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Learning from This War

BY KIM BELLARD

There’s an old military adage that generals are always fighting the last war.  It’s not that they haven’t learned any lessons, it’s more than they learned the wrong lessons.  I fear we’re doing that with the COVID pandemic.  

The next big health crisis may not come from another COVID variant; it may not be caused by coronavirus at all.  Even if we learn lessons from this pandemic, those may not be lessons that will apply to the next big health crisis.  

What started me thinking about this is a C4ISRNET interview with Mike Brown, the Director of the Defense Innovation Unit, and DARPA Director Dr. Stefanie Tompkins.  Dr. Tompkins and Mr. Brown are both watching the war in the Ukraine closely.  As Dr. Tompkins says in the interview, the war is a “really good test” about the programs her agency has invested in and/or is investing in for the future.

E.g., Russia has clear advantages in numerical superiority, and in “traditional” weapons like tanks, airplanes, ships, and artillery, but Ukraine has been able to blunt the invasion through asymmetrical warfare, using things that DARPA helped foster, including Javelin missiles, drones, satellite imagery, secure communications, and GPS.  Even Russia’s vaunted cyber capabilities have been overmatched by Ukraine’s own capabilities.  Current DARPA investments like hypersonic missiles and AI are being tested.

I’m comforted that DARPA and DIU are learning in real time what lessons their agencies can learn to help fight future wars, but I’m wondering who in our healthcare system, and who in our governments (federal/state/local), are not just fighting COVID but learning the bigger lessons from it to fight future crises.  

I trust that smarter people than me are looking at this, but here are some the lessons I hope we’ve learned:

Information: it’s shocking, but we don’t really know how many people have had COVID.  We don’t really know how many have it now.  We like to think we know how many have been hospitalized and how many have died, but due to reporting inconsistencies those numbers are, at best, approximations.  

We need early warning systems, like through wastewater monitoring.  We need standardized public health reporting, with real-time data and a central repository in which it can be analyzed.  We need easy-to-understand dashboards that both public officials and the public can access and base their decisions on.  We can’t be building these during a health crisis.

Supply Chains: just-in-time, globally distributed supply chains are a marvel of modern life, bringing us greater variety of products at more affordable prices, but, in retrospect, we should have understood that in a global health crisis they would prove to be an Achilles heel.  Masks and other PPE, ventilators, vaccines and other prescription drugs have all suffered from supply chain issues during the pandemic.  Shortages led to unevenly distributed supplies and higher prices.  

We’re never going back to the days of local production, but we do need to prioritize what things need to be produced regionally/nationally, how that production can scale in time of crisis, and how that production should be fairly allocated.  The mechanisms to do that can’t be built on the fly.

The sick and the dead: Among the many images of the pandemic’s worst (so far) days, some of the most haunting are the ones of hospitals filled to overflowing, with patients on gurneys in hallways, or the refrigerator trucks filled with dead bodies.  Our healthcare system’s capabilities for both were simply overwhelmed – as was the healthcare workforce.

Hospital beds are expensive to build, and expensive to maintain.  We can’t afford a healthcare system that builds them for the worst case scenario.  But we can learn from innovative efforts during the pandemic, like building temporary hospitals that can be expanded or contracted as needed.  

Similarly, there has to be a strategy for dealing with dead bodies during a global health crisis, especially one in which those bodies themselves may carry ongoing risks.  Existing morgues, mortuaries, and even graveyards may not be sufficient.  There needs to be a plan.

Hardest to solve are healthcare workforce shortages.  It’s not easy to train new healthcare workers, and retaining them when they’re stressed beyond belief proved to be a challenge.  In a crisis, we need them all working at the top of the licenses, able to cross workplaces and even state lines, and properly supplied and compensated.  None of those is a “normal” state of affairs for our healthcare system, and all are inexcusable in a crisis.

Telehealth: telehealth seemed to finally gets its day during the pandemic, with relaxed regulation, improved reimbursement, provider adoption, and consumer preference.  It took pandemic to make us realize that making sick, potentially contagious, patients travel to get care is not a good idea.

