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"20 doctor |nc|uded": specu|at|ons & mus|ngs of a techno|ogy opt|m|st

by vlnod khosla

ln recenL Lalks aL Lhe unlverslLy of Callfornla, San lranclsco and oLher venues, l lald ouL my Lhesls on
how moblle devlces, blg daLa, and arLlflclal lnLelllgence wlll dlsrupL healLhcare. l belleve lL ls lnevlLable
LhaL Lhe ma[orlLy of physlclans' dlagnosLlc and prescrlpLlon work (physlclans do oLher work Loo) wlll be
replaced wlLh smarL hardware and sofLware, and healLhcare wlll become beLLer, more conslsLenL across
physlclans, and more sclenLlflc. 1he remalnlng 20 of physlclans' work wlll be AMLlllLu, glvlng Lhem
beLLer capablllLy. Clven Lhe lmporLance of havlng clarlLy on whaL l hypoLheslzed (my forecasLs are
dlrecLlonal guesses raLher Lhan preclse predlcLlons) abouL how healLhcare mlghL change, l'd llke Lo make
clarlfy my vlews and respond Lo some of Lhe recenL commenLary.
LeL me sLarL wlLh a summary:
1. PealLhcare Loday ls ofLen really Lhe pracLlce of medlclne" raLher Lhan Lhe sclence of
medlclne". ln Lhe worsL cases of Lhe pracLlce of medlclne, docLors [usL Lake moderaLely
educaLed shoLs ln Lhe dark when lL comes Lo paLlenL care. hyslclans should be much more
sclenLlflc and daLa-drlven. 1haL's hard for Lhe average physlclan Lo pull off wlLhouL Lechnology,
because of Lhe lncreaslng amounL of daLa and research released every year. nexL-generaLlon
medlclne wlll be Lhe sclenLlflc arrlval aL dlagnosLlc and LreaLmenL concluslons and real LesLlng of
whaL's acLually golng on ln your body. And, lL wlll be much more personallzed Lhan your
physlclan can provlde. uaLa sclence wlll be key Lo Lhls.
2. 1echnology makes up for human deflclencles and ampllfles sLrengLhs - Mus and even oLher less
Lralned medlcal professlonals can do much more Lhan Lhey do now. 8y 2023 more daLa-drlven,
auLomaLed healLhcare wlll dlsplace up Lo 80 of physlclans' dlagnosLlc and prescrlpLlon work. lL
wlll AMLll? physlclans by armlng Lhem wlLh more compleLe, synLheslzed, and up-Lo-daLe
research daLa, all leadlng Lo beLLer paLlenL ouLcomes. CompuLers are much beLLer Lhan people
aL organlzlng and recalllng lnformaLlon. 1hey have larger and less corrupLlble memorles,
remember more complex lnformaLlon much more qulckly and compleLely, and make far fewer
mlsLakes Lhan a hoL shoL Mu from Parvard. ConLrary Lo popular oplnlon, Lhey're also beLLer aL
lnLegraLlng and balanclng conslderaLlons of paLlenL sympLoms, hlsLory, demeanor,
envlronmenLal facLors, and populaLlon managemenL guldellnes Lhan Lhe average physlclan.
3. 1he healLhcare LranslLlon wlll sLarL lncremenLally and develop slowly ln sophlsLlcaLlon, much llke
a greaL Mu who sLarLs wlLh seven years of med school and Lhen spends a decade Lralnlng wlLh
Lhe besL pracLlLloners by waLchlng, learnlng, and experlenclng. LxpecL many laughlng-sLock
aLLempLs by Loddler Mu compuLer sysLems" early ln Lhelr evoluLlon and learnlng. 1hese
sysLems wlll grow wlLh Lhe help of Lhe Lop Mus and AMLll? Lhem so everyone can have Lhe
besL, mosL researched care, noL Lhe average, overburdened, and rushed docLor Lhe average
person geLs Loday! ln facL, Lhe very besL Mus wlll be an lnLegral parL of deslgnlng and bulldlng
Lhese advanced sysLems.
4. 1he sysLems of 10-13 years from now (whlch ls Lhe Llme frame l am Lalklng abouL) wlll overcome
many of Lhe shorL-Lerm deflclencles of Loday's Lechnologles. 8y analogy, uslng Loday's
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Lechnology Lhen would be llke our carrylng Lhe mulLl-pound phones from 1987 (Lhey were floor
mounLed cell phones wlLh blg handseLs and heavy cords) ln our pockeLs raLher Lhan lhones.
1here wlll be polnL lnnovaLlons LhaL seem lmmaLerlal, buL, when Lhere are enough of Lhem, Lhey
wlll lnLegraLe wlLh each oLher and sLarL Lo feel llke a revoluLlon. ln Lhe meanLlme, expecL Lhese
early sysLems and Lools Lo be Lhe buLL of [okes from many a wrlLer or Mu. Larly prlnLers,
Lyplcally doL maLrlx", dld noL exacLly cuL lL for buslness correspondence, leL alone replace
LradlLlonal means. Larly medlcal sysLems wlll be used ln non-crlLlcal roles or under physlclan
supervlslon. LvenLually, Lhls shlfL ln how healLhcare ls dellvered wlll allow for less money Lo be
spenL on caplLal equlpmenL, cuLLlng healLh care cosLs. lL wlll allow us Lo provlde care Lo Lhose
who don'L have lL now. And, lL wlll prevenL slmple Lhlngs from geLLlng worse before belng
addressed.
3. 1he human elemenL of care, provlded by humane humans, noL rushed, overloaded Mus, wlll sLlll
be around. 1hese people may have Mus anyway, buL Lhey won'L need Len or LwenLy years of
medlcal school Lralnlng. Cr, when Lhey have Lhe Lralnlng, Lhey wlll become much beLLer
dlagnosLlclans and careglvers. 8eyond dlagnosls and LreaLmenL, Lhere are many Lhlngs docLors
do LhaL won'L be replaced.
6. 1he problem ln healLhcare ls noL wlLh docLors, many of whom are accompllshed, carlng, honesL,
and compasslonaLe provlders. 1he problem ls Lhe lncredlble lncrease ln complexlLy of Lhe newly
enabled daLa (some exLrlnslc), vasL amounLs of research, longlLudlnal healLh records, and
hlsLorles wlLhouL Lhe self-reporLlng lnaccuracles of Lhe paLlenL LhaL allows for Lhe much more
lnLegraLlve analysls LhaL ls now posslble. 1he problem ls also Lhe mlsallgnmenL of lncenLlves ln
medlclne, where organlzaLlons Lry Lo maxlmlze revenue (exLra surgerles anyone?) aL Lhe
expense of opLlmlzlng care. 1hls ls why lnnovaLlon wlll mosL llkely happen from Lhe ouLslde. lL ls
also lmporLanL Lo reallze LhaL l refer Lo Lhe AvL8ACL CLC8AL docLor" or healLhcare concern,
noL every docLor or company. 1he sLandards of performance ln some parLs of Lhe world and ln
some parLs of Lhls counLry are very dlfferenL Lhan Lhose ln Lhe besL meLropollLan hosplLals ln Lhe
unlLed SLaLes. l also noLe LhaL 30 of Mu's are below average Lhough every docLor mosL people
know ls above average!

