How a Futurist Sees Healthcare Being Delivered!

Brian Urban:

This is the Healthcare Rethink podcast. I'm your host, Brian Urban. And today joining us we have Trond Undheim, a author, technologist, healthcare strategist. And I think the most amazing part about your background, Trond, is you are a professor in Stanford University and then also a senior lecturer at MIT Sloan School of Management, one of the most prestigious MBAs that you can get on your wall across the planet. So, you're all over the map geographically. We're excited to have you discuss your book here today, Health Tech: Rebooting Society's Software, Hardware and Mindset. So Trond, welcome to the little show.

Trond Arne Undheim:

Thank you, thanks so much. And by the way, I can't be in two places at the same time. So, the MIT thing is actually in the past, current affiliation is Stanford. I do some consulting on the side, and a bunch of advising of startups and things like that, and I write books. But yeah, it's impossible to teach full-time at two different universities at the same time, but yeah.

Brian Urban:

Hey, I wanted to keep going with your background, but I figured I would stop there, and thank you for the updates for our audience.

Trond Arne Undheim:

Well background is not so interesting anymore, it's what you do in the future.

Brian Urban:

You are a futurist, speaking of that, and talking through your book today, Health Tech, I'm sorry, it's quite fascinating. The way that you built the reading is through very digestible portions of your research applicable to what's happening in our healthcare ecosystem in the U.S. and globally today, which is really, really cool. But before you've become a multi-time author, I want to go back a little bit here just to give some of our audience context into the life of Trond. How did you find yourself writing these books about health tech, healthcare, the ecosystem abroad, being a futurist? How did you get into this world that you're in today? Where did it all start?

Trond Arne Undheim:

Look, I mean, it all started with my parents because they were academics and taught me to question the world. So that's how most things start, or other people get other influences. And then when I start traveling around and investigating more issues, I think this interest in technology has always been there for me. But it was accidental actually that I got so deeply involved in technology. I thought I really wanted to go more into publishing and books and stuff, but I got this opportunity to do a PhD in technology studies. And ever since that point in time, I've just been digesting various emerging technologies. And then obviously the application domains of those technologies spans industries. And healthcare is just one of those very peculiar industries where a plethora of technologies and use cases emerge. Yet, and this explains why I wrote the book, we have remarkably little to show considering how enormous the investments, the advancements are in medical science, health technology has really not made a dent in this industry yet. And it's a mystery, that's why I wrote the book.

Brian Urban:

Yeah, it truly is. And it's fascinating the way that you break out some of these highlights, and what we've seen in these milestone investments, some private, some public backed, and it's just so fascinating to work through the book. The one thing I caught immediately in the beginning of your book in the acknowledgement sections is the deep thank you that you have for your longtime primary care physician, Dr. Mark Pasternak. So, chief pediatric infectious disease leader at Mass General, tell me what that relationship has meant to you and why that strong of an acknowledgement? I'm curious.

Trond Arne Undheim:

Yeah. I mean, I think that sometimes we are not so lucky that we get to stay with the same healthcare provider over time. And I, however, have had, when I was little, I had one primary care physician who stayed with me until I guess graduated college, and a little bit into my student years, but then I moved permanently, I guess away from the city where he practices and he also moved into another role. But then I was lucky fairly early in my work career to stabilize a relationship with not just any practitioner, but with someone who is a mind, who actually both is deeply involved with some of the hardest to solve mysteries of bugs and things that you encounter at a major research hospital, which fascinated me independently, and then also then gets to know you and has real deep conversations about life and health, and the intricacies of the above.

And he just seemed to me like he was my natural interlocutor when I was thinking what is going on in the healthcare system. So, he is the one that I care the most about, that cares the most about me, where we have had these conversations about how dysfunctional the system is, yet how passionate we both are about it, me both as a patient and as an observer, and innovator, and he obviously as a practitioner, and someone with a very privileged viewpoint on research-based medicine and the practicalities of really how to do that in a very, very resource constrained environment with so many patients and so many demands for his time.

So yeah, I wanted to dedicate it to him because I think he represents the last generation of the people that actually will have time to have that kind of relationship. Because I don't think now, even with the advances in AI and things, we are not going to have a human relationship with one doctor anymore. He's also perhaps the last generation of people who will have that encyclopedic knowledge that a GP needs I also think. So, this is not to go into my futuristic prediction, but the role of a GP, the whole encyclopedic idea that you not only should know about all diseases, but you should also know about all of these individual people, that is not a role for a human anymore. So I found it a little nostalgic, a little wonderful reminder also that this relationship in the past was possible, and I think a little warning that it's probably not possible anymore.