That being said, now that the pandemic is in a more manageable phase, the bloom seems to be off the telehealth rose, with regulations being reapplied, providers not fully incorporating into their practice patterns, and patients returning to in-person visits.

Hey: it’s 2022.  We have the technology to do telehealth “right.”  Aside from, say, a heart attack or an auto accident, telehealth should always our first course of action.  Our licensing, our reimbursements, and our work flows need to facilitate this – not just to prepare for the next health crisis, but simply as part of a 21st century healthcare system. 

Communication: One of the most unexpected results of the pandemic is the distrust of public heath advice – vilifying public health officials, spurning mitigation efforts like masking or isolation, and spurring on the already-present anti-vaxx movement.  “Science” is seen as in the eye of the beholder. It’s an information war, and health is losing.

We need the tools to fight the health information war more effectively. We need to learn how to communicate more effectively.  We need to reestablish faith in science.  We need responses to a health care crisis to be a health issue, not a political one.  

————

We will be taken by surprise by the next health crisis.  We had plans for a pandemic, but, when it hit, we fumbled every response.  Next time we’ll be expecting another COVID, and, if it’s not, we’ll be caught flat-footed again.  

The current crisis is, to use Dr. Tompkins’ words, a really good test for whether we’re working on the right things for our next health crisis.  I’m not so sure we are.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

#HealthTechDeals Episode 25: Biofourmis, Reify Health, Nex Health, and Amae Health

In this week’s episode of Health Tech Deals, everyone cheats on each other: Eugene Borukhovich is the guest host replacing Jess! Eugene is cheating on Jim Joyce, while I cheat on Jess; though Jess has cheated on me with Eugene before! Jess is on a cult retreat in Costa Rica, but Eugene and I have some deals to discuss: Biofourmis raises $300 million; Reify Health raises $220 million; Nex Health raises $125 million; and Amae Health raises “several million.”

-Matthew Holt

#HealthTechDeals Episode 23; Real, Iris Telehealth, 9am Health, Eko & Duos

In this episode of Health Tech Deals, Jess thinks the music has stopped as Rock Health reports Q1’s funding total being below Q4 2022! No $100m rounds today! But still $37m for Real; $40m for Iris Telehealth; only $16m for 9am Health but lots of Livongo connections; $30m for Eko and $15m for Papa-lookalike Duos

-Matthew Holt

DALL-E, Draw an AI Doctor

BY KIM BELLARD

I can’t believe I somehow missed when OpenAI introduced DALL-E in January 2021 – a neural network that could “generate images from text descriptions” — so I’m sure not going to miss now that OpenAI has unveiled DALL-E 2.  As they describe it, “DALL-E 2 is a new AI system that can create realistic images and art from a description in natural language.”  The name, by the way, is a playful combination of the animated robot WALL-E  and the idiosyncratic artist Salvator Dali.

This is not your father’s AI.  If you think it’s just about art, think again.  If you think it doesn’t matter for healthcare, well, you’ve been warned.

Here are further descriptions of what OpenAI is claiming:

“DALL·E 2 can create original, realistic images and art from a text description. It can combine concepts, attributes, and styles.

DALL·E 2 can make realistic edits to existing images from a natural language caption. It can add and remove elements while taking shadows, reflections, and textures into account.

DALL·E 2 can take an image and create different variations of it inspired by the original.”

Here’s their video:

I’ll leave it to others to explain exactly how it does all that, aside from saying it uses a process called diffusion, “which starts with a pattern of random dots and gradually alters that pattern towards an image when it recognizes specific aspects of that image.”  The end result is that, relative to DALL-E, DALL-E 2 “generates more realistic and accurate images with 4x greater resolution.”  

Continue reading…

Matthew’s health care tidbits: Hospital System Concentration is a Money Machine

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For today’s health care tidbits, there’s an old chestnut that I can’t seem to stay away from. I was triggered by three articles this week. Merril Goozner on GoozNews looked at the hospital building boom. Meanwhile perennial favorite Sutter Health and its price-making ability came up in a report showing that 11 of the 19 most expensive hospital markets were in N. Cal where it’s dominant. Finally the Gist newsletter pointed out that almost all the actual profits of the big health systems came from their investing activities rather than their operations.