ract|ce vs. sc|ence
Cne of my prlnclpal concerns abouL healLhcare Loday ls LhaL lL's ofLen really Lhe pracLlce of medlclne"
raLher Lhan Lhe sclence of medlclne". 1ake modern medlclne's vlew Lowards fever as an example. lor
130 years, docLors have rouLlnely prescrlbed anLlpyreLlcs (asplrln, aceLamlnophen, eLc.) Lo help reduce
fever, slnce fever was vlewed as an lnablllLy of Lhe body Lo regulaLe lLself and Lherefore needed Lo be
reduced aggresslvely ln all cases. 8uL ln 2003, researchers aL Lhe unlverslLy of Mlaml, llorlda, ran a sLudy
of 82 lnLenslve care paLlenLs, for whom proLecLlon from hlgh LemperaLures was LradlLlonally LhoughL Lo
be lmporLanL. 1he paLlenLs were randomly asslgned Lo recelve anLlpyreLlcs elLher lf Lhelr LemperaLure
rose beyond 101.3l (Lhe sLandard LreaLmenL") or only lf Lhelr LemperaLure reached 104l. As Lhe Lrlal
progressed, seven people geLLlng Lhe sLandard LreaLmenL dled, whlle Lhere was only one deaLh ln Lhe
group of paLlenLs allowed Lo have a hlgher fever. AL Lhls polnL, Lhe Lrlal was sLopped because Lhe Leam
felL lL would be uneLhlcal Lo allow any more paLlenLs Lo geL Lhe !"#$%#&% "&(#")($". So when someLhlng
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as baslc as fever reducLlon ls a hallmark of Lhe pracLlce of medlclne" and hasn'L been challenged for
100+ years, we have Lo ask whaL else mlghL be pracLlced due Lo LradlLlon raLher Lhan sclence?"
ln Lhe worsL cases of Lhe pracLlce of medlclne, Lhe average" docLors [usL Lake moderaLely educaLed
shoLs ln Lhe dark when lL comes Lo paLlenL care. A dlagnosls ls parLlally lnformed by Lhe paLlenL's medlcal
hlsLory (buL ofLen noL really), parLlally lnformed by sympLoms (buL paLlenLs aren'L very good aL
communlcaLlng whaL's really golng on), and mosLly lnformed by pharma adverLlslng and Lhe docLor's
half-remembered lessons from medlcal school (whlch are laden wlLh cognlLlve blases, recency blases,
and oLher very human errors, besldes poLenLlally havlng been obsoleLed by more recenL research).
Many Llmes, lf you ask Lhree docLors Lo look aL Lhe same problem, you'll geL Lhree dlfferenL dlagnoses
and Lhree dlfferenL LreaLmenL plans. As a paLlenL, how do you feel when a docLor keeps changlng hls
mlnd abouL your dlsease over Llme? Pow do you feel lf dlfferenL docLors say dlfferenL Lhlngs abouL your
dlsease? 1oday, Lhls happens ofLen. ln some areas, psychlaLry for example, docLors frequenLly dlsagree
on dlagnoses. 8esearch has found LhaL psychlaLrlsLs uslng Lhe ulagnosLlc and SLaLlsLlcal Manual of
MenLal ulsorders (uSM), Lhe sLandard desk reference for psychlaLrlc dlagnoses, have dangerously low
dlagnosLlc agreemenL. 1he uSM v uses a sLaLlsLlc called Lhe kappa" Lo measure Lhe level of agreemenL
beLween psychlaLrlsLs (ranglng from 0 for no agreemenL and 1 for compleLe agreemenL). ln research
Lrlals, Lhe uSM v, whlch ls seL Lo be publlshed ln May 2013, generaLes a kappa of 0.2 for generallzed
anxleLy dlsorder and 0.3 for ma[or depresslve dlsorder. SclenLlflc Amerlcan descrlbed Lhese resulLs for
Lhe sLandard of psychlaLrlc care as Lwo plLlful kappas". And ofLen, Lhere are errors of omlsslon where a
dlagnosls ls [usL mlssed enLlrely.
1he neL effecL of all Lhls ls paLlenL ouLcomes LhaL are far lnferlor Lo and more expenslve Lhan whaL Lhey
should be. 1he currenL benchmarks of performance aren'L good enough, and lL's Lrlvlally easy Lo flnd
sLudy afLer sLudy LhaL demonsLraLes Lhe shorLcomlngs of Lhe pracLlce of medlclne. A !ohns Popklns
sLudy found LhaL as many as 40,300 paLlenLs dle ln an lCu ln Lhe uS each year due Lo mlsdlagnosls,
rlvallng Lhe number of deaLhs from breasL cancer. ?eL anoLher sLudy found LhaL 'sysLem-relaLed facLors',
e.g. poor processes, Leamwork, and communlcaLlon, were lnvolved ln 63 of sLudled dlagnosLlc error
cases. 'CognlLlve facLors' were lnvolved ln 73, wlLh 'premaLure closure' (sLlcklng wlLh Lhe lnlLlal
dlagnosls and lgnorlng reasonable alLernaLlves, or, more fanclfully Lermed, Lhe conflrmaLlon blas") as
Lhe mosL common cause. 1hese Lypes of dlagnosLlc errors also add Lo rlslng healLhcare expendlLures,
cosLlng $300,000 per malpracLlce clalm.
hyslclans should be much more sclenLlflc and daLa-drlven ln provldlng paLlenL care. 1haL's hard Lo pull
off wlLhouL Lechnology, because of Lhe lncreaslng amounL of daLa and research released every year. lor
example, sLandard operaLlng procedure lnvolves glvlng Lhe same drug Lo mllllons of people even Lhough
we know LhaL each paLlenL meLabollzes medlcaLlon aL dlfferenL raLes and wlLh dlfferenL effecLlveness.
Many of us are even reslsLanL Lo asplrln. Lach person should be LreaLed dlfferenLly, buL Lhe average
docLor can'L handle Lhe lnformaLlon requlred Lo do LhaL. nor does he have enough Llme or knowledge Lo
do lL. PealLhcare needs Lo become much more abouL daLa-drlven deducLlon and less abouL Lrlal-and-
error. nexL-generaLlon medlclne wlll be Lhe sclenLlflc arrlval aL dlagnosLlc and LreaLmenL concluslons
based on probablllLles and real LesLlng of whaL's acLually golng on ln your body. And, lL wlll be much
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more personallzed Lhan your physlclan can provlde. SysLems wlll uLlllze more complex models of
lnLeracLlons wlLhln Lhe human body and much more sensor daLa Lhan a human Mu could comprehend
Lo suggesL dlagnosls. 1housands of basellne and dlsease mullL-ohmlc (genomlc, meLabolomlcs,
mlcroblomlc, and oLher) daLa polnLs, more lnLegraLlve hlsLory, and demeanor wlll go lnLo each dlagnosls.