Brian Urban:

I love that you opened up in that way to the detail that you've taken us into here, Trond. And I think it is so thoughtful for you to talk about that because the future probably is of a bionic physician nature, and less of what the intimate patient to provider relationship has been for many years in the early growing of U.S. healthcare, which I think is just so fascinating to just think about the historical nature of how we experience and consume healthcare. But what's so fascinating is beyond the acknowledgement section, and thank you for taking us to that depth, Trond, we go into emerging technologies right off the bat, something I'm passionate about in my pursuits inside and outside of my world in academia, and yourself as well.

And I immediately started to look at the specifics when you detail out longevity, my mind jumped into remote patient monitoring devices and what we've seen around how technology can enable physicians to do a little bit more. And then now how I think about CMS is allowing a new revenue stream for healthcare organizations using these devices as they adhere to, I think over 15 daily touch points in the course of the month, something like that in terms of reimbursement. But I'm curious, emerging technologies and longevity as a new marketplace. I want to talk about that a little bit. So you put in there, "Is it the next trillion dollar marketplace?" I want to know about your thoughts on longevity and tech, and really what the marketplace will start to look like here.

Trond Arne Undheim:

Well I mean, it depends on which market because the existing market for healthcare, it's a western urban market, and we have had trouble delivering any sort of remote care beyond that. So, when I mourn this relationship with a doctor, I also celebrate the possibility that remote monitoring brings to new groups of people who don't live close. Even in the U.S. there's hospital deserts, and there are entire continents with one doctor per 50 or 100,000 people, or even worse in some countries and regions in Africa specifically. So, I think that when we think about longevity and you think about expanding the market, both in terms of geography so that a lot more people can live longer lives who were previously not living very long lives at all, and then secondly that a lot of unfortunately quite wealthy people will have the option of living 30% to 50% longer, and some of them already have today expanded their lifespans by 20, 30 years on average.

And that obviously represents a whole new market. It's like when you live longer, the market expands for those who are providing services for those people. So, in that sense it's win-win, the question of course is who wants to live longer and for what reason? And I think health span is a very, very important part of that debate, because nobody should live very long in relative health disparity. So, I think the debate here is not just one of eternal longevity, however long we can stretch the longevity concept, beyond 130 years of age lifespan is what the goalpost is, contemporary goalpost. But really the question is what kinds of services can we provide to those aging beyond 100 and 130 years old? What sort of services can we give to them, and who would actually be able to afford that?

So, it has to do with which business models we can then enable. And yes, I think remote monitoring is a very big part of it because without delivering longevity services at scale, we're not changing anything. First of all, the market's not expanding, so you can't finance these innovations in health care, but also it serves no purpose, I think to artificially prolong 10% of the population's lives if they're going to be suffering from a myriad of diseases.

Brian Urban:

Yeah, that's a very good point in terms of the population health perspective on this and the quality of life perspective of ... Well, so I like the global view that you took us there in terms of technology enabling physicians, when we think about a physician ratio of one to many thousands, tens of thousands in developing nations. So, that in and of itself is fascinating for you to think. I'm seeing the futuristic side of your brain and reaching that way. And I'm curious too, when you talk about, I guess the socioeconomic gaps, those specifically in the U.S. that are living longer that have the affordability or the access to live an age in home healthy are ideal candidates for remote patient monitoring if they're managing a manageable chronic condition. But for those of lower socioeconomic means in the U.S. that have lower health literacy, low access and challenges staying adherent, a device is not going to close that gap. And I guess that's the application and challenge that you see in this technology right now?

Trond Arne Undheim:

Well, I think that what's coming now much more rapidly than all of us, I mean not all of us, most of us assumed is with generative AIs ability to dig into previously hard to tap into systems, but also generate speech and conversation based on that. There really is going to be an enormous opportunity for, well first of all, remote service provision of health services at all levels, including multiplying a doctor services, perhaps one to many services from one doctor, which would be path breaking in and of itself. There are very few offerings there. But also ostensibly things like empowering nurses to becoming doctor-like. I know this is extremely controversial in the U.S. health care context, it is immensely necessary and a daily life on many other continents of the planet. Nurses, even in the U.S., have always been performing pretty significant levels of care provision.