None of this is any great surprise. Over the past three decades, the big hospital systems have become more concentrated in their markets. They’ve acquired smaller community hospitals and, more importantly, feeder systems of primary care doctors. Meanwhile they’ve cut deals with and acquired specialty practices. For more than two decades now, owned-physicians have been the loss leader and hospitals have made money on their high cost inpatient services, and increasingly on what used to be inpatient services which are now delivered in outpatient settings at essentially inpatient rates. Prices, though, have not fallen – as the HCCI report shows.

Source: HCCI

The overall cost of care, now more and more delivered in these increasingly oligopolistic health systems, continues to increase. Consequently so do overall insurance premiums, costs for self insured employers and employees, and out of pocket costs. And as a by-product, the reserves of those health systems, invested like and by hedge funds, are increasing–enabling them to buy more feeder systems.

Wendell Potter, former Cigna PR guy and now overall heath insurer critic, wrote a piece this week on how much bigger and more concentrated the health plans have become in the last decade. But the bigger story is the growth of hospital systems, and their cost and clout. Dave Chase likes to say that America has gone to war for less than what hospitals have done to the American economy. That may be a tad hyperbolic, but no one would rationally design a health care environment where non-profit hospitals are getting bigger and richer, and don’t seem to be able to restrain any aspect of their growth.

#HealthTechDeals Episode 21: IntelyCare, Avi Medical, Eleos Health, Evernow & Vivosense

Well at least my hair is under control today. What’s not under control is the chatter about Olive from Erin Brodwin at Axios, even if I don’t get Jess’ joke about the internet of Health Care. Meanwhile deals in nursing recruitment for IntelyCare ($115m), Avi Medical (50M Euros), Eleos Health ($20m), Evernow ($20m) and $25m for Vivosense–note my total inability to say their investor’s name!–Matthew Holt

If You’ve Seen One Robot – Wait, What?

BY KIM BELLARD

If You’ve Seen One Robot – Wait, What?

We think we know robots, from the old school Robbie the Robot to the beloved R2-D2/C-3PO to the acrobatic Boston Dynamics robots or the very human-like Westworld ones.   But you have to love those scientists: they keep coming up with new versions, ones that shatter our preconceptions.  Two, in particular, caught my attention, in part because both expect to have health care applications, and in part because of how they’re described.

Hint: the marketing people are going to have some work to do on the names. 

———–

Let’s start with the robot called by its creators – a team at The Chinese University of Hong Kong — a “magnetic slime robot,” which some in the press have referred to as a “magnetic turd robot” (see what I mean about the names?).  It has what are called “visco-elastic properties,” which co-creator Professor Li Zhang explained means “sometimes it behaves like a solid, sometimes it behaves like a liquid…When you touch it very quickly it behaves like a solid. When you touch it gently and slowly it behaves like a liquid”  

The slime is made from a polymer called polyvinyl alcohol, borax, and particles of neodymium magnet. The magnetic particles allow it to be controlled by other magnets, but also are toxic, so researchers added a protective layer of silica, which would, in theory, allow it to be ingested (although Professor Zhang warned: “The safety [would] also strongly depend on how long you would keep them inside of your body.”).  

The big advantage of the slime is that it can easily deform and travel through very tight spaces.  The researchers believe it is capable of “grasping solid objects, swallowing and transporting harmful things, human motion monitoring, and circuit switching and repair.”  It even has self-healing properties.

Watch it in action:

In the video, among other tasks, the slime surrounds a small battery; researchers see using the slime to assist when someone swallows one.  “To avoid toxic electrolytes leak[ing] out, we can maybe use this kind of slime robot to do an encapsulation, to form some kind of inert coating,” Professor Zhang said.

As fate would have it, the news of the discovery hit the on April 1st, leading some to think it was an April Fool’s joke, which the researchers insist it is not.  Others have compared the magnetic slime to Flubber or Venom, but we’ll have to hope we make better use of it.  