Lver-lmprovlng dlalog manager sysLems wlll help make daLa capLure and exploraLlon from paLlenLs more
accuraLe and comprehenslve. uaLa sclence wlll be key Lo Lhls. ln Lhe end, Lhls would reduce cosLs,
reduce physlclan workloads, and lmprove paLlenL care. uocLors wlll also be able Lo Lallor Lhelr
explanaLlons Lo Lhe healLh llLeracy level of paLlenLs uslng common-language Lerms and adapLlng Lhe
sophlsLlcaLlon level uslng compuLerlzed dlalog managers. 1hese compuLerlzed managers wlll be paLlenL,
unllke your Lyplcal docLor ln a hurry" wlLh Lhe usual unforLunaLe case overload. 1hls maLLers because,
accordlng Lo Lhe lnsLlLuLe of Medlclne, nearly 100M uS adulLs have llmlLed healLh llLeracy skllls" LhaL
are mosL llkely Lo affecL Lhelr healLh ouLcomes!

kep|ac|ng 80 of what doctors do?
AL Lhe hearL of my vlew ls LhaL much of whaL physlclans do (checkups, LesLlng, dlagnosls, prescrlpLlon,
behavlor modlflcaLlon, eLc.) can be done beLLer by well-deslgned sensors, passlve and acLlve daLa
collecLlon, and analyLlcs, wlLhouL necessarlly Laklng away from Lhe human elemenL of care (especlally ln
Lhe 2020's decade when Lhls Lechnology wlll be ln lLs flfLh or LenLh evoluLlon)! LeL's Lake a brlef look aL a
sLandard physlcal as an example. uurlng a physlcal, a paLlenL wlll geL measured ln mulLlple ways ! from
welghL and blood pressure Lo pulse and resplraLlon. A nurse, docLor, or oLher careglver wlll spend 13-30
mlnuLes Lo run Lhrough all Lhese dlfferenL rouLlnes. Lvery slngle one of Lhese measuremenLs could be
done ln real-Llme by Lhe paLlenL ln more represenLaLlve envlronmenLs aL home lf he or she [usL had Lhe
rlghL sensors hooked up wlrelessly Lo a moblle devlce. All LhaL daLa could be measured and LransmlLLed
Lo Lhe docLor's offlce ln less Llme and for less money Lhan lL Lakes Lo gas up Lhe car and geL Lo Lhe
hosplLal ln Lhe flrsL place (leave aslde slLLlng ln Lhe walLlng room). Zocuoc* allows paLlenLs Lo check ln
for an appolnLmenL and provlde baslc lnformaLlon ahead of Llme. 1hls Lype of form could easlly be
expanded Lo lnclude vlLals. And our dlalog manager" could ask many follow-on quesLlons and probe
oLher sympLom posslblllLles, provldlng a more compleLe paLlenL record WPlLL reduclng Lhe amounL of
Llme Lhe docLor has Lo spend wlLh Lhe paLlenL, lf any!). no doubL, Lhe besL docLors wlll llkely do Lhls
beLLer Lhan our dlalog manager, even for Lhe nexL one or Lwo decades. 8uL, Lhe sysLem wlll be an
lmmedlaLe dramaLlc lmprovemenL compared Lo Lhe average hurrled and overloaded docLor (or worse,
Lhe developlng world no medlcal-school docLor" llvlng wlLhln 30 mlles of a rural paLlenL)!
Cf course, docLors aren'L supposed Lo [usL measure. 1hey're supposed Lo consume all LhaL daLa,
carefully conslder lL ln conLexL of Lhe laLesL medlcal flndlngs and Lhe paLlenL's hlsLory, and flgure ouL lf
someLhlng's wrong. CompuLers can Lake on much of dlagnosls and LreaLmenL work, and even do Lhese
funcLlons beLLer Lhan an average docLor could (whlle conslderlng more opLlons and maklng fewer
errors). WhaL lf you're a hearL paLlenL? lL's a slmple facL LhaL mosL docLors couldn'L posslbly read and
dlgesL all of Lhe laLesL 3,000 research arLlcles on hearL dlsease. ln facL, mosL of Lhe average docLor's
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medlcal knowledge ls from when Lhey were ln medlcal school, and cognlLlve llmlLaLlons prevenL Lhem
from rememberlng Lhe 10,000+ dlseases humans can geL.
CompuLers are much beLLer Lhan people aL organlzlng and recalllng lnformaLlon. 1hey have larger and
less corrupLlble memorles, remember more complex lnformaLlon much more qulckly and compleLely,
and make far fewer mlsLakes Lhan a hoLshoL Mu from Parvard. ConLrary Lo popular oplnlon, Lhey're also
beLLer aL lnLegraLlng and balanclng conslderaLlons of paLlenL sympLoms, hlsLory, demeanor,
envlronmenLal facLors, and populaLlon managemenL guldellnes Lhan Lhe average physlclan. 8esldes,
who wanLs Lo be LreaLed by Lhe average or below-average physlclan? 8emember, 30 of Mus are
below-average! noL only LhaL, compuLers have much lower error raLes. Shouldn'L we Lake advanLage of
LhaL when lL comes Lo our healLh?!
1echnology makes up for human deflclencles and ampllfles sLrengLhs - Mus and even oLher less Lralned
medlcal professlonals can do much more. LvenLually, compuLers *+,, replace 80 of whaL docLors do buL
ampllfy Lhe docLor's capablllLles, reduclng mlsdlagnosls, ln whaL Lhey do by armlng Lhem wlLh more
compleLe, synLheslzed, and up-Lo-daLe daLa, all leadlng Lo beLLer paLlenL ouLcomes. hyslclans spend Loo
much Llme dolng Lhlngs compuLers can do, and we should glve Lhem more Llme for Lhlngs LhaL unlquely
requlre human lnvolvemenL, llke provldlng paLlenLs warm & fuzzles", comforLlng klds ln pedlaLrlc care,
maklng lnherenLly sub[ecLlve declslons LhaL requlre empaLhy or a conslderaLlon of eLhlcs, and provldlng
a frlendly ear for lonely paLlenLs. Some of Lhese funcLlons may noL need medlcal school Lralnlng aL all,
buL raLher draw on more empaLhlc skllls and could acLually be done by non-Mus. Llfecom, an Al
dlagnosLlcs englne company, showed ln cllnlcal Lrlals LhaL medlcal asslsLanLs uslng a knowledge englne
were 91 accuraLe ln dlagnosls *+"-./" /!+$0 ,#1!2 +)#0+$02 .& (3#)!. AnoLher cllnlcal sLudy by Lhe
same company demonsLraLed LhaL greaLer Lhan 73 of cases can be safely Lrlaged Lo be LreaLed by 8ns,
wlLh Lhe remalnder handled by docLors. AnoLher sLudy aL MassCen found LhaL 23 of Lhe Llme, a
medlcal record for paLlenLs who wound up wlLh 'hlgh rlsk dlagnoses' had 'hlgh lnformaLlon cllnlcal
flndlngs' before a physlclan evenLually made Lhe dlagnosls - ln oLher words, Lhere was a slgnlflcanL
delay LhaL mlghL have been avolded had a cllnlcal declslon supporL sysLem been used Lo parse Lhe noLes!
lnlLlally, many docLors wlll be agalnsL Lhls LranslLlon and won'L supporL lL, buL new Lechnologles wlll
make Lhe recepLlve docLors much beLLer aL Lhelr [ob - qulcker, more accuraLe, and more facL-based.