But I also think that with AI, we are moving into peer-to-peer medicine, where the combination of a live human interpreting AI insights and perhaps even surgery skills. So, now we're looking at a future where medicine will be executed at the edge. So, that's the term I use in my book. Very, very advanced medical services will be distributed out into the end points of the system, and can be updated at very high levels. Obviously some level of quality control by humans would be required or desired, but even if that is not available we are not far away from being able to deliver, if we want to, healthcare to the furthest regions of the world, or even into the lowest socioeconomic environments in urban areas in the U.S. who are currently not receiving the kind of cancer care, the kind of care for long-term conditions that they need. And that would actually be very, very possible to deliver now at scale.

Brian Urban:

And in thinking about the access to care relative to specialty oncology, something I thought was fascinating that we talked a little bit a few moments ago, but the access to advanced medicine at edge, I love that phrasing. Academic medical centers, I think about these teaching schools and how many there are in the U.S., you noted there's about 1,100 in the U.S. And of them, they cumulatively account for about $562 billion in healthcare spent from the utilization of the services provided to patients. So, I want to go to a specific example. Do you think the survival and the existence of academic medical centers are based on acquisition? I mean, we're seeing Kaiser Permanente finish their acquisition of Geisinger, so that's a rural health strategy they're having across the U.S. Inevitably, it should help close a lot of gaps from a quality perspective and improve access to care. But are teaching medicine centers really going to be dependent on being bought and financially supported? Or do you think it's still a strong backbone in the U.S. and they will be more technologically enabled in the future?

Trond Arne Undheim:

Well, I think I'm seeing both things happening, Brian, you're seeing consolidation across the board, which does sometimes lead to less competition, fewer providers, fewer centers, more larger constellations of entities, which isn't necessarily good for quality. But also academic medical centers are expensive to operate, and sometimes the function that they perform is so much more important than perhaps the cost or just looking at their structure really reveals. So, I think it is instrumental that these particular institutions gets to thrive. But I think it's also important to remember that one of the reasons, and my book is mostly about technology, but as you know, technology isn't about technology, it's about everything else.

Business models in healthcare are so, so important. So, I think one of the conundrums in the book is talking about how even if the technology has been available to do many of these things for a long time, if the business models don't allow for it, and if we're basically just using this let's all grow bigger and let's create these monopolies of a health provision, that doesn't necessarily bode well for the kind of thing that I'm talking about, which is a distributed, both efficient and effective health innovation system.

And the most instrumental actor in that system is a research hospital, because you can come up with any fancy little gadget or monitoring device, but if it's not connected to a health system that fully understands what's actually happening, can interpret the data, now you're in real trouble. Because now you have advanced healthcare provision on the cheap by providers who are not connected to the research agenda in the field, and it could lead to disastrous consequences. Imagine AI is going haywire, no control, no adults in the room. So, there's also a dystopian scenario here where basically somebody buys into the Kool-Aid of Health Tech and starts to just provide willy-nilly services all across the board, and now you get all these health scandals that we have also seen, which destroy the faith in good health provision.

Brian Urban:

Yeah, I think immediately of Theranos going back, and then the investment that even Walgreens, from a retail perspective, had in that, and that very fraudulent attempt at improving healthcare from a diagnostic perspective. But obviously a crazy milestone in our history of advancing technology and diagnostic care. But you did dabble into the big innovators in your book. So, speaking about how the business model of healthcare needs to support technology, you mentioned a variety of retail organizations that have had a foothold in healthcare delivery in some facet. CVS was mentioned in your book, and I'm thinking now recently, and I want to get your take on this, about the health clinic closures from Walmart. They had a vision in 2018 of having over 8,000. They went to the 51 mark and decided to peel back the whole thing. And then there was some write-off in terms of a $6 billion loss from Walgreens on the Village MD side.

But there's still some growth in the space of having a physical primary care setting in a retail backed investment. And I'm curious, I mean, there's payment infrastructure barriers upfront with primary care regardless of who's backing at, retail or public sector, private, a hospital entity, academic medical center. But I guess is technology from a retail perspective the best way retail can enable physicians to do a better job? I mean, I think of Best Buy Health doing that. They don't have physical locations, they have a technical squad that goes in and helps people, and it's aging in home and wellness. Is that the play, or do you think retail health as a big innovator still has a valuable space in the U.S. ecosystem with healthcare delivery from a primary care sense?

Trond Arne Undheim:

Well I mean, I have a bias towards face-to-face delivery of any service, or I believe that the human touch is indispensable when you can afford to have it. So, I would say priority should be to have that available in as many locations as possible. Now, it is notoriously expensive to maintain a physical presence. And sometimes what happens in these retail locations is that, well, you certainly don't have a doctor, but even the nurses, it's hard to be when you're not in a setting where you're fully exposed to what you are exposed to in a hospital or even in a little bit of a larger constellation with doctors on patrol, so to speak, and walking around on a daily basis, it is challenging. So, I think both from a cost and from a quality perspective, I'm sure that what went into the closure decisions was not just cost, but it was also a realization that the kind of cost-quality ratio was also hard to maintain.

