In May 2017, I got the call no one ever wants to get. My mother was diagnosed with breast cancer. I remember standing just outside of my building at Microsoft, feeling helpless. Do I catch the next flight home? Do I tell my friends or my boss?
Surprisingly, the surgery, radiation, 6 months of chemo, and hundreds of doctors visits was not the hardest part for her. Dealing with the medical system which was designed to save her life became a daily battle.
Most recently, my mom admitted herself to the hospital one morning after her heart rate jumped rapidly as she was getting ready for work.
It immediately became clear that something was not right. First, my mom noticed that no one gave her a hospital gown. As unusual as this was, she initially did not think anything of it. Next, she noticed that the doctors were missing nearly all of the scheduled tests and a number of sensors were not even connected to their machines. Simple tasks such as getting dinner were ignored even after calling the cafeteria 4 times. The final straw was not receiving any of her regular, daily medications during her 24 hours in the hospital. Something was clearly wrong.
Only later would she understand — she was never entered into the system as a patient. It explained everything.
As it turns out, the nurse who welcomed her to the cardiac unit was interrupted while completing the intake form for the electronic healthcare system, meaning my mom was never registered as a patient. If she had experienced complications while there, no doctor or nurse would have come running. Her 24-hour stay felt like a complete waste of time.
Each and every one of us has a relationship with the healthcare system. From the moment we are born, we are thrust into a complex system plagued with problems at every corner. From R&D to pharmaceuticals to end-of-life care, costs are skyrocketing while measurable outcomes are becoming worse.
While many of us believe that the healthcare system does everything it can to save our lives, reality is often far from the truth. During the past two years of seeing my mom experience the healthcare system, a trend has emerged for me — while society is conversing about whether or not to regulate technology companies, those very technology companies are preparing strategies to inject their technology across the healthcare market, simultaneously creating a better healthcare experience AND even larger trust issues across healthcare and technology.
Before understanding what technology companies are doing, we must understand context around the US healthcare system.
A TON of money is spent on healthcare — a topic that has been written about heavily. The US spends over $3.5 T on healthcare every single year — a whopping 18% of GDP, yet 15% of our population remains uninsured. In stark contrast, no other OECD country spends more than 13% of its GDP on healthcare, with most of these countries providing healthcare to all citizens. These costs are not just charged to insurance companies: a recent study showed that 42% of cancer patients lost their life savings within two years of starting treatment and 62% are in debt because of the disease.
There are many reasons behind this excessive and growing cost. The US is one of only a few countries where pharmaceutical companies are legally able to advertise directly to consumers, which cost those companies more than $5B in 2018. The for-profit nature of insurance companies increases administrative burden on hospitals while de-incentivizing long term preventative care. Doctors in the US make significantly more. The list goes on and on.
Not only is the US healthcare system the most expensive, it often fails to provide great care to patients. While healthcare outcomes are measured in different ways across hospitals, the US struggles regardless of how you look at it. The US has a lower life expectancy at birth than comparable OECD countries, lower access to healthcare services, and fewer hospital beds and physicians. Across the most common disease types, outcomes are a mixed bag but certainly not worth the money we are paying.
If you paid 50% more for a nice steak, you would expect a better steak. If you paid $50,000 more for car, you would expect a significantly better car. Yet for some reason, we have failed to expect the same from our healthcare.
This history of costly care with little-to-no impact on outcomes has led to massive trust issues within the healthcare system. Patients do not trust the broader healthcare system, a fact that has been widely written about. Open any social media platform and you’ll find heated debates about whether the measles vaccine causes autism, despite study after study from well-respected medical institutions refuting this association. This is not the first time the cracks in trust have been shown; Wide scale trust breakdowns with Ebola treatment protocols likely extended the growth of the disease.
Yet, trust between a patient and their direct physician has never been higher. The US ranks 3rd in the world with 56% of patients being ‘Completely’ or ‘Very Satisfied’ with the treatment they received when they last visited a doctor. Only Switzerland and Denmark scored higher with 64% and 61%, respectively.
What many patients do not realize is that their trust in their doctor is about to experience a shakeup.