1here ls a Lremendous opporLunlLy here ln Lhe lnflux of daLa LhaL has never before been avallable. AL
flrsL, compuLers wlll [usL help ln declslon supporL, sLarLlng by leveraglng guldance from Lhe very besL
docLors. LvenLually (someLlme ln Lhe nexL 10-13 years), compuLers wlll become beLLer dlagnosLlclans
Lhan your average docLor. Cnce we have a large enough daLaseL on dlfferenL people ln dlfferenL
slLuaLlons, along wlLh an addressable daLabase of research sLudles, we wlll be amazed aL how much
beLLer compuLers can do over Loday's paLlenL ouLcomes. We'll be able Lo ldenLlfy paLLerns and
lnLeracLlons among varlous areas of physlology ln ways LhaL weren'L posslble before, maklng Lhe llnk
beLween changes ln one area of Lhe body causlng sympLoms ln anoLher area. uocLors wlll sLruggle Lo
keep up, buL Lhen wlll lncreaslngly rely on Lhese Lools Lo make declslons. Cver Llme, Lhey wlll lncrease
Lhelr rellance on Lechnology for Lrlage, dlagnosls, and declslon-maklng, so LhaL we'll need fewer docLors
and every paLlenL wlll recelve Lhe besL care. ulagnosls and LreaLmenL plannlng wlll be done by a
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compuLer, used ln concerL wlLh Lhe empaLheLlc supporL from medlcal personnel selecLed and Lralned
more for Lhelr carlng personallLles Lhan for Lhelr dlagnosLlc ablllLles. no brllllanL dlagnosLlclan wlLh bad
manners, a la ur. Pouse", wlll be needed ln dlrecL paLlenL conLacL. Pe can besL serve as Lhe Lralner for
Lhe new ur. AlgorlLhm", whlch we'll use Lo provlde Lhe dlagnosls, whlle Lhe mosL humane humans ,
(nurse pracLlLloners or oLher medlcal professlonals) wlll provlde Lhe care.
LvenLually, compuLers wlll model and Lrack your enLlre healLh sLaLe. 1hey'll read your mood by analyzlng
your faclal expresslon, gauge your soclal acLlvlLy Lhrough Lhe number of emalls you senL, calls you made,
or Lhlngs you LweeLed, Lrack your moblllLy and acLlvlLy from your CS as Clnger.lo* does ln asslsLlng
menLal healLh paLlenLs or !awbone* u band, and monlLor your vlLals Lhrough your food lnLake, galvanlc
skln response, hearL raLe, and skln LemperaLure, among oLher Lhlngs. no docLor could be Lhls
lnLegraLlve. 1here are already numerous sLarLups (and oLhers soon Lo be launched) LhaL plan Lo collecL
healLh daLa ln a frlcLlonless, easy way ln order Lo creaLe beLLer basellne sysLems models of Lhe body for
paLlenLs. CLhers wlll do predlcLlve analyLlcs on LhaL lnformaLlon and head off problems before Lhey
arlse. SLlll more wlll suggesL llfesLyle approaches Lo lmprove Lhe way people llve. Some of Lhls change ls
already happenlng, buL Lhls quleL rumbllng of daLa-drlven dlagnosLlcs wlll become an avalanche ln Lhe
fuLure, playlng ouL slmllarly Lo Lhe exploslon of cellphones. lmaglne Loday's sysLems, lmproved 10x by a
decade or Lwo of evoluLlon and compeLlLlon. nobody expecLed cell phones Lo Lake over lndla ln 2000,
buL now ln 2012, few people remember LhaL cell phones weren'L expecLed Lo be unlversal (A1&1 even
kllled off Lhelr moblle buslness ln Lhe 80s because Mcklnsey Lold Lhem Lhe LoLal uS markeL would be less
Lhan a mllllon devlces by 2020).
uevlce- and daLa-drlven healLhcare wlll also exLend Lhe reach of medlclne. lL wlll change publlc healLh,
especlally ln Lhe developlng world. A counLry llke lndla needs Len Llmes as many docLors Lo serve
everyone well, and LhaL's noL affordable. MosL docLors Lhere don'L have access Lo Lhe laLesL, expenslve
research [ournals and couldn'L asslmllaLe all Lhe lnformaLlon conLalned ln Lhem even lf Lhey had Lhe
Llme, paLlence, and lncllnaLlon Lo read Lhem. A moblle phone could provlde Lhe needed LesLlng and
dlagnosls Lo Lhe remoLesL vlllages and aL very affordable cosLs. 1hls Lype of care ls [usL noL posslble uslng
Loday's medlcal school graduaLes, who Lend Lo be clusLered around clLles.

Systems w||| start as c|umsy todd|ers and deve|op to matur|ty and eff|c|ency!
uon'L expecL ace dlagnosls sysLems overnlghL. 1hey may sLarL as seemlngly mlnor polnL lnnovaLlons or as
clumsy-soundlng sysLems noL ready for prlme Llme.
lmaglne uslng a devlce llke Lhe AllveCor* lhone case Lo Lake an LCC afLer every workouL. WhaL abouL
every Llme you feel llghLheaded or numb? WhaL abouL every slngle mornlng, [usL llke dlabeLlcs who
measure Lhelr blood sugar mulLlple Llmes a day? now whaL lf you could geL an LCC case for free and do
measuremenLs for less Lhan $1/LesL? lf you're a hearL paLlenL, Lhls devlce and oLhers llke lL would
capLure a loL more lnformaLlon Lhan your annual or semlannual LCC check aL Lhe docLor's offlce. noL
only LhaL, Lhe offlce check wlll cosL hundreds Lo even Lhousands of dollars, and whaL's more, you
- 7 -
probably wouldn'L be exhlblLlng any sympLoms durlng Lhe ln-person vlslL anyway lf your condlLlon ls
lnLermlLLenL. WhaL lf you lnsLead senL 300 LCCs Lo your docLor over Lhe course of a year for less Lhan lL
cosLs Lo geL one LCC done ln Lhe hosplLal? WhaL do you Lhlnk Lhe average physlclan would do wlLh all
LhaL valuable daLa? Pe or she would have no clue whaL Lo do wlLh lL, whlch ls why we'd need sofLware
Lo auLo-dlagnose" Lhe LCC. 1oday, mosL hearL dlsease ls ldenLlfled only afLer paLlenLs have hearL
aLLacks. 8uL lmaglne havlng prevenLaLlve cardlac care, wlLh every aL-rlsk paLlenL havlng an LCC every
mornlng for less Lhan a buck. AfLer belng Lralned Lo ldenLlfy abnormallLles, machlne-learnlng sofLware
could 4&(%+5" eplsodes lndlcaLed by Lhe Len or so LCCs ouL of LhaL seL of 300 LhaL Lhe cardlologlsL should
pay aLLenLlon Lo (before geLLlng Lo a polnL compuLers can do an LkC read Lhemselves for pennles),
slmulLaneously maklng hls or her [ob easler Anu more effecLlve. We could dlscover mosL hearL dlsease
well before a hearL aLLack or sLroke and address lL aL a fracLlon of Lhe cosL of care LhaL would be needed
followlng such a Lrauma. 8uL we need a decade of daLa Lo be really good aL lL.
Many dermaLology appolnLmenLs could be handled by CellScope* whlch produces low-cosL lhone
aLLachmenLs for lmaglng skln moles, rashes, ear lnfecLlons, and (ln Lhe fuLure) your reLlna or LhroaL. 1he
resulLlng lmages, Laken aL home, could be processed by sophlsLlcaLed algorlLhms runnlng ln Lhe cloud Lo
deLecL paLLerns LhaL warranL closer lnspecLlon (e.g. Sklnvlslon uses Lhe fracLal naLure of paLLerns ln a
skln lmage Lo deLermlne more accuraLely Lhan mosL general physlclans wheLher you have skln cancer).
