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TEDMED 2009

Eric Dishman: Take health care off the mainframe

November 11, 2009

At TEDMED, Eric Dishman makes a bold argument: The US health care system is like computing circa 1959, tethered to big, unwieldy central systems: hospitals, doctors, nursing homes. As our aging population booms, it's imperative, he says, to create personal, networked, home-based health care for all.

Eric Dishman - Social scientist
Eric Dishman does health care research for Intel -- studying how new technology can solve big problems in the system for the sick, the aging and, well, all of us. Full bio

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Double-click the English subtitles below to play the video.
If you think about the phone --
00:15
and Intel has tested
00:17
a lot of the things I'm going to show you,
00:19
over the last 10 years,
00:21
in about 600 elderly households --
00:23
300 in Ireland, and 300 in Portland --
00:25
trying to understand: How do we measure
00:28
and monitor behavior
00:30
in a medically meaningful way?
00:32
And if you think about the phone, right,
00:34
it's something that we can use for some incredible ways
00:36
to help people actually take the right medication at the right time.
00:38
We're testing these kinds of simple
00:41
sensor-network technologies in the home
00:43
so that any phone that a senior is already comfortable with
00:45
can help them deal with their medications.
00:47
And a lot of what they do is they pick up the phone,
00:49
and it's our system whispering to them which pill they need to take,
00:51
and they fake like they're having a conversation with a friend.
00:54
And they're not embarrassed by a meds caddy that's ugly,
00:57
that sits on their kitchen table and says,
00:59
"I'm old. I'm frail."
01:01
It's surreptitious technology
01:03
that's helping them do a simple task
01:05
of taking the right pill at the right time.
01:07
Now, we also do some pretty amazing things with these phones.
01:09
Because that moment when you answer the phone
01:12
is a cognitive test every time that you do it.
01:15
Think about it, all right? I'm going to answer the phone three different times.
01:18
"Hello? Hey."
01:21
All right? That's the first time.
01:23
"Hello? Uh, hey."
01:26
"Hello? Uh, who?
01:30
Oh, hey."
01:34
All right? Very big differences
01:37
between the way I answered the phone the three times.
01:40
And as we monitor phone usage
01:43
by seniors over a long period of time,
01:45
down to the tenths of a microsecond,
01:48
that recognition moment
01:50
of whether they can figure out that person on the other end
01:52
is a friend and we start talking to them immediately,
01:54
or they do a lot of what's called trouble talk,
01:56
where they're like, "Wait, who is this? Oh." Right?
01:58
Waiting for that recognition moment
02:01
may be the best early indicator of the onset of dementia
02:03
than anything that shows up clinically today.
02:05
We call these behavioral markers.
02:07
There's lots of others. Is the person going to the phone
02:09
as quickly, when it rings, as they used to?
02:11
Is it a hearing problem or is it a physicality problem?
02:14
Has their voice gotten more quiet? We're doing a lot of work with people
02:17
with Alzheimer's and particularly with Parkinson's,
02:19
where that quiet voice that sometimes shows up with Parkinson's patients
02:22
may be the best early indicator
02:25
of Parkinson's five to 10 years before it shows up clinically.
02:28
But those subtle changes in your voice over a long period of time
02:31
are hard for you or your spouse to notice until it becomes so extreme
02:34
and your voice has become so quiet.
02:37
So, sensors are looking at that kind of voice.
02:39
When you pick up the phone,
02:41
how much tremor are you having,
02:43
and what is that like, and what is that trend like over a period of time?
02:45
Are you having more trouble dialing the phone than you used to?
02:48
Is it a dexterity problem? Is it the onset of arthritis?
02:50
Are you using the phone? Are you socializing less than you used to?
02:53
And looking at that pattern. And what does that decline in social health
02:57
mean, as a kind of a vital sign of the future?
03:00
And then wow, what a radical idea,
03:03
we -- except in the United States --
03:06
might be able to use this newfangled technology
03:08
to actually interact with a nurse or a doctor on the other end of the line.
03:11
Wow, what a great day that will be
03:14
once we're allowed to actually do those kinds of things.
03:16
So, these are what I would call behavioral markers.
03:19