So, there is that challenge once you spread yourself too thin, because they're still going to be faced with unfortunately all kinds of conditions. They can maybe have a disclaimer to say, "Come in here if your ailment is limited," but that's not how healthcare works. You show up and you could have a heart attack, or your blood pressure is so high you have to send them off in an ambulance. So, I'm sure both of those things are true pressures, because obviously in a retail environment you don't want any of that happening. The first few deaths in a pharmacy slash health facility would not be really good. So, I think there are many, many reasons why retailers are perhaps holding back and not pushing that whole edge vision out just yet. But again, I think for me this ties back to many of the challenges I described in the book.

I have a whole chapter on interoperability. As long as we just have these individual sensor based technologies or very advanced medical knowledge, but it's not tied together and it's just so expensive to tie together all the software solutions, it's impossible at the edge to have all the data, all the knowledge, all the updated conditions that you could be faced with. So unless you have top quality healthcare, you shouldn't try to do it at the edge. So, I'm not sitting here with some sort of naive idea that it's very easy, and we can outsource, and no doctors are needed. Far from it.

But it's just that the promise is so great, but that's why I say that the entire system, not just the U.S. system, but that's what we're talking about now, it needs a major technical and mentality reboot. It also needs to rehash business models and really just from the ground up be rebuilt. And I think it's worth it, because it's on its way towards becoming a third of GDP. I mean, it's irrational. With a third of GDP, what could you do? You and I together with a third of GDP of America, you should be able to create something great.

Brian Urban:

Yes. Yeah, you should be able to almost reverse some of the societal fissures that need closed from due part poverty, racism, and a lot of the business model in the healthcare ecosystem for the U.S. being profit first and person second, and obviously the payment infrastructures still dictate that in many ways, being volume focused. But not to go too deep into that space, I did want to talk about something that I felt came out of that section of your book was these big innovators did not have very strong, I'd say matrix partners to help them scale whether an impact or the actual physical locations that they were developing. And then I looked a little bit further and tried to connect this here, I'm not sure you were going this way, but to paraphrase, you were looking at electronic health records and the position for dominance.

So, EHR dominance. And right now I'm seeing a lot of EHR leading vendors starting to realize third party vendor technology needs to sit on top of them, and they need partnerships to grow organically or inorganically into the future. And Epic, you called them out, they're huge. They're the leader in terms of volume, in terms of virtual intake on the front end of revenue cycle, and even in the middle, and the backend and then back end analytics relative to revenue cycle management and EHR vendors really seems where future investments are going. So, there's the big player of Epic, there's Cerner, there's MEDITECH, and then there's bunch of other little ones. Do you see more partnerships starting to spring up in the EHR space, or do you still get the sense from your research that the big players are going to keep their flag in the ground and continue to invest and build out in their technology, and just own their entire state within the marketplace? Or what do you think is happening there-

Trond Arne Undheim:

Well, I think that their incentive is obviously to try to do so, or at least to extend their monopolies for another decade or so. But I just think that there is an incentive to rethink that whole model and sort of say, "We're willing to rebuild on a new platform." The other thing that is the X factor is of course, what consumers, what patients are going to be saying about their own data, because there is now the potential that we can to leverage our own data more than before. So, to the extent that becomes possible in the U.S., and I think at some point it'll be so easy that no amount of vendors could stop that.

In other words, getting your access to your own health records and then sharing it on a point basically at the edge, which is my concept, you bring them with you in a safe way, and then you share them at the moment of care, maybe through some automated ways of sharing. I think that will become the model of the future. So, anonymized operation of health records without your knowledge, or even worse having your full name and health record in an abstract system that you don't control, I think is going to hopefully become a thing of the past. Then the business model will change. It's going to be a revenue sharing between people who have valuable data, that is people with rare diseases and other things, and then representing large and attractive population groups. We're doing a lot of research on those population groups, that will be valuable data. And sharing that data, it will increasingly become easy. So, I think health records and owning health records is, for me, it's not a viable business.

Brian Urban:

No, not from a futuristic-

Trond Arne Undheim:

Long-term.