?ou mlghL geL a dlagnosls a loL fasLer Lhan lL Lakes Lo geL a docLor's appolnLmenL and Lhen Lake your
chlld Lo Lhe cllnlc. And follow-up 'vlslLs' could happen every slx or Lwelve hours! A devlce llke Lhe
LyeneLra* could glve you an eye LesL and flL you for eyeglasses aL llLLle cosL or hassle. 1echnology could
handle dlagnoses, lab orders, and wrlLlng prescrlpLlons, asklng for human asslsLance or lnpuL only when
necessary.
Lvery meLabollc process LhaL has a volaLlle byproducL causes changes ln your breaLh. AdamanL* ls a very
rlsky sLarLup LhaL's aLLempLlng Lo produce a chlp LhaL can deLecL hundreds of gases ln your breaLh. lf
you're asLhmaLlc, lL can measure Lhe level of nlLrous oxlde and predlcL wheLher you're aL rlsk of havlng
an aLLack. lf you're dlabeLlc and have keLones ln your breaLh, lL can deLecL LhaL Loo and Lell you LhaL your
body ls undergolng keLosls. lL can deLecL lf you have lung cancer and even Lell you whaL "64( of lung
cancer. lL wlll even deLecL wheLher you're burnlng faL or sugars durlng exerclse, because each resulLs ln
dlfferenL componenL concenLraLlons ln your breaLh. 1hls llLLle chlp wlll do all Lhls lnexpenslvely, for far
less Lhan a blg, expenslve C1 scanner LhaL'll [usL Lell you LhaL you have a nodule ln your lungs buL can'L
Lell you whaL klnd of lung cancer you have. LvenLually, you won'L have a docLor sLare aL you and Lell you
LhaL you look well, lnsLead, your docLor wlll be able Lo look aL Lhe levels of hundreds of compounds ln
your breaLh and 7$.* wheLher you're well.
Speaklng of looklng well, a sLarLup named Clnger.lo* deLermlnes paLlenLs' menLal healLh based on a
varleLy of meLrlcs. lL can monlLor your raLe of emalllng, LweeLlng, LexLlng, and calllng Lo gauge your
soclal acLlvlLy. uslng moLlon sensors and your phone's CS, lL can even know lf you're hldlng ln your
bedroom, eaLlng ln your klLchen, or [usL sLaylng ln bed. 8y waLchlng for changes ln your behavlor, lL can
Lell how you're dolng far beLLer Lhan a psychlaLrlsL could posslbly deLermlne and acLually calls your
psychlaLrlsL lf you're ln Lhe danger zone of an eplsode. lor example, deLecLlng a behavloral paLLern
- 8 -
change LhaL's lndlcaLlve of blpolar dlsorder could help us prevenL shooLlng sprees of Lhe Lype we've seen
recenLly.
1here are many oLher sLarLups dolng lnnovaLlve Lhlngs ln healLhcare. roLeus ls helplng address drug
non-compllance, one of Lhe blggesL problems ln medlclne. 1hey've deslgned a clever sysLem LhaL
comblnes a plll sensor, a body paLch, and a moblle app. 1hey aLLach a Llny, lngesLlble sensor Lo pllls LhaL
geLs acLlvaLed by sLomach aclds. When a paLlenL Lakes Lhe plll, Lhe sensor sends a slgnal Lo Lhe body
paLch, whlch Lhen relays Lhe slgnal Lo Lhe app. 1hls sysLem wlll allow careglvers Lo remoLely monlLor
paLlenL adherence by lndlvldual, Llme-sLamped plll consumpLlon evenLs. 1hls ls a far beLLer soluLlon Lhan
havlng your docLor base a dlagnosls on Lhe one-Llme blood LesL done ln Lhe cllnlc. LmpaLlca uses sensors
on paLlenLs' wrlsLs Lo measure blo-slgnals LhaL correlaLe wlLh emoLlon. lmaglne havlng a conLlnuous and,
more lmporLanLly, accuraLe and ob[ecLlve measuremenL of your emoLlons for a monLh lnsLead of only
Lhe laLesL, blased descrlpLlon LhaL you mlghL glve (or forgeL Lo glve) Lo your hurrled physlclan. Several
companles are also lmprovlng remoLe monlLorlng and dlagnosls ln Lhe cllnlcal seLLlng. AlrSLrlp
1echnologles provldes real-Llme vlLal slgns Lo physlclans' moblle devlces. SoLera Wlreless provldes a
baLLery-powered moblle devlce for monlLorlng vlLal slgns. Aglle ulagnosls and Llfecom are lmprovlng
cllnlcal declslon-maklng by provldlng declslon Lrees wlLh probablllLy-based ouLcomes for physlclans aL
Lhe polnL of care. 1hese and oLher sLarLups are forclng us Lo reLhlnk healLhcare from dlagnosLlcs Lo
LreaLmenL.
1hls ls only Lhe beglnnlng of Lhe many generaLlons of lmprovemenL LhaL are llkely Lo happen ln Lhe nexL
Lwo decades, buL we have already begun Lo see meanlngful lmpacLs on healLhcare. SLudles have
demonsLraLed Lhe ablllLy of compuLerlzed cllnlcal declslon supporL sysLems Lo lower dlagnosLlc errors of
omlsslon slgnlflcanLly, dlrecLly counLerlng Lhe 'premaLure closure' cognlLlve blas. lsabel ls a dlfferenLlal
dlagnosls Lool and, accordlng Lo a SLony 8ook sLudy, maLched Lhe dlagnoses of experlenced cllnlclans ln
74 of complex cases. 1he sysLem lmproved Lo a 93 maLch afLer a more rlgorous enLry of paLlenL daLa.
Lven l8M's fancy WaLson compuLer, afLer beaLlng all humans aL Lhe very human lnLelllgence-based Lask
of playlng 8(.4#&%6, ls now Lurnlng lLs aLLenLlon Lo medlcal dlagnosls. lL can process naLural language
quesLlons and ls fasL aL parslng hlgh volumes of medlcal lnformaLlon, readlng and undersLandlng 200
mllllon pages of LexL ln 3 seconds.
8lghL now, lsabel and WaLson requlre physlclans Lo ask follow-up quesLlons of Lhe paLlenL, a polnL of
lnefflclency and poLenLlal cognlLlve blas lnLroducLlon. 8uL, Llfecom has Lhe medlcal LexL-parslng,
knowledge-base generaLlon, and runLlme dlagnosLlc capablllLles of WaLson, whlle also belng able Lo
auLomaLlcally propose a follow-on quesLlon or LesL Lo ellmlnaLe candldaLes from Lhe dlfferenLlal
dlagnosls llsL. 1hls acceleraLes Lhe dlagnosLlc process and lessens blases lnLroduced by Lhe human
elemenL of quesLlon-framlng. WaLson also relles on machlne-learned, purely sLaLlsLlcal relaLlonshlps
among sympLoms, flndlngs, and causes, whereas a sysLem llke Llfecom adds Lo LhaL ablllLy Lhe use of a
medlcal onLology, Lhe web of physlologlcal, anaLomlcal, and oLher concepLs, as well as Lhelr
lnLerrelaLlonshlps. lL's Loo early Lo Lell whlch approach wlll work beLLer ln Lhe long Lerm, buL Lhe polnL ls
LhaL Lhese sysLems wlll conLlnue Lo evolve and, evenLually, won'L need physlclans as lnLermedlarles.