And it's the whole field that we've been trying to work on
03:23
for the last 10 years at Intel.
03:26
How do you put simple disruptive technologies,
03:28
and the first of five phrases that I'm going to talk about in this talk?
03:30
Behavioral markers matter.
03:32
How do we change behavior?
03:34
How do we measure changes in behavior
03:36
in a meaningful way that's going to help us with
03:38
prevention of disease, early onset of disease,
03:40
and tracking the progression of disease over a long period of time?
03:42
Now, why would Intel let me
03:45
spend a lot of time and money, over the last 10 years,
03:48
trying to understand the needs of seniors
03:51
and start thinking about these kinds of behavioral markers?
03:53
This is some of the field work that we've done.
03:55
We have now lived with 1,000 elderly households
03:58
in 20 countries over the last 10 years.
04:01
We study people in Rochester, New York.
04:03
We go live with them in the winter
04:05
because what they do in the winter,
04:07
and their access to healthcare, and how much they socialize,
04:09
is very different than in the summer.
04:11
If they have a hip fracture we go with them
04:13
and we study their entire discharge experience.
04:15
If they have a family member who is a key part of their care network,
04:17
we fly and study them as well.
04:19
So, we study the holistic health experience
04:21
of 1,000 seniors over the last 10 years
04:24
in 20 different countries.
04:26
Why is Intel willing to fund that?
04:28
It's because of the second slogan that I want to talk about.
04:31
Ten years ago, when I started trying to convince Intel
04:33
to let me go start looking at disruptive technologies
04:35
that could help with independent living,
04:37
this is what I called it: "Y2K + 10."
04:39
You know, back in 2000,
04:42
we were all so obsessed with paying attention
04:44
to the aging of our computers,
04:46
and whether or not they were going to survive
04:48
the tick of the clock from 1999 to 2000,
04:50
that we missed a moment that only demographers were paying attention to.
04:52
It was right around New Years.
04:57
And that switchover,
04:59
when we had the larger number of older people on the planet,
05:01
for the first time than younger people.
05:04
For the first time in human history -- and barring aliens landing
05:06
or some major other pandemic,
05:08
that's the expectation from demographers, going forward.
05:10
And 10 years ago it seemed like I had a lot of time
05:13
to convince Intel to work on this. Right?
05:15
Y2K + 10 was coming,
05:17
the baby boomers starting to retire.
05:19
Well folks, it's like we know these demographics here.
05:22
This is a map of the entire world.
05:26
It's like the lights are on,
05:28
but nobody's home on this demographic
05:30
Y2K + 10 problem. Right?
05:32
I mean we sort of get it here, but we don't get it here,
05:34
and we're not doing anything about it.
05:38
The health reform bill is largely ignoring
05:40
the realities of the age wave that's coming,
05:42
and the implications for what we need to do to change
05:44
not only how we pay for care,
05:46
but deliver care in some radically different ways.
05:49
And in fact, it's upon us.
05:52
I mean you probably saw these headlines. This is Catherine Casey
05:54
who is the first boomer to actually get Social Security.
05:57
That actually occurred this year. She took early retirement.
06:00
She was born one second after midnight in 1946.
06:02
A retired school teacher,
06:06
there she is with a Social Security administrator.
06:08
The first boomer actually, we didn't even wait till 2011, next year.
06:10
We're already starting to see early retirement occur this year.
06:13
All right, so it's here. This Y2K + 10 problem is at our door.
06:16
This is 50 tsunamis scheduled on the calendar,
06:19
but somehow we can't sort of marshal our government
06:24
and innovative forces to sort of get out in front of it
06:27
and do something about it. We'll wait until
06:29
it's more of a catastrophe, and react,
06:31
as opposed to prepare for it.
06:33
So, one of the reasons it's so
06:35
challenging to prepare for this Y2K problem
06:37
is, I want to argue, we have what I would call
06:39
mainframe poisoning.
06:41
Andy Grove, about six or seven years ago,
06:43
he doesn't even know or remember this, in a Fortune Magazine article
06:46
he used the phrase "mainframe healthcare,"
06:48
and I've been extending and expanding this.
06:51
He saw it written down somewhere. He's like, "Eric that's a really cool concept."
06:53
I was like, "Actually it was your idea. You said it in a Fortune Magazine article.
06:56
I just extended it."
06:58
