HIC2012 The Future of Healthcare: Innovation at the Edge

Slide! Prepared Remarks!
Thank you … for the introduction.!
!
As mentioned, I’m here representing
Quantiﬁed Self. I’d especially like to thank
the Health Informatics Society of Australia
for their boldness in extending this
invitation. You see, Quantiﬁed Self has
been covered by major news
organizations such as the Economist
magazine and the Guardian newspaper,
but usually with a tone of “Aren’t these
people odd?” To be invited to share some
thoughts on an important topic … it’s a
nice change.!
!
“The Future of Healthcare” Well …
predicting the future … tricky stuff.
Chances are, no matter what you say,
you’re likely to be wrong. !

Rajiv Mehta • rajiv@bhageera.com • 2 August 2012 • HIC2012 Sydney, Australia!

1

Computer scientist Alan Kay famously said
“The best way to predict the future is to
invent it.” This seems to work for a few
people.!


2

Another way is to consider author William
Gibson’s claim that “The future is already
here — it’s just not very evenly
distributed.”!
!
What this means is that ...!


3

… somebody, somewhere is already doing
something, out on the fringes of society,
that in the future will be commonplace.
The challenge then is knowing where to
look.!
!
I think I have come across a few of these
somebodies. Let me tell you about them.!


4

I’ll begin with someone from right here.
Well, Melbourne actually.!


5

A year ago, in 2011, entrepreneur Jeremy
Howard attended the Beijing Language
University, the top language school in
China. He was placed amongst other
advanced students, …!
!


6

and three months later ﬁnished ﬁrst in his
class. What made this especially notable
was that Jeremy had only been learning
Chinese for one year to that point, while
most of his classmates had been studying
for much longer, and that he was self-
taught.!


7

His study was sparked by an article he
read in Wired magazine, about the work of
Piotr Wozniak of Poland on the best way
to memorize material, an approach called
spaced repetition learning. !
!


8

The basic idea is that there is an ideal
moment to re-learn something. Wait too
long and you’ve completely forgotten, and
so you are starting over. Re-learn too
quickly and you’re just wasting your time.
Ideally you re-learn just before you are
about to forget. If you can do that, you will
forget more slowly the next time, and so
the time for the next re-learning will be
longer. The difﬁculty is in knowing when
this right moment is, as it varies not just
from person to person, but also from item
to item. However, you can use a computer
program to track your learning and to tell
you the right moment to re-learn the
material. Jeremy decided to test this idea
by trying to learn Chinese. Obviously it
worked!!
!


9

One of the beneﬁts of using such a
program is that you can track your
learning. You can gather statistics on your
performance, such as how well you recall
material, or how quickly you answer
questions. Jeremy used these statistics to
understand his own learning patterns, and
the inﬂuence of environmental factors.!


10

For example, he found that he learned
better when walking slowly on a treadmill
— 1.2 mph at a 1 degree incline — than
sitting at his desk. While walking he was
able to memorize better, and he was able
to concentrate for much longer.!
!
In fact, he discovered that this didn’t just
apply to learning Chinese. He found that
his mind generally worked better, that he
was able to do more and better work,
when walking than sitting. It turns out the
treadmill was good not just for physical
health, but for his mental performance as
well. So, he’s purchased many treadmill-
desks for the employees in his company.
He’ll soon discover whether treadmills are
good for productivity generally, or
something unique to him.!


11

Jeremy told this story a few months ago at
a meeting in Silicon Valley of the
Quantiﬁed Self. This group was started by
journalist Gary Wolf, the author of the story
that sparked Jeremy’s learning Chinese.!
!
The Quantiﬁed Self is a global
collaboration of users and makers of
tracking tools. It is full of people, like
Jeremy, who track various aspects of their
lives with the expectation that they’ll learn
something about themselves and perhaps
use that knowledge to improve their lives
in some way. On one hand it is a very
modern phenomenon, the result of the
wide availability of powerful and tiny and
inexpensive computers. On the other
hand, philosophers such as the Buddha
have long been advising us to be mindful,
to be self-aware. People are simply using
new technology to assist their
mindfulness.!


12

The ﬁrst meeting of the Quantiﬁed Self
took place in September 2008, in a home
in a San Francisco suburb. About 30 of us
were there, pleased and somewhat
surprised to discover that there were
others with a similar interest. We have
been even more surprised to see how
rapidly this has grown. We now have over
60 groups around the world, including one
right here in Sydney.!
!


13

People come to the meetings to share
stories of personal self-tracking
experiments. They address three simple
questions. They tell us what they tracked
and why. How they did it — what tools they
used to collect and analyze their data. And
what they learned. The answers are often
surprising.!
!


14

Another recent speaker was Sky
Christopherson. Sky had once been an
elite athlete. !


15

At the age of 19 he was a US national
champion in velodrome cycling, he was
part of the US Olympics team in Atlanta in
1996 and Sydney in 2000, and had been
ranked 4th in the world. In preparation for
those Olympics he had participated in the
most sophisticated training program in
sports, at the time, where they measured
every aspect of his performance, training
and life as well as they could, and
developed training programs tailored for
each event.!


16

Some years later, in 2006, he started a
business and approached the company’s
performance with the same mindset —
measuring everything and working hard to
optimize every aspect of his business. The
relentless pursuit of business performance
led to business success, but his health
suffered. Within a year he had many, many
health complaints, from joint pain to
bleeding gums to a low sex drive. !


17

Things kept getting worse, and at one
point he found himself being rushed to the
hospital in an ambulance with the medics
wondering whether he had suffered a
heart attack. The doctors suggested a long
list of interventions for his long list of
ailments. Especially for someone who had
once been in fantastic shape, this was a
hard pill to swallow.!
!


18

Fortuitously he heard a talk by Dr Eric
Topol about the new tools available for
self-tracking, reminding of his Olympic
training, …!


19

and he decided to embark on a year of
intensive data gathering. Collecting data
on sleep, diet, exercise, and general well-
being.!
!
On sleep he was able to see data about
when he went to bed and when he woke
up, and how much of that time he was
awake, in REM sleep, and in deep sleep.
The data itself was motivational — if he
could see a number, he could tap into his
competitive instincts to improve the
number. The data also helped him
experiment, and he soon made lifestyle
changes that stabilized his sleep.!
!


20

However, over several months, from
January to June, he also noticed a steady
decline in the amount of deep sleep. After
considering various potential causes, he
decided it had to do with the weather, that
it was the result of the room getting
warmer as he didn’t have air conditioning. !


21

Sky got a cooling pad, a temperature
controlled pad that goes underneath the
sheets. And soon discovered that with a
setting of 66° Fahrenheit his deep sleep
went up signiﬁcantly.!


22

After another year, due to the combination
of improvements to sleep, diet, etc., he
had an almost complete reversal of
symptoms. So much so that last year, at
the age of 35, he set a new world record
for track cycling.!


23

It is worth noting that Sky’s self-monitoring,
using his own funds and widely available
technologies, is in many ways far more
comprehensive, and results in far more
personally tailored wellness regimens,
than the best-that-money-could-buy for his
Olympics training only 10 years earlier.!


24

He is now applying all that he has learned
about self-tracking, and about the new