- 9 -
ln Lhe beglnnlng, Lhese polnL lnnovaLlons wlll seem lmmaLerlal, buL, when Lhere are enough of Lhem,
Lhey wlll lnLegraLe wlLh each oLher and sLarL Lo feel llke a revoluLlon. 1he medlcal devlces and sofLware
sysLems of 2020 wlll be as dlfferenL from Loday's compuLers as Lhe car floor-mounLed, mulLl-pound cell
phones wlLh bulky handseL cords of 1986 are from Loday's lhones!

D|g|ta| f|rst-a|d k|ts
1he confluence of all Lhese dlfferenL senslng, monlLorlng, and communlcaLlon Lechnologles wlll naLurally
lead Lo Lhe creaLlon of 'dlglLal flrsL ald klLs' LhaL cosL < $100 and can used aL home beLween docLor vlslLs.
1hese klLs wlll lnclude moblle apps Lo help paLlenLs deLermlne how serlous a new medlcal problem
mlghL be, as well as monlLorlng devlces LhaL can Lrack and analyze blood pressure, A1c levels, LCC
waveforms, blood oxygen levels, skln/ear/Ln1 condlLlons, soclal lnLeracLlon, and oLher lndlcaLors of how
well paLlenLs are managlng Lhelr dlabeLes, asLhma, depresslon, and oLher chronlc condlLlons. Cllnlcal
sLaff wlll help Lraln paLlenLs on Lhese devlces and apps, and, uslng sofLware, Lhey'll help Lhem lnLerpreL
healLh Lrend daLa and provlde recommendaLlons durlng reLurn vlslLs.

nea|thcare serv|ce stat|ons of the future
1he emergence of healLhcare servlce sLaLlons, found ln your local pharmacy or supermarkeL, wlll be
anoLher exclLlng phenomenon resulLlng from Lhe prollferaLlon of devlces and daLa. 1hese walk-ln
sLaLlons wlll be convenlenL - 73 of Lhe uS populaLlon llves wlLhln a 3-mlnuLe drlve of a Walgreens.
8lghL now, you can go Lo mosL of Lhese sLores and geL some baslc advlce, recelve a flu shoL, or have your
eyes checked, buL noL much else. ln Lhe near fuLure, new Lechnologles wlll enable many more servlces,
provldlng hlgh-quallLy care aL low cosL. ln Lhese cenLers, pharmaclsLs and nurse pracLlLloners wlll Lake
paLlenL hlsLorles, do slmple exams, and prescrlbe medlcaLlons or follow-on LesLs, alded by compuLerlzed
dlagnosLlcs and Lelemedlclne well before 2023.
aLlenLs wlll be able Lo walk lnLo Lhese advanced healLhcare sLaLlons wlLhouL appolnLmenLs and glve
Lhelr medlcal updaLes Lo personally-chosen avaLars on prlvaLe screens. 1hese avaLars wlll serve as
healLhcare conclerges, elucldaLlng sympLoms, wlrelessly uploadlng daLa collecLed by sensors on Lhe
paLlenL's phone, suggesLlng LesLs (Lo be done by Lhe paLlenL uslng easy-Lo-use Lools on-slLe or aL home),
and glvlng prescrlpLlons Lhrough a cllnlcal supporL sysLem, whose ablllLy Lo dlagnose and recommend
effecLlve LreaLmenLs wlll have been valldaLed agalnsL Lhe besL general pracLlLloners and speclallsLs.
SofLware wlll help 8ns dlagnose lllnesses, recommend effecLlve LreaLmenL opLlons, and refer paLlenLs Lo
speclallsLs when necessary. ln Len years, lL's llkely LhaL geneLlc LesLlng wlll be rouLlne, exLendlng
dlagnosLlc capablllLy and allowlng LreaLmenL selecLlon based on genoLype. nurse pracLlLloners wlll
perform exams and Lake lmage scans uslng lnexpenslve, dlsposable Lools (some of whlch mlghL be parL
of Lhe dlglLal flrsL-ald klL). lmages wlll be analyzed ln real-Llme by dlagnosLlc sofLware and LransmlLLed Lo
an on-call speclallsL, who pulls up paLlenL lnformaLlon, sLored ln Lhe cloud, and connecLs wlLh Lhe n and
paLlenL uslng Lelepresence sysLems. AssessmenL and LreaLmenL apps wlll be prescrlbed, downloaded,
- 10 -
and lnsLalled on paLlenLs' phones, [usL as easlly as prescrlpLlons for cold medlclne. And avaLars wlll be
accesslble whlle paLlenLs are aL home, provldlng real conLlnulLy of care. ulLlmaLely, wlLh ublqulLous
walk-ln cllnlcs ln Lhe reLall seLLlng drlven by powerful declslon-supporL sofLware, Lhe dlsLrlbuLlon of
healLhcare professlonals wlll change ln parallel wlLh Lhe dlsLrlbuLlon channel. 1he pyramld wlll flaLLen,
wlLh many more 8n-level professlonals Lralned Lo effecLlvely leverage sofLware and lnLeracL wlLh
paLlenLs, and many fewer expenslve Mus speclallzed Lo handle whaL wlll become Lhe long Lall of care.

1he human e|ement
Some of Lhe crlLlcs of more auLomaLed healLhcare argue LhaL medlclne lsn'L [usL abouL lnpuLLlng
sympLoms and recelvlng a dlagnosls, lL's abouL bulldlng personal relaLlonshlps of LrusL beLween
provlders and paLlenLs. 1he move Lowards sensor-based, daLa-drlven healLhcare doesn'L mean LhaL we'll
geL rld of human lnLeracLlon. SeroLonln admlnlsLered by comforLlng humans and Lhe placebo effecL are
only a few of many ways LhaL complex lnLeracLlons help recovery, and we shouldn'L lose Lhese Lools
(lnsLead, leL's undersLand Lhem beLLer, quanLlfy Lhem, and ampllfy Lhem). rovldlng good bedslde
manner, glvlng comforL, and answerlng cerLaln Lypes of quesLlons can ofLen be handled beLLer by a
person Lhan a machlne, buL you don'L need a medlcal degree Lo do LhaL (excepL ln some speclalLy areas
llke surgery or research). nurses, nurse pracLlLloners, soclal workers, and oLher Lypes of less expenslve,
non-Mu careglvers could do Lhls [usL as well as docLors (lf noL beLLer) and spend more Llme provldlng
personal, compasslonaLe care. lor a whlle, surgery and oLher procedures may requlre human docLors
wlLh greaLer knowledge Lhan a nurse pracLlLloner. 1he polnL ls LhaL noL every funcLlon docLors do wlll be
replaced, buL Lhe ma[orlLy wlll be done ln less Llme and wlLh greaLer efflcacy over Lhe nexL Lwo decades.