You know, this is the mainframe.
07:00
This mentality of traveling to
07:02
and timesharing large, expensive healthcare systems
07:05
actually began in 1787.
07:08
This is the first general hospital in Vienna.
07:10
And actually the second general hospital in Vienna,
07:13
in about 1850, was where we started to build out
07:15
an entire curriculum for teaching med students specialties.
07:18
And it's a place in which we started developing
07:22
architecture that literally divided the body,
07:24
and divided care into departments and compartments.
07:26
And it was reflected in our architecture,
07:29
it was reflected in the way that we taught students,
07:31
and this mainframe mentality persists today.
07:33
Now, I'm not anti-hospital.
07:36
With my own healthcare problems, I've taken drug therapies,
07:39
I've traveled to this hospital and others, many, many times.
07:41
But we worship the high hospital on a hill. Right?
07:44
And this is mainframe healthcare.
07:48
And just as 30 years ago
07:50
we couldn't conceive that we would have the power
07:52
of a mainframe computer that took up a room this size
07:55
in our purses and on our belts,
07:58
that we're carrying around in our cell phone today,
08:00
and suddenly, computing,
08:02
that used to be an expert driven system,
08:04
it was a personal system that we all owned as part of our daily lives --
08:06
that shift from mainframe to personal computing
08:09
is what we have to do for healthcare.
08:12
We have to shift from this mainframe mentality of healthcare
08:14
to a personal model of healthcare.
08:17
We are obsessed with this way of thinking.
08:19
When Intel does surveys all around the world and we say,
08:22
"Quick response: healthcare."
08:24
The first word that comes up is "doctor."
08:26
The second that comes up is "hospital." And the third is "illness" or "sickness." Right?
08:28
We are wired, in our imagination, to think about healthcare
08:31
and healthcare innovation as something
08:35
that goes into that place.
08:37
Our entire health reform discussion right now,
08:39
health I.T., when we talk with policy makers,
08:41
equals "How are we going to get doctors using
08:44
electronic medical records in the mainframe?"
08:46
We're not thinking about
08:48
how do we shift from the mainframe to the home.
08:50
And the problem with this is
08:52
the way we conceive healthcare. Right?
08:54
This is a very reactive, crisis-driven system.
08:56
We're doing 15-minute exams with patients.
08:58
It's population-based.
09:00
We collect a bunch of biological information in this artificial setting,
09:02
and we fix them up, like Humpty-Dumpty all over again,
09:05
and send them home,
09:07
and hope -- we might hand them a brochure, maybe an interactive website --
09:09
that they do as asked and don't come back into the mainframe.
09:12
And the problem is we can't afford it today, folks.
09:16
We can't afford mainframe healthcare today to include the uninsured.
09:19
And now we want to do a double-double
09:23
of the age wave coming through?
09:25
Business as usual in healthcare is broken and we've got to do something different.
09:27
We've got to focus on the home.
09:30
We've got to focus on a personal healthcare paradigm
09:32
that moves care to the home. How do we be more proactive,
09:34
prevention-driven?
09:36
How do we collect vital signs and other kinds of information 24 by 7?
09:38
How do we get a personal baseline about what's going to work for you?
09:42
How do we collect not just biological data
09:45
but behavioral data, psychological data,
09:47
relational data, in and on and around the home?
09:49
And how do we drive compliance to be a customized care plan
09:52
that uses all this great technology that's around us
09:55
to change our behavior?
09:57
That's what we need to do for our personal health model.
09:59
I want to give you a couple of examples. This is Mimi
10:02
from one of our studies --
10:04
in her 90s, had to move out of her home
10:06
because her family was worried about falls.
10:08
Raise your hand if you had a serious fall
10:10
in your household, or any of your loved ones,
10:12
your parents or so forth. Right?
10:14
Classic. Hip fracture often leads to institutionalization of a senior.
10:16
This is what was happening to Mimi; the family was worried about it,
10:20
moved her out of her own home into an assisted living facility.
10:22
She tripped over her oxygen tank.
10:25
Many people in this generation won't press the button,
10:28
even if they have an alert call system, because they don't want to bother anybody,
10:30
even though they've been paying 30 dollars a month.
10:32
