Medicine's future? There's an app for that - Daniel Kraft

A couple of years ago, when I was attending the TED conference in Long Beach, I met Harriet. Now, we'd actually met online before. You know, not the way you're thinking. We were actually introduced because we both knew Linda A.V., one of the founders of the first online personal genomic companies. Because we shared our genetic information with Linda, she could see that Harriet and I shared a very rare type of mitochondrial DNA haplotype K 1 A 1 B 1 A, which meant that we were distantly related. We actually shared the same genealogy with Ozzie the Iceman. So, Ozzie, Harriet, and me. And being the current day, of course, we start our own Facebook group. You're all welcome to join.

When I met Harriet in person the next year at the TED conference, she had gone online and ordered our own haplotype t-shirts. Now, why am I telling you this story? What does this have to do with the future of health? Well, the way I met Harriet is actually an example of how leveraging cross-disciplinary, exponentially growing technologies is affecting our future of health and wellness. From low-cost gene analysis to the ability to do powerful bioinformatics to the connection of the internet and social networking, what I like to talk about today is understanding these exponential technologies.

You know, we often think linearly. But if you think about it, if you have a lily pad and it just divided every single day—2, 4, 8, 16—15 days of 32,000, what do you think you have in a month or at a billion? So if we start to think exponentially, we can see how this is starting to affect all the technologies around us. Many of these technologies, speaking as a physician and innovator, we can really start to leverage to impact the future of our own health and of healthcare, and to address many of the major challenges that we have in healthcare today. Ranging from the really exponential costs to the aging population, the way we really don't use information very well today, the fragmentation of care, and often the very difficult course of adoption of innovation.

One of the major things we can do—we've talked a bit about here today—is moving the curve to the left. We spend most of our money on the last 20% of life. What if we spend and incentivize physicians and healthcare systems in our own selves to move the curve to the left, improve our health, leveraging technology as well? Now, my favorite technology example of exponential technology we all have in our pocket. So if you just think about it, these are really dramatically improving. I mean, this is the iPhone 4. Imagine what the iPhone 8 will be able to do.

Now, I've gained some insight into this. I've been the track chair for the medicine portion of a new institution called Singularity University, based in Silicon Valley. We bring together each summer about 100 very talented students from around the world, and we look at these exponential technologies: from medicine, biotech, artificial intelligence, robotics, nanotechnology, and space, addressing how we could cross-train and leverage these to impact major unmet goals. We also have seven-day executive programs, and coming up next month is actually Future Med, a program to help cross-train and leverage technologies into medicine.

Now, I mentioned the phone. These mobile phones have over, I think, 20,000 different mobile apps available, to the point where there's one out of the UK where you can pee in a little chip, connect it to your iPhone, and check yourself for an STD. I haven't tried that yet, but that's available. There are other sorts of applications merging your phone and diagnostics, for example, measuring your blood glucose on your iPhone and sending that prudentially to your physician so they can better understand and you can better understand your blood sugars as a diabetic.

So let's see now how exponential technologies are taking healthcare. Let's start with faster. Well, it's no secret that computers, through Moore's Law, are speeding up faster and faster. We have the ability to do more powerful things with them; they're really approaching, in many cases, surpassing the ability of the human mind. But what I think computational speed is most applicable to is that of imaging. The ability now to look inside the body in real-time with very high resolution is really becoming incredible. We're layering multiple technologies—PET scans, CT scans, and molecular diagnostics—to find and seek things at different levels.

Here, you're going to see the very highest resolution MRI scan done to date, reconstructed by Bartho, the curator of TEDMED, and now we can see inside of the brain at a resolution and ability that was never before available. We can essentially learn how to reconstruct and maybe even re-engineer, or backwards engineer, the brain so we can better understand pathology, disease, and therapy. We can look inside with real-time fMRI in the brain in real-time, and by understanding these sorts of processes and these connections, we're going to understand the effects of medication or meditation, and better personalize and make effective, for example, psychoactive drugs.

The scanners for these are getting smaller and less expensive and more portable, and this sort of data explosion available from these is really almost becoming a challenge. The scan of today takes up about 800 books or 20 gigabytes. The scan of just in a couple of years will be one terabyte or 800,000 books. How do we leverage the information?