Every large technology company is preparing an entry into healthcare. Google, Microsoft, Facebook and Amazon, companies in the middle of hacks, misuse of information and unethical practices, are leading the hoards of technology companies aiming to take a slice of the $3.5 trillion US healthcare market.
While the public attention has been on how these companies control our search results, news feeds, and spending habits, very little has been written about their dealings to control your medical diagnosis. Imagine if Google, a company which receives 86% of its revenue from advertising, was deciding whether or not you had skin cancer. Or what if Amazon, a company that is the entry point to eCommerce was recommending to doctors which medication you should take?
Most surprisingly, even in the technology capitol of the world, San Francisco, many of the below efforts surprise people. Even employees of the companies discussed below often times do not realize the depths at which their companies are exploring technology for healthcare.
Let’s look at several companies to give you a flavor for how much these companies are investing in controlling your healthcare.
Of the technology companies with healthcare initiatives, Google is the most ambitious. Their healthcare goals align to three main pillars. First, Google will leverage their in-house technologies to gather and standardize medical data for training AI/ML. Second, they will create a way for doctors to utilize AI/ML models within clinics to make more informed diagnoses. Finally, Google will build lifecycle management tools to control long-standing, preventable diseases such as diabetes.
Google’s aim is not just to apply these 3 pillars to one disease. Between COPD, cancer, mental and behavioral health, and aging, it is clear that Google aims to impact the health of almost every person in the US.
A grid outlining the various efforts Google has across health conditions. (Aggregated by CBInsights)
It is important to note that not all of these are happening specifically within Google. It is hard to understand the exact structure of Google’s healthcare initiatives. Google is only one subsidiary of Alphabet, alongside Verily and Calico, where various pieces of the medical strategy are being executed.
Beyond in-house incubations, Google and Alphabet have invested heavily in external healthcare startups. Since 2012, Google has invested in more than 92 deals within healthcare from various funds including GV, Verily Life Sciences, and CapitalG. Further, through these various investment opportunities, Google has been a part of 14 of the 15 largest healthcare rounds of 2018. Within healthcare, Google is heavily invested in biotechnology, participating in more than 30 deals since 2012. One of the more interesting deals is Alector’s recent $133M series E that is funding new drugs for Alzheimer’s disease — a disease that has seen no new drugs approved by the FDA since 2003.
Amazon
Of all the major companies, Amazon has been the most vocal with its healthcare efforts.
First, the formation of Haven with JP Morgan and Berkshire Hathaway has given Amazon a clear outlet to experiment with healthcare solutions. While very little is known about Amazon’s strategy, one can speculate that their goal is to create a health marketplace, similar to their e-commerce marketplace. This would create a strong competitive market and intuitive user interface to provide lower prices for consumers, starting with Amazon’s own employees. Ben Thompson dives deep into this theory here. Once established, this marketplace also provides a strong ability for Amazon to make significant profits by selling whitelisted products.
Beyond Haven, Amazon sent shockwaves through the pharmaceuticals market with the acquisition of PillPack, a direct-to-consumer pharmaceutical brand that now gives Amazon a direct link to consumers. Ben Thompson again provides great analysis about why this matters in healthcare broadly:
“Consider the two biggest players in the pharmacy space, Walgreens and CVS: the former has sought to drive profit through horizontal integration, particularly the acquisition of several thousand Rite-Aid stores; the latter has vertically integrated, buying a benefits manager. Neither acquisition was about delivering a better user experience for the end user.” (Amazon acquires PillPack)
This acquisition clearly had a huge impact on nearly every part of the healthcare ecosystem, as evidenced by the immediate decline of their stock prices below. Companies and investors believe Amazon will shake up this market.
Various stock prices following Amazon’s acquisition of PillPack for more than $1B. (Aggregated by the WSJ)
Finally, Amazon will leverage its stronghold in users’ lives with Amazon Echos that help detect health conditions. These intentions are clearly outlined by Amazon’s recent patent focused on determining whether or not a user is sick simply by their voice. As the patent states directly
“the disclosure may determine one or more physical and/or emotional characteristics of a user based at least in part on a voice input from the user. For example, physical conditions such as sore throats and coughs may be determined based at least in part on a voice input from the user, and emotional conditions such as an excited emotional state or a sad emotional state may be determined based at least in part on voice input from a user.”