It is not yet autonomous, so some would argue it is not actually a robot, but Professor Zhang insists, “The ultimate goal is to deploy it like a robot.”  

———-

If magnetic slime/turd robots don’t do it for you, how about a “magnetic tentacle robot” – which some have deemed a “snakelike” robot?  This one comes from researchers at the STORM Lab at the University of Leeds.  STORM Lab’s mission is: 

We strive to enable earlier diagnosis, wider screening and more effective treatment for life-threatening diseases such as cancer…We do so by creating affordable and intelligent robotic solutions that can improve the quality of life for people undergoing flexible endoscopy and laparoscopic surgery in settings with limited access to healthcare infrastructures.

In this particular case, rather than using traditional bronchoscopes, which might have a diameter of 3.5 – 4 millimeters and which are guided by physicians, the magnetic tenacle robot offers a smaller, more flexible, and autonomous option.  Professor Pietro Valdastri, the STORM Lab Director, explained:

A magnetic tentacle robot or catheter that measures 2 millimetres and whose shape can be magnetically controlled to conform to the bronchial tree anatomy can reach most areas of the lung, and would be an important clinical tool in the investigation and treatment of possible lung cancer and other lung diseases.   

Moreover, “Our system uses an autonomous magnetic guidance system which does away for the need for patients to be X-rayed while the procedure is carried out.” A patient-specific route, based on pre-operative scans, would be programmed into the robotic system.  It could then inspect suspicious lesions or even deliver drugs. 

Dr. Cecillia Pompili, a thoracic surgeon who was a member of them team, says: “This new technology will allow to diagnose and treat lung cancer more reliably and safely, guiding the instruments at the periphery of the lungs without the use of additional X-rays.”  

Watch it in action:

Magnetic Tentacle Robot – YouTube

The robot was tested on a 3D replica of a bronchial tree, and will next be tested on lungs from a cadaver.  It will likely take several years to reach clinical settings.  The team has also created a prototype of a low-cost endoscope and a robotic colonoscopy system, among other things.   

The researchers conclude

We demonstrate that the proposed approach can perform less invasive navigation and more accurate targeting, compared with previously proposed magnetic catheterization techniques… we believe that atraumatic autonomous exploration of a wide range of anatomical features will be possible, with the potential to reduce trauma and improve diagnostic yield.”

“It’s creepy,” Professor Valdastri admitted to The Washington Post. “But my goal … is to find a way to reach as deep as possible inside the human body in the least invasive way as possible… Depending on where a tumor is, this may be the only way to reach [it] successfully.”  

Nitish V. Thakor, a professor of biomedical engineering at Johns Hopkins University, told The Post: I can imagine a future where a full CAT scan is done of the lungs, and the surgeon sits down on a computer and lays out this navigation path of this kind of a snake robot and says: ‘Go get it.’ ”  He also sees potential for uses outside the lungs, such as in the heart.  

Similarly, Dr. Janani S. Reisenauer, a surgeon at The Mayo Clinic, declared to The Post: “If it’s a small, maneuverable autonomous system that can get out there and then do something when it’s out there, that would be revolutionary.” 

———-

Personally, I’m still holding out hope for nanoparticles, but these kinds of soft, flexible robots could be important until we get there.  Sure, maybe people will be reluctant to be told they have to ingest magnetic slime – much less a magnetic turd – or have a snakelike robot put down their throats, but it may beat having a scope inserted or being cut open.

The researchers can keep working on the robots; others of us can work on better names. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

#HealthTechDeals Episode 20: Clarify Health, Season, Altoida, nirvanaHealth, and Pluto

What’s with my baseball hat? Find out in this episode! Apparently, someone thinks my hair is a bit out of control and needs some trimming. In this episode of Health Tech Deals, Jess and I review Clarify Health raising $150 million; Season raising $34 million; Altoida grabbing $20 million; nirvanaHealth getting $60 million; and Pluto Health raising $9 million–Matthew Holt