AL Lhe oLher end, some surglcal procedures requlrlng exLreme preclslon (e.g. Lumor lrradlaLlon) are besL
handled by surglcal roboLs or roboLs and humans worklng ln concerL.
Conslder hosplLal dlscharge for a momenL. ?ou mlghL Lhlnk Lhls ls a funcLlon LhaL could (or should) only
be performed by a human belng. lnLeresLlngly, a 8osLon Medlcal CenLer sLudy showed LhaL paLlenLs
preferred recelvlng dlscharge lnsLrucLlons from a compuLer lnsLead of a human and appreclaLed Lhe
amounL of Llme and lnformaLlon provlded by Lhe compuLer. AddlLlonally, paLlenLs wlLh lower healLh
llLeracy reporLed a slgnlflcanLly greaLer bond wlLh Lhe compuLer compared Lo paLlenLs wlLh hlgher
healLh llLeracy, supporLlng Lhe noLlon LhaL compuLers can provlde adequaLe emoLlonal supporL ln
cerLaln clrcumsLances.
l'm noL advocaLlng Lhe removal of Lhe human fronL-end Lo paLlenL care. l'm argulng LhaL we should focus
on bulldlng robusL back-end sensor Lechnology and dlagnosLlcs Lhrough sophlsLlcaLed machlne learnlng
and arLlflclal lnLelllgence operaLlng on cllnlcal and non-cllnlcal daLa ln greaLer volumes Lhan humans can
handle, ln order Lo creaLe a much more comprehenslve undersLandlng of paLlenLs. WhaL's more, Lhese
comblned hardware/sofLware sysLems wlll do beLLer aL follow-ups Lhan over-burdened, Llme-
consLralned docLors. 1hey'll recognlze and flag excepLlons ln LCCs, resplraLlon, movemenL, or anyLhlng
else for careglvers Lo respond Lo ln more LargeLed ways, acLually lmprovlng provlder-paLlenL lnLeracLlons
and healLh ouLcomes.
- 11 -
A LranslLlon Lo auLomaLlon has already happened ln several oLher areas where we once LhoughL human
[udgmenL was requlred. When you're on board LhaL cross-counLry fllghL from new ?ork Lo Los Angeles,
mosL of Lhe flylng ls belng done by auLo-plloL, noL by a human (Lhough a human ls Lhere for cerLaln
emergency slLuaLlons). lnvesLlng was long consldered a unlque basLlon of human [udgmenL. AlgorlLhmlc
Lradlng now drlves Lhe vasL ma[orlLy of volume ln Lhe sLock markeLs, wlLh compuLers long ago replaclng
gesLurlng Lraders wearlng funny-looklng coaLs ln Lhe sLock plLs. Cars have been parklng Lhemselves and
avoldlng accldenLs uslng lane-asslsL for some Llme now, and Coogle already has a self-drlvlng car LhaL's
had zero accldenLs drlvlng more Lhan 300,000 mlles on normal sLreeLs (a much harder problem Lhan
auLomaLlng many physlclan funcLlons). MosL humans couldn'L drlve LhaL much wlLhouL aL leasL hlLLlng a
curb or Lwo. WlLhln a few decades, vehlcles wlLh sLeerlng wheels wlll become as qualnL a concepL as
hand-cranked englnes. uavld Cope aL unlverslLy of SanLa Cruz has even developed sofLware LhaL has
maLched orlglnal 8ach and a muslc professor composlng ln Lhe 8ach LradlLlon ln Lhe muslc's 8achness"
Lo Lhe chagrln of many.1he same menLal shlfL abouL human lnvolvemenL and lLs gradual replacemenL by
compuLers wlll also happen ln healLhcare. 1hls would creaLe a much more comprehenslve
undersLandlng of paLlenLs and acLually lmprove provlder-paLlenL lnLeracLlons and healLh ouLcomes wlLh
more personallzed LreaLmenL. ln Lhe end, physlclans wlll be able Lo spend more, hlgher quallLy Llme wlLh
each paLlenL, as lf Lhey had only 300 Lo manage, raLher Lhan 3,000 (Lhough he wlll be able Lo manage
10,000+ paLlenLs wlLh compuLer asslsL)! Careglvers wlll acLually have MC8L Llme Lo spend Lalklng Lo
Lhelr paLlenLs, maklng sure Lhey undersLand, soclallzlng care, and flndlng ouL Lhe harder-Lo-measure
pleces of lnformaLlon from paLlenLs because Lhey wlll be spendlng a loL less Llme gaLherlng daLa and
referrlng Lo old noLes. And Lhey wlll be able Lo handle many more paLlenLs, reduclng cosLs ln Lhe sysLem.

1he source of hea|thcare |nnovat|on
Where wlll all Lhls lnnovaLlon ln healLhcare come from? Some belleve we have Lo work wlLhln Lhe
consLralnLs of Lhe medlcal esLabllshmenL ln order Lo advance lL. l dlsagree. Some wlll follow relucLanLly,
and some wlll Lry Lo lead, buL mosL organlzaLlons ln LradlLlonal healLhcare wlll flghL Lhls Lrend Lowards
reduced cosLs because lL reduces proflLs. 1haL's why Lhe sysLem wlll mosL llkely be dlsrupLed by
ouLslders. Land-llne phone call raLes dldn'L decllne unLll moblle operaLors changed Lhe rules of whaL a
phone call should cosL. 8emember how expenslve long dlsLance calllng was noL very long ago?
lnnovaLlon seldom happens from Lhe lnslde because exlsLlng lncenLlves are usually seL up Lo dlscourage
dlsrupLlon, and docLors and hosplLals are all lnvesLed ln dolng Lhlngs Lhe same way. lf a hosplLal could
cure you ln half Lhe Llme, would Lhey be wllllng Lo cuL Lhelr buslness ln half? harma companles push
marglnally dlfferenL drugs lnsLead of generlc soluLlons LhaL may acLually be beLLer for paLlenLs because
Lhey don'L necessarlly wanL Lo cure you, Lhey wanL you Lo be a drug subscrlber and generaLe recurrlng
revenue for as long as posslble. 1hey'd raLher sell you a cholesLerol-lowerlng drug Lhan encourage you
Lo eaL healLhler and reduce Lhelr own proflLs. lf Lhey permanenLly reduced your cholesLerol, Lhey would
lose a cusLomer! sychlaLrlsLs ln general have Lhe same problem wlLh lncenLlves. 1hey don'L geL pald Lo
cure you, Lhey geL pald Lo LreaL you over mulLlple expenslve Lherapy sesslons LhaL never end. WhaL
would you raLher do as a LheraplsL: have a sLeady sLream of repeaL paLlenLs LhaL flll your hours or have
- 12 -
Lo aLLracL new paLlenLs? 1he former has mlnlmal paLlenL acqulslLlon cosLs. Medlcal devlce
manufacLurers, llke Lhose LhaL bulld and sell huge scannlng sysLems, don'L wanL Lo cannlballze sales of
Lhelr expenslve equlpmenL by provldlng cheaper, more accesslble monlLorlng devlces llke a $29 * LCC
machlne. 1he LradlLlonal players wlll lobby/goad/pay/lnLlmldaLe docLors and regulaLors Lo re[ecL Lhese
new devlces, empLlly clalmlng LhaL Lhey aren'L as good" and provlde only 90 of Lhe funcLlonallLy (buL
aL 3 of Lhe cosL). LxpecLlng Lhe medlcal esLabllshmenL Lo do anyLhlng dlfferenL ls llke expecLlng Lhem Lo
reduce Lhelr own proflLs. 1o be falr, Lhese are generallzaLlons and Lhere are many greaL docLors and
many eLhlcal organlzaLlons and people. 1he polnL ls LhaL Lhe lncenLlves ln healLhcare make lnnovaLlon
from wlLhln exLremely unllkely. lorLunaLely, lL doesn'L maLLer lf Lhe esLabllshmenL Lrles Lo do Lhls or noL,
because lL wlll happen regardless. And lL may sLarL aL Lhe perlphery, e.g. wlLh Lhe 40 mllllon unlnsured
people ln Lhls counLry or Lhe hundreds of mllllons of people ln lndla wlLh no access Lo any docLor. 1here
aren'L enough rural docLors ln lndla and few of Lhem have access Lo Lhe new Lngland !ournal of
Medlclne or a C1 scanner or even rellable elecLrlclLy. 8uL, mosL poLenLlal paLlenLs have cell phones. 1hls
shlfL ln how healLhcare ls dellvered wlll allow for less money Lo be spenL on caplLal equlpmenL, cuLLlng
healLh care cosLs. lL wlll allow us Lo provlde care Lo Lhose who don'L have lL now. lL wlll help avold errors
and provlde baslc servlces Lo Lhose who cannoL afford full healLhcare servlces. And, lL wlll prevenL
slmple Lhlngs from geLLlng worse before belng addressed.