Let's get personal. I won't ask you how to colonoscopy, but if you're over age 50, it's time for your screening colonoscopy. How would you like to avoid the pointy end of the stick? Well, now there's essentially virtual colonoscopy. Compare those two pictures, and now as the radiologist, you can sochi fly through your patient's colon, augmenting that with artificial intelligence to identify potential—as you see here—a lesion that we might have missed. Using AI on top of radiology, we can find lesions that were missed before, and maybe this will encourage people to get colonoscopies that wouldn't have otherwise.

This is an example of this paradigm shift. We're moving to this integration of biomedicine, information technology, wireless, and I would say mobile. Now, this era of digital medicine. Even my stethoscope is now digital, and of course, there's an app for that. We're moving, obviously, to the era of the tricorder. The handheld ultrasound is visually surpassing and supplanting the stethoscope. These are now at a price point of what used to be a hundred thousand euros or a couple of hundred thousand dollars, for about five thousand dollars. I can have the power of a very powerful diagnostic device in my hand.

Merging this now with the advent of electronic medical records, in the United States, we're still less than 20% electronic. Here in the Netherlands, I think it's more than 80%. But now that we're switching to merging medical data, making it available electronically, we can crowdsource that information, and now, as a physician, I can access my patient's data from wherever I am just through my mobile device.

Now, of course, we're in the era of the iPad, even the iPad 2, and just last month, the first FDA-approved application was approved to allow radiologists to do actual reading on these sorts of devices. So, certainly, the physicians of the day, including myself, are completely reliable on these devices. As you saw just about a month ago, Watson from IBM beat the two champions in Jeopardy. So, I want you to imagine, in a couple of years, we start to apply this cloud-based information.

Well, we really have the AI physician and leverage our own brains and connectivity to make decisions and diagnostics at a level never done today. You don't need to go to visit your physician in many cases. Only about 20% of actual visits need you to lay hands on the patient. We're now in the era of virtual visits, from sort of the Skype-type visits you can do with American Well to Cisco, which developed a very complex health presence system.

The ability to interact with your healthcare provider is different, and this is being augmented even by our devices. Again, today, my friend Jessica sent me a picture of her head laceration, so I can save her a trip to the emergency room. I can do some diagnostics in that way. Or might we be able to leverage today's gaming technology, like the Microsoft Kinect, and hack that to enable, let's say, diagnostics? For example, in diagnosing stroke using simple motion detection. Using $100 devices, we can actually now visit our patients robotically. This is the RP7. If I'm a hematologist, I can visit another clinic or hospital.

These are being augmented by a whole suite of tools, actually in the home now. So imagine we already have wireless scales. You can step on the scale, you can tweet your way to your friends, and they can keep you in line. We've got wireless blood pressure cuffs; a whole gamut of these technologies are being put together. Instead of wearing these glucometer devices, we can put on a simple—this is developed by colleagues at Stanford—called the iRhythm, which completely supplants the prior technology and has a much lower price point with much more effective technology.

Now, we're also in the era today of quantified self. Consumers now can buy basically hundred-dollar devices, like this little Fitbit. I can measure my steps, my caloric intake. I can get insight into that on a daily basis. I can share that with my friends, with my physician. There are watches coming now that will measure your heart rate, Zeo sleep monitors, a whole suite of tools that can enable getting leverage and have insight into your own health.

If we start to integrate this information, we're going to know better what to do with it and how better to have insight into our own pathologies, health, and wellness. There's even mirrors today that can pick up your pulse rate, and I would argue in the future we'll have wearable devices in our clothes, monitoring ourselves 24/7. Just like we have the OnStar system in cars, your red light might go on, and once a check engine light goes on, it's going to be check your body light, and you need to go in and take care of it.

Probably in a few years, we'll check in to your mirror, and it's going to be diagnosing you. For those of you with kiddos at home, how would you like to have the wireless diaper that supports...here's too much information, I think, that you might need, but it's going to be here. Now, we've heard a lot today about technology and connection, and I think actually some of these technologies will enable us to be more connected with our patients and take more time and actually do the important human touch elements of medicine as augmented by these sorts of technologies.

Now, we talk about augmenting the patient to some degree. How about augmenting the physician? We're now near super-labeling the surgeon who can now go inside the body and do things with robotic surgery, which is here today at a level that was not really possible even five years ago. This has been automated further with layers of technology, like augmented reality, so the surgeon can see inside the patient through their lens—where the tumor is, where the blood vessels are. This can be integrated with decision support. A surgeon in New York can be helping a surgeon in Amsterdam, for example.

