a way to survive. So I will share with you, now 29 years of a journey in one slide in just a matter of minutes of my own particular situation.<\/p>\n That\u2019s a picture of me on the right, really big forehead, it\u2019s embarrassing, I don\u2019t know why I keep showing it. I just told my parents they could rent billboard space on the top of my forehead when I was a baby.<\/p>\n I was born without hip sockets. I have met people who are wheelchair bound \u2013 because knowledge is survival, there, my parents \u2026 when they got this proclamation that my hip sockets hadn\u2019t been formed said, we have got to find somebody else who has the knowledge on how to fix this. And this was about the time that new procedures were coming out. I mean I grew up with the notion that knowledge is survival because if they hadn\u2019t gotten a second, third, fourth, fifth opinion until they found one that they actually wanted to go with, I would, you would have been wheeling me up here today, right instead I am a runner.<\/p>\n So I mean it\u2019s been in my life for a long time that\u2019s a picture of my transplant care team up there, that\u2019s a picture of me in the ICU after my successful kidney transplant. So here is the thing, collaborative distributed personalized care is something I have had to create and fight to create for myself all these years. From collaborative care as I had cancer, I had a life threatening cardio event because of meds mix that my team had no idea of what each other was putting me on, first off-label uses, right? How did I fix this? I started using paper lists, I started tattooing it on my body, saying here I am, this is what I have, please make sure you are not killing me, by adding yet another medication to the cocktail.<\/p>\n I used Groove which was an early sort of social networking tool and forced all of my clinicians to get a login and use Groove to monitor whether or not they were killing me or not, because they weren\u2019t talking to each other.<\/p>\n And then I eventually used different fields in the EHR that I knew were not used by clinicians very often that would pop-up to the top of the screen and said, put these meds right there, I want all of them to see it when they go look into the EHR, right? An example of me forcing collaborative care and collaborative communication by my, you know at some points I have had at one time 21 different experts working on me at one time, right? I am much healthier today \u2013 it\u2019s down to four.<\/p>\n In terms of distributed, my two other, my three near death experiences \u2013 well the first was that one, my other two were both hospital-borne infections while I was on intense chemotherapy and they had wiped out my immune system, right. I mean, hospice-kind-of, you know, bringing in last rites kinds of things.<\/p>\n And after the second one of those happened, I said, \u201cI will do chemotherapy at home; you will teach me either how to help self administer, you will send a nurse in and we will start using videoconferencing.\u201d And I would force my clinicians with the, you know I mean, God, what were the first videoconferencing tools you could get on a PC \u2013 I would teach them that and I said, you are going to do this because you have just told me not to go to Toys \u201cR\u201d Us or the public library because those are two dangerous places with germs but actually the place that you want me to come to, ranks above those \u2013 right?? It just doesn\u2019t make cognitive sense. So I started forcing this.<\/p>\n I gave a TED Talk a couple of years ago, even \u2026 just showing after my transplant, how you could start to use a cellphone based ultrasound to not have to go into the transplant office for the three months afterwards three times a week, which is very painful after you just had a transplant.<\/p>\n And then the third was personalized, 23 years with cancer \u2013 I told you I was diagnosed at age 19, said you had 9 months to live \u2013 more than about five dozen rounds of chemotherapy, radiation and\/or immunotherapy over those years, 57 different definitive diagnosis codes and $6 million in cost.<\/p>\n I am about to die, I am about to go my, I am going on my last Intel business trip, a startup that needed computing power sequences me, and comes back and says, after seven months by the way it took seven months, three months of compute, to do the computing part.<\/p>\n I got the whole genome sequenced. It took three months of compute time, four months of humans to try to find all of the data from all the clinical trials and places I had been and pulled my EHR data together. And after all that I didn\u2019t even know they were doing it, I walk into, I was seeing a doctor at three times a week, I was about to go on dialysis, I had put in the AV fistula in my hand to support the dialysis. And I walk in and they are like, it\u2019s multiple doctors, two on video conferencing and my doctor from Seattle had come down to Portland and they\u2019re in the same place. I mean if you are a patient, you just know this never happens unless it\u2019s bad news, right?<\/p>\n But this was good news and they said, \u201c92% of what we put you on was destined never to have worked. We have never used this kind of data for a patient before, it was very painful for us to learn how to do it. We were FedExing 2 terabyte hard-drives of data back and forth and it took forever to get your EHR data together to try to figure this out. That was the bad news \u2013 my wife still struggles with that: \u201c92% of the things that almost killed you for all of those years, we now understood were not supposed to work.\u201d<\/p>\n And they said, \u201cWe think, even though your cancer is in your kidneys and it has wiped them out, it looks more like pancreatic cancer, the mechanism. And we are going to put you on an experimental drug for pancreatic cancer. Three months \u2013 not a bad round of chemo \u2013 it was the kidney failure that was really making me sick. I come out of it, I walk in, they do the test two days in a row and they said, \u201cYou\u2019re cancer free for the first time in 23 years.\u201d All right?<\/p>\n [Applause]<\/p>\n And they said \u201cYou\u2019re eligible for a kidney transplant.\u201d Me, Mr. Proactive Patient, have advocated for well over a thousand people with cancer, didn\u2019t even know what was entailed in a kidney transplant because it had never been in the realm of possibility. Intel employee who doesn\u2019t know me donates to me and suddenly I am healthier today than I was at age 48 than I was at 19.<\/p>\n\n
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