Amazon’s unique position as the leader in e-commerce and its vast logistics network give it unique leverage to influence buying potential for consumers without their knowledge. Amazon has already exploited this knowledge base with the creation of hundreds of white-label brands which quickly eliminates competition from these spaces. It is not unlikely that Amazon does the same in areas within healthcare, specific pharmaceuticals.
Apple
Being one of the more-trusted companies due to their consistent focus on privacy, Apple will likely be a welcome entrant into the healthcare market. Regardless, they are a major player that needs to be discussed alongside ad-based internet companies. As you might imagine, Apple’s strategy is at the intersection of hardware and software. Let’s start with software.
Apple’s healthcare software strategy comes in a triplet of tools aimed to help both doctors and patients. First, and most popular, is HealthKit. The goal of HealthKit is simple — provide a seamless connection between patients and their healthcare data. Most of you reading will have used HealthKit before. Today, it prompts users to make simple, yet powerful, daily changes which in combination make a meaningful impact on their health including getting a full night of sleep and taking 10,000 steps per day.
Second, Apple launched ResearchKit, a system that helps researchers conduct large scale research studies. Historically, recruiting thousands of participants required tremendous effort by research organizations, and this was a leading cause of the ever expanding cost for FDA trials. Once recruited, tracking participants at each phase of the study became an administrative mess.
A breakdown of costs associated with each stage of the Clinical Trial process. (Aggregated by CBInsights)
Launched in 2015, ResearchKit allows Apple to leverage its strong customer relationship to connect researchers with potential study participants. It has already proven to be powerful: mPower, an app that tracks patients with Parkinson’s Disease, used ResearchKit to enroll 10,000 study participants and create the largest study on Parkinson’s Disease in history. Simply by leveraging the iPhone gyroscope, the app measures dexterity, balance, and memory to provide insights about the development of the disease.
Rounding out the trio of software tools is CareKit. Apple’s website describes it best:
“With the right tools, you can play an active role in managing your own health. That’s why we created CareKit — an open source software framework enabling developers to build apps that help you manage your medical conditions. Rather than relying solely on doctor visits, you’ll be able to regularly track your symptoms and medications, and even share the information with your care team for a bigger — and better — picture of your health.”
It is yet to be seen the full extent of CareKit. Combining CareKit with HealthKit gives Apple a clear advantage to connect humans to doctors at unprecedented scale, regardless of location.
Now let’s look at the hardware side. Some of these pieces are extremely public (Apple Watch EKG and heart rate monitoring) while others are not (AirPods becoming a healthcare device).
Apple Watch has been widely written about as a healthcare device, especially with the release of EKG functionality with Watch 4. The data from the Apple Watch has been shown to be reliable in many situations.
Beyond heart rate monitoring and EKG, it has been rumored that apple’s wants to be a part of the diagnoses and monitoring of diseases.
“Apple has a team working on finding ways to do non-invasive glucose monitoring, which could be a possible add-on to the Watch if scaled down sufficiently. Monitoring both heart rate and glucose means Apple could target two of the most expensive chronic diseases in healthcare: heart disease and diabetes.” (CBInsights Apple Healthcare breakdown)
Another rumor suggests that
“Apple seems to already be thinking about AirPods in healthcare contexts, based on this patent for biometric monitoring (core temperature, VO2, heartbeat, etc.) via headphones. Apple’s focus on wellness and lifestyle management, combined with the AirPods and Siri, could mean that Apple will explore the coaching and fitness space to proactively keep people healthy…” (CBInsights Apple Healthcare breakdown)
Finally, Apple is rumored to be investigating if Siri could be used within the clinical space.