We're entering an era of really truly scarless surgery called NOTES, where the endoscope, robotic endoscope, can come out the stomach and pull out that gallbladder all on a scarless wedding and robotically. This is called NOTES, and this is coming. Basically, scarless surgery is mediated by robotic surgery. Now, how about controlling other elements? For those who have disabilities, the paraplegic—there’s the era of brain-computer interface, or BCI, where chips have been put on the motor cortex of completely quadriplegic patients, and they can control a cursor or wheelchair or even initially a robotic arm.

These devices are getting smaller and going into more and more of these patients still in clinical trials. But imagine when we can connect these, for example, to the amazing bionic limb, such as those of the DECA arm built by Dean Kamen and colleagues, which has 17 degrees of motion and freedom, and can allow the person who's lost a limb to have much higher levels of dexterity or control than they've had in the past. So we're really entering the era of wearable robotics. Actually, if you haven't lost a limb, but you've had a stroke, for example, you can wear these augmented limbs.

Or if you're a paraplegic, like I visited the folks at Brooklyn Bionics, they’ve developed a legs. I took this video last week. Here's a paraplegic patient actually walking by strapping on these exoskeletons. These otherwise would be complete wheelchair-bound. This is the early era of wearable robotics, and I think by leveraging these sorts of technologies, we're going to change the definition of disability to, in some cases, be super ability or super enabling.

This is Aimee Mullins, who lost her lower limbs as a young child, and Hugh, her professor at MIT, who lost his limbs in a climbing accident. Both of these can climb better, move faster, swim differently with their prosthetics than us normal-abled persons. Now, how about other exponentials? Consider the obesity trend, which is exponentially going in the wrong direction, including with huge costs. But the trend in medicine actually is to get exponentially smaller.

So a few examples: We’re now in the era of "Fantastic Voyage." The iPill you can swallow—this completely integrated device can take pictures of your GI system, help diagnose and treat as it moves through your GI tract. We need to even smaller micro robots that will eventually autonomously move through your system and be able to do things that surgeons can't do in a much less invasive manner. Sometimes, it might even self-assemble in your GI system and be augmented reality.

On the cardiac side, pacemakers are getting smaller and much easier to place, so you don't need to train an interventional cardiologist to place them, and they’re going to wirelessly connect to your mobile devices, so you can go places and be monitored remotely. These are shrinking even further. Here’s one that’s in prototyping by Medtronic. It's smaller than a penny. Artificial retinas, the ability to put these arrays on the back of the eyeball, allow the blind to see again in early trials. Moving into the future, these are going to be game-changing.

For those of us who are sighted, how about having the assisted living contact lens with Bluetooth and Wi-Fi available, which beams back images to your eye? Now if you have trouble maintaining your diet, it might help to have some extra imagery to remind you how many calories will be coming at you. How about enabling the pathologist to use their cellphone again to see at a microscopic level and tell ember that data back to the cloud, making better diagnostics?

In fact, the whole era of laboratory medicine is completely changing. We can now leverage microfluidics, like this chip made by Steve Quake at Stanford. Microfluidics can replace an entire lab of technicians and put it on a chip, enabling thousands of tests to be done at the point-of-care, anywhere in the world. This is really going to leverage technology to the rural and underserved. What used to be thousand-dollar tests will be done at pennies and at the point of care.

If we go down the small pathway a little bit further, we're entering the era of nanomedicine—the ability to make devices super small to the point where we can design red blood cells or micro robots that will monitor our blood system or immune system, or even those that might even clear out the plaque from our arteries. Now, how about exponentially cheaper? Not something we usually think about in the era of medicine—that's hard. It just used to be $3,400 for 10 megabytes. It's getting probably exponentially cheaper in genomics.

Now, the genome cost about a billion dollars about ten years ago when the first one came out. We're now approaching essentially a thousand-dollar genome. Probably next year, in two years, about a hundred-dollar genome. What are we going to do with hundred-dollar genomes? Soon, we'll have millions of these tests available, and that's when it gets interesting. When we start to crowdsource that information, we enter the era of truly personalized medicine—the right drug for the right person at the right time—instead of what we're doing today, which is essentially the same drug for everybody.

So, two blockbuster drug medications, in many cases, which don't work for you, the individual. Many, many different companies are working on leveraging these approaches. I'll just show you a simple example from 23andMe. Again, my data indicates that I've got by average risk for developing macular degeneration—two kinds of blindness—but if I take that same data, upload it to Decode me, I can look at my risk for example of type 2 diabetes. I'm at almost twice the risk for type 2 diabetes. I might want to watch how much dessert I have at lunch break, for example.