Boomers will press the button. Trust me.
10:34
They're going to be pressing that button non-stop. Right?
10:36
Mimi broke her pelvis, lay all night, all morning,
10:40
finally somebody came in and found her,
10:44
sent her to the hospital.
10:46
They fixed her back up. She was never going to be able to move back
10:48
into the assisted living. They put her into the nursing home unit.
10:50
First night in the nursing home unit where she had been
10:52
in the same assisted living facility, moved her from one bed to another,
10:54
kind of threw her, rebroke her pelvis,
10:57
sent her back to the hospital that she had just come from,
10:59
no one read the chart, put her on Tylenol,
11:02
which she is allergic to, broke out, got bedsores,
11:04
basically, had heart problems, and died
11:06
from the fall and the complications and the errors that were there.
11:09
Now, the most frightening thing about this is
11:12
this is my wife's grandmother.
11:16
Now, I'm Eric Dishman. I speak English,
11:19
I work for Intel, I make a good salary,
11:21
I'm smart about falls and fall-related injuries --
11:23
it's an area of research that I work on.
11:26
I have access to senators and CEOs.
11:28
I can't stop this from happening.
11:31
What happens if you don't have money, you don't speak English
11:33
or don't have the kind of access
11:35
to deal with these kinds of problems that inevitably occur?
11:37
How do we actually prevent the vast majority of falls
11:40
from ever occurring in the first place?
11:43
Let me give you a quick example of work that we're doing
11:45
to try to do exactly that.
11:47
I've been wearing a little technology that we call Shimmer.
11:49
It's a research platform.
11:52
It has accelerometry. You can plug in a three-lead ECG.
11:54
There is all kinds of sort of plug-and-play
11:57
kind of Legos that you can do to capture, in the wild,
11:59
in the real world,
12:01
things like tremor, gait,
12:03
stride length and those kinds of things.
12:05
The problem is, our understanding of falls today,
12:07
like Mimi, is get a survey in the mail three months after you fell,
12:11
from the State, saying, "What were you doing when you fell?"
12:14
That's sort of the state of the art.
12:17
But with something like Shimmer, or we have something called the Magic Carpet,
12:19
embedded sensors in carpet, or camera-based systems
12:22
that we borrowed from sports medicine,
12:24
we're starting for the first time in those 600 elderly households
12:26
to collect actual kinematic motion data
12:29
to understand: What are the subtle changes that are occurring
12:32
that can show us that mom has become risk at falls?
12:36
And most often we can do two interventions,
12:39
fix the meds mix.
12:41
I'm a qualitative researcher, but when I look at these data streams coming in
12:43
from these homes, I can look at the data and tell you the day
12:46
that some doctor prescribed them something that nobody else
12:49
knew that they were on, because we see the changes
12:51
in their patterns in the household. Right?
12:53
These discoveries of behavioral markers,
12:56
and behavioral changes
12:59
are game changing, and like the discovery of the microscope
13:01
because of our collecting data streams that we've actually never done before.
13:03
This is an example in our TRIL Clinic in Ireland
13:06
of -- actually what you're seeing is
13:08
she's looking at data,
13:10
in this picture, from the Magic Carpet.
13:12
So, we have a little carpet that you can look at your amount of postural sway,
13:14
and look at the changes in your postural sway over many months.
13:17
Here's what some of this data might look like.
13:20
This is actually sensor firings.
13:22
These are two different subjects in our study.
13:24
It's about a year's worth of data.
13:26
The color represents different rooms they are in the house.
13:28
This person on the left is living in their own home.
13:31
This person on the right is actually living in an assisted living facility.
13:33
I know this because look at how punctuated meal time is
13:36
when they are no longer in their particular rooms here. Right?
13:39
Now, this doesn't mean that much to you.
13:42
But when we look at these cycles of data
13:45
over a longer period of time -- and we're looking at everything from
13:47
motion around different rooms in the house,
13:49
to sort of micro-motions that Shimmer picks up,
13:51
about gait and stride length -- these streams of data
13:54
are starting to tell us things about behavioral patterns
13:56
that we've never understood before.
13:58
You can go to ORCATech.org --
14:00
it has nothing to do with whales, it's the Oregon Center for Aging and Technology --