Brian Urban:

Yeah, a futuristic perspective. And I love that you went toward the patient led journey, patient led autonomy of having your own health information at your disposal and being able to use that in a way that helps your access, and your understanding, and your even affordability of certain services as well. That is at the edge there, that is fascinating. And to me, that seems where it would be a very thoughtful, long-term strategic investment on these EHR vendors have if they would go beyond what's in their walls and start to think, "How do we use our patient population in terms of record keeping to our advantage?" And not just to what they're continuing to build out inside their house-

Trond Arne Undheim:

Yeah, and I think that's where I would hope that the research hospitals would see their natural role, which is as innovators they should be brave enough. And a few hospital centers have unfortunately lately consolidated their positions in the old vendor space without making these kinds of demands, because there's two ways of doing it. You could throw the vendor out, or you could just set some new demands for that vendor and say, "Well, we're moving into a different world. You can walk with us if you have this." So, I think that's where it's a little bit, I guess annoying to watch how slowly things are moving along, because despite all these innovations inside of the system, whether on the R&D front in specific technologies that are made available, the system itself is not able to absorb it and come out of it in a better state.

It's almost like everything just gets absorbed by some sort of amorphous mass, which just says, "Yes, thank you. We will take this into account," and then nothing comes out. And I think that's how most people see the health system, unfortunately that's also how the experts see the health system.

Brian Urban:

Yeah, I think from an outside perspective, for myself not being inside a healthcare organization or inside a health plan anymore, I very much see that as almost the generational style of leadership continuing to be inherited down the line as we're not changing the model, there's no incentive to, there's no need to, but we're seeing this gigantic bubble. You mentioned third of our gross domestic product value being inside one industry in healthcare, and the spend relative to it, it's not stopping, and we're seeing larger gaps in health disparities grow. So, the futuristic-

Trond Arne Undheim:

No, it's staggering. But I mean, it is also a fact that in order to defend healthcare investment, the people who are involved in it should be compensated for it. And I'm not suggesting a communist approach where you're not going to give fair compensation to innovators or professionals who have invested their careers here. So I mean, this is not easy to do. To turn the system off is not easy to do, but it's almost like the entire system currently is so abstract, and irrational, and dysfunctional that shutting it off for a while, even if that is a decade's serious reform, might really be worth it. Because right now, patching that system does not seem very rational.

Brian Urban:

It doesn't. And it seems like that's been everyone's approach from retail, to tech, to really being a bridge player and not making a progressive movement toward transformation. And with that, Trond, I wanted to conclude our conversation with a bit of a tease for our audience to look deeper into your latest book here, Health Tech. And my question to close us out here is, what point will science and technology be transformed to not be just emerging, but to be the actual keystone of healthcare? I mean, how is this hybrid discipline of science and technology going to be more the center of healthcare? Do you think that's going to be progressively put in place 5 plus, 10 plus years from now? Or is science and technology going to just continue to influence the way healthcare is delivered?

Trond Arne Undheim:

So, I'm going to take the long view here. I think that healthcare is going to be the last sector to be changed entirely by emerging technologies. So, what that means is that the most important things we're talking about now, that whole changeover, the whole entire shift of the healthcare system will take 30 to 50 years. All other sectors will be vastly more advanced by that time. But just because of the sheer volume and the sheer interests that are at play here, I don't foresee that this is going to happen. I don't think politicians are ready to take this burden on. And I think the incentives inside from outsiders, from tech industries are knocking in, they would prefer to take the system down from the outside as opposed to go into the system and then try to reform it. I don't know exactly how this reboot is going to happen, but I think without major, major political and economic support from the top players in the current healthcare system, plus the governments affected, it'll take us way past 2050.

Brian Urban:

Wow. Well, the view you have on this is purely objective, it's evidence-based, it's a lot of thought that you've put into your latest book, Health Tech, highly encourage our audience to dive deep into this reading, and to follow you and your podcasting adventures as well, Trond. And I'll tell you what, as long as we continue to address climate and then we can figure out healthcare, then we'll all be around and we'll still be okay. But we'll [inaudible 00:35:31]

Trond Arne Undheim:

Yeah, I agree with that. I think that that might be something we should deal with before 2050, because otherwise we'll all be in trouble. But health is the ultimate thing we all care about so it all boils down to health. So, let's hope we get there before that.

Brian Urban:

I agree, and I love the message that you are leading with across the minds you're shaping in academia, and then also in the healthcare industry itself. Trond Undheim, author, futurist, professor, check out the book, Health Tech: Rebooting Society's Software, Hardware and Mindset. Thank you so much, Trond, for visiting us on our podcast here today.

Trond Arne Undheim:

It's a great pleasure.

Brian Urban:

And for more exciting excerpts and insights, visit us at finthrive.com.