It might change my behavior, leveraging my knowledge of my pharmacogenetics—how my genes modulate what my drugs do and what doses I need—are going to become increasingly important, and what's in the hands of the individual and the patient will make better drug dosing and selection available. So again, it's not just genes; it's multiple details, our habits, our environmental exposures. When was the last time your physician asked you where you've lived? Geo medicine, where you live, and what you've been exposed to can dramatically affect your health. We can capture that information.

So, genomics, proteomics, the environment—all this data streaming at us individually and as poor physicians. How do we manage it? Well, we're now entering the era of systems medicine or systems biology, where we can start to integrate all this information. By looking at the patterns, for example, in our blood of 10,000 biomarkers at a single test, we can start to look for these little patterns and detect disease at a much earlier stage.

This is being called by Li Hood the father of the fear of P4 medicine. We're going to be predictive; we're going to know what you're likely to have. We can be preventive; that prevention can be personalized. More importantly, it's going to become increasingly participatory through websites like Patients Like Me or managing your data on a Microsoft Health Vault or a Google Health. Leveraging this together in participatory ways is going to become increasingly important.

So I'll finish up with exponentially better. We’d like to get therapies that are better and more effective. Now, today, we treat high blood pressure mostly with pills. What if we took a new device and knocked out the nerve vessels that delayed blood pressure, and a single therapy basically cured hypertension? This is a new device that essentially is doing that, and it should be on the market within a year or two.

How about more targeted therapies for cancer? Right? I'm an oncologist, and I know today most of what we give is essentially poison. We've learned at Stanford and other places that we can discover cancer stem cells, so once it seemed to be really responsible for disease relapse. If you think of cancer as a weed, we often can whack the weed away. It seems to shrink, but often it comes back.

So we're attacking the wrong target. The cancer stem cells remain, and the tumor can return months or years later. We're now learning to identify the cancer stem cells and identify those as targets and go for the long-term cure. We're ending the era of personalized oncology—the ability to leverage all this data together, analyze the tumor, and come up with a real specific cocktail for the individual patient.

Now, I'll close with regenerative medicine. So I've studied a lot about stem cells. Embryonic stem cells are particularly powerful. We also have adult stem cells throughout our body. We use those in my field of bone marrow transplantation. Geron just last year started the first trial using human embryonic stem cells to treat spinal cord injuries. Still in phase one trials, but evolving.

We've been actually using adult stem cells now in clinical trials for about 15 years to approach a whole range of topics, particularly in treating cardiovascular disease. If we take our own bone marrow cells and treat a patient with a heart attack, we can see much improved heart function and actually better survival using our own bone marrow stem cells after a heart attack. I invented a bicycle, the Marrow Miner, a much less invasive way for harvesting bone marrow. It's now been FDA approved and will hopefully be on the market in the next year.

So, hopefully, you can appreciate the device that curves through the patient's body and removes the bone marrow instead of with 200 punctures, which is a single puncture under local anesthesia. But where is stem cell therapy really going? If you think about it, every cell in your body has the same DNA as you had when you were an embryo. We can have reprogrammed your skin cells to actually act like a pluripotent embryonic stem cell and utilize those potentially to treat multiple organs in that same patient, making your own personalized stem cell lines.

I think there'll be a new era of your own stem cell banking to have in the freezer. Your own cardiac cells, myocytes, neural cells to use them in the future should you need them. We're integrating this now with a whole new era of cellular engineering and integrating exponential technologies for essentially 3D organ printing, replacing the ink with cells, and essentially building and reconstructing a 3D organ. That's where things are going to head; still very early days.

But I think, as we integrate these exponential technologies, this is the example. So, in closing, as you think about the technologies and how to impact health and medicine, we're entering an era of miniaturization, decentralization, and personalization. I think by pulling these things together, we can start to think about how to understand and leverage these. We're going to empower the patient, enable the doctor, enhance wellness, and begin to cure the well before they get sick.

Because I know, as a doctor, if someone comes to me with stage one disease, I'm thrilled. We can often cure them. But often it's too late, and it's stage three or four cancer, for example. By leveraging these technologies together, I think we'll enter a new era that I like to call stage zero medicine. And as a cancer doctor, I'm looking forward to being out of a job. Thanks very much!