14:02
to see more about that.
14:05
The problem is, Intel is still one of the largest
14:07
funders in the world
14:09
of independent living technology research.
14:11
I'm not bragging about how much we fund;
14:14
it's how little anyone else actually pays attention
14:16
to aging and funds innovation on aging,
14:18
chronic disease management and independent living in the home.
14:21
So, my mantra here, my fourth slogan is:
14:24
10,000 households or bust.
14:26
We need to drive
14:29
a national, if not international, Framingham-type heart study
14:31
of independent living technologies,
14:35
where we have 10,000 elderly connected households
14:37
with broadband, full medical characterization,
14:40
and a platform by which we can start to experiment
14:43
and turn these from 20-household anecdotal studies
14:45
that the universities fund,
14:48
to large clinical trials that prove out the value of these technologies.
14:50
So, 10,000 households or bust.
14:53
These are just some of the households that we've done in the Intel studies.
14:55
My fifth and final phrase:
14:59
I have tried for two years,
15:01
and there were moments when we were quite close,
15:03
to make this healthcare reform bill be about reform
15:06
from something and to something,
15:09
from a mainframe model
15:11
to a personal health model,
15:13
or to mean something more than just a debate
15:15
about the public option and how we're going to finance.
15:17
It doesn't matter how we finance healthcare.
15:19
We're going to figure something out
15:22
for the next 10 years, and try it.
15:24
No matter who pays for it,
15:26
we better start doing care in a fundamentally different way
15:28
and treating the home and the patient
15:30
and the family member and the caregivers
15:33
as part of these coordinated care teams
15:35
and using disruptive technologies that are already here
15:37
to do care in some pretty fundamental different ways.
15:41
The president needs to stand up and say,
15:44
at the end of a healthcare reform debate,
15:47
"Our goal as a country is to move 50 percent of care
15:50
out of institutions, clinics, hospitals and nursing homes,
15:53
to the home, in 10 years."
15:56
It's achievable. We should do it economically,
15:58
we should do it morally,
16:00
and we should do it for quality of life.
16:02
But there is no goal within this health reform.
16:04
It's just a mess today.
16:06
So, you know, that's my last message to you.
16:08
How do we set a going-to-the-moon goal
16:10
of dealing with the Y2K +10 problem that's coming?
16:13
It's not that innovation and technology is going to be the
16:17
magic pill that cures all, but it's going to be part of the solution.
16:19
And if we don't create a personal health movement,
16:22
something that we're all aiming towards in reform,
16:25
then we're going to move nowhere.
16:27
So, I hope you'll turn this conference into that kind of movement forward.
16:29
Thanks very much.
16:31
(Applause)
16:33

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Eric Dishman - Social scientist
Eric Dishman does health care research for Intel -- studying how new technology can solve big problems in the system for the sick, the aging and, well, all of us.

Why you should listen

Eric Dishman is an Intel Fellow and general manager of Intel's Health Strategy & Solutions Group. He founded the product research and innovation team responsible for driving Intel’s worldwide healthcare research, new product innovation, strategic planning, and health policy and standards activities.

Dishman is recognized globally for driving healthcare reform through home and community-based technologies and services, with a focus on enabling independent living for seniors. His work has been featured in The New York Times, Washington Post and Businessweek, and The Wall Street Journal named him one of “12 People Who Are Changing Your Retirement.” He has delivered keynotes on independent living for events such as the annual Consumer Electronics Show, the IAHSA International Conference and the National Governors Association. He has published numerous articles on independent living technologies and co-authored government reports on health information technologies and health reform.

He has co-founded organizations devoted to advancing independent living, including the Technology Research for Independent Living Centre, the Center for Aging Services Technologies, the Everyday Technologies for Alzheimer’s Care program, and the Oregon Center for Aging & Technology.

The original video is available on TED.com
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