1here has been much ado ln Lhe blogs abouL how Slllcon valley and ouLslders don'L undersLand
healLhcare and hence should noL or cannoL Lry Lo undersLand and lnnovaLe ln lL. As l explalned above,
and granLlng Lhe rare excepLlons, lL ls hard for lnslders Lo lnnovaLe wlLhln a sysLem, aL leasL when lL
comes Lo radlcal lnnovaLlon. 1haL's noL Lo say Lhese Slllcon valley and oLher ouLslder lnnovaLors" won'L
leverage Lhe sysLem or have parLners and docLors from lnslde helplng Lhem. Llfecom's CLC ls a Lrauma
surgeon and Leaches surgery and crlLlcal care on faculLy. Cne of roLeus' founders ls an Mu, as ls one of
Lhe founders of AlrSLrlp 1echnologles. l8M WaLson ls worklng wlLh . Many oLhers work wlLh ln LesLlng
and sLudylng Lhelr ldeas and Lechnologles. MosL sLarLups we are fundlng have Mus on Lhelr Leam and
collaboraLe wlLh oLher healLhcare parLners.
1he reallLy ls LhaL healLhcare has Lo move ln Lhls dlrecLlon ln order Lo make lL affordable Lo everyone.
1here are many argumenLs and challenglng quesLlons ln Lhe blogs abouL Lhls polnL of vlew. Some have
answers, many reflecLlng nalveLy ln undersLandlng how Lechnology lncremenLs and evolves, and many
quesLlons and crlLlclsms don'L have answers. 8uL, [usL because an answer doesn'L exlsL Loday does noL
mean lL LhaL lL won'L be found or LhaL we won'L flnd workarounds. Some Lhlngs wlll come as Lradeoffs Lo
make healLhcare more affordable. My guessLlmaLes wlll be wrong on many counLs as new Lechnologles
and approaches, and someLlmes unforeseen problems, emerge. Many commenLs have come from good
and passlonaLe docLors (Lhere are plenLy of Lhem around) and bloggers who have healLh lnsurance and
can afford good care. l personally worry abouL Lhe boLLom half of docLors globally who are Loo rushed,
Loo overburdened, Loo mercenary, or Loo ouL of daLe wlLh Lhelr educaLlon, especlally ln Lhe developlng
world.
LnLrepreneurs can come aL Lhese challenges from Lhe ouLslde or lnslde Lhe sysLem and ln[ecL new
lnslghL. 1hey can ask naive quesLlons LhaL geL aL Lhe hearL of assumpLlons LhaL may be boLh pervaslve
and unpercelved. 1hey can leverage Lhe many lnslders aL Lhe rlghL Llme Lo provlde real undersLandlng of
- 13 -
medlclne. 1hey can bulld smarL compuLers Lo be ob[ecLlve cosL mlnlmlzers WPlLL belng care opLlmlzers.
uomaln experLlse 5#$ have a place, and Lhe smarLesL docLors aren'L ouLraged aL Lhls ldea ([usL Lhe ones
wlLh knee-[erk reacLlons). eople always reacL agalnsL Lechnologlcal progress, and many don'L have Lhe
lmaglnaLlon Lo see how Lhe world ls changlng. 8uL, Lhere wlll be many good docLors wllllng Lo asslsL ln
Lhls LranslLlon. Lrlc 1opol (auLhor of 1he CreaLlve uesLrucLlon of Medlclne") and ur. uanlel krafL, have
called for a daLa-drlven approach Lo healLhcare and are examples of lnslders who Lhlnk llke ouLslders.
1here's no quesLlon LhaL many naive lnnovaLors from ouLslde Lhe sysLem, maybe even 90 of Lhem, wlll
aLLempL Lhls change and fall. 8uL, a few of Lhese ouLslders wlll succeed and change Lhe sysLem. 1hey wlll
geL Lhe approprlaLe help from lnslders and leverage Lhelr experLlse. And Lhere wlll be many good
docLors wllllng Lo asslsL ln Lhls LranslLlon.
1hls evoluLlon from an enLlrely human-based Lo an lncreaslngly auLomaLed healLhcare sysLem wlll Lake
Llme, and Lhere are many ways ln whlch lL can happen, buL lL won'L Lake as long as people Lhlnk. 1he
move wlll happen ln flLs and sLarLs along dlfferenL paLhways, wlLh many course correcLlons, sLeps
backward, and mlsLakes as we flgure ouL Lhe besL approach forward. lL's lmposslble Lo predlcL how Lhls
wlll ulLlmaLely happen. lL may be Lhe case LhaL all slgnlflcanL efforLs wlll have Lo be caLalyzed by
ouLslders. 1he healLhcare sysLem mlghL acLually sLarL respondlng Lo Lhese LhreaLs from Lhe lnslde and
change as a resulL. Maybe we'll sLarL seelng dlsrupLlon aL Lhe frlnges along sllppery buL shallow slopes.
1he LranslLlon could sLarL as a hundred small changes ln dlfferenL areas of medlclne and ln dlfferenL
ways, endlng wlLh an overhaul of healLhcare LhaL Lakes place over a couple decades. uurlng all Lhls,
many or mosL ln Lhls efforL wlll fall, buL a few wlll succeed and change Lhe world. lor Lhose of us who
supporL enLrepreneurs and companles LhaL help creaLe Lhls change, mosL lnvesLmenLs wlll be losL buL
more money wlll be made Lhan losL Lhrough Lhe few successes. none of us knows for sure how Lhls
space wlll Lurn ouL, buL Lhere's a huge opporLunlLy for LechnologlsLs, enLrepreneurs, and oLher forward-
Lhlnkers Lo reduce healLhcare expendlLures and lmprove paLlenL care aL Lhe very same Llme.

* A khosla venLures lnvesLmenL