“Siri’s speech-to-text could be used to dictate notes while procedures are being conducted. This would also help Apple get a stronger footing into hospitals as well.” (CBInsights Apple Healthcare breakdown)
Apple’s combination of software and hardware paired with their immense customer trust brings a unique advantage to their efforts in healthcare. Their strategy is clear; Apple will leverage their install base of iOS devices to make health records more transparent and accessible, while filling in the gaps around those records with data gathered from iOS devices (AirPods, Apple Watch, and potentially future versions of FaceID).
Facebook is one of the most un-trusted brands across the world right now. From data leaks to just plain over-leveraging of user trust, Facebook has made some incredible missteps over the past few years. Although there are rumors about Facebook’s healthcare initiatives dating back to 2016, neither Facebook, nor its subsidiaries WhatsApp, Instagram, and Oculus, have officially launched any products or features in the healthcare space.
There are certainly rumors though. One example —
“A hospital or health system might one day buy data from Facebook to find out which users may be looking for fertility services and lure in new patients. But it could be a two-way street. Facebook could get data from the hospital, combine it with the user data it already has, and give the hospital the same sort of information.” (Link)
The reasons Facebook might be asking around about healthcare data may not all be bad.
“Dr. Steven Lee, co-founder and chief science officer of Opternative, an eye health startup. “One of the key benefits of linking Facebook data to healthcare data is compliance,” he said. The platform might, for example, send medication reminders.” (Link)
One of the biggest questions regarding Facebook and health is why they have been absent from the numerous conversations regarding mental health. Studies like this conducted at universities and health institutions around the world have shown that Facebook has a large impact on the mental state of users, specifically teenagers, yet Facebook seems to have done very little to help drive this conversation in the right way. This is a huge opportunity missed.
Regardless, with Facebook more than anyone, we need to be asking questions about what this looks like for the future. Is this something we are okay with?
Microsoft
While Microsoft has had numerous large scale healthcare failures, most recently HealthVault, the company continues to be an active driver of healthcare technology from various angles.
Similar to Google, Microsoft is leveraging its large computing power to allow researchers to analyze genetic information at a speed and scale previously unavailable. It has partnered with a number of high profile organizations to get this effort kick-started.
Second, Microsoft is ensuring Office 365 is HIPAA-compliant for use across healthcare institutions. This builds trust with hospitals and doctors forging pathways for future research partnerships.
Finally, and most unusual, Microsoft has successfully stored data on DNA rather than magnetically. While this process is extremely time consuming and costly right now, Microsoft aims to have this fully production ready within a few years.
China
This work is not limited to the US-based technology companies. Baidu, Alibaba and Tencent are all investing in healthcare. The unique government architecture in China may provide one of those companies monopolistic access to China’s vast healthcare system, creating true Black Mirror potential. Far more on BAT’s jump into healthcare can be found here.
We’re at a major inflection point, not just with pushing companies to ethical news feeds or advertising, but also the systems which keep us alive. We must recognize that as we fight for privacy and fight for companies to act on our best interests, we are not simply fighting to fight. We are fighting to help save our future diagnoses.
Simply asking companies do better has failed time and time again. Conversations around healthcare are significantly more intense than even those we have begun to have around news. Healthcare is significantly more personal. Healthcare carries significantly more downside when technology fails. Regardless of how much we ‘disconnect from technology’, we do not have a choice of disconnecting from the healthcare system.
These solutions are not far off. Google has already proven better than clinically trained physicians at diagnosing breast cancer. Amazon (through PillPack) has approval to ship prescription drugs to 49 out of 50 states. The FDA has approved Apple Watch’s ECG for clinical use.
What can you do? Ask questions.
It is easy to feel like one person will not change anything, especially when the companies above control nearly every part of our daily lives and it may be nearly impossible to break away from all of them. By simply asking questions to family, colleagues, and most importantly healthcare providers, we can drive the conversation forward.
Would these technology companies have solved the issues my mom experienced a few weeks ago? Almost certainly.
Heck, our email is already capable of reminding us to follow up with an email, so it should be simple enough to remind a nurse or doctor to finish registering a patient.
Would I be okay with Google tracking my family’s medical history to predict when something has gone wrong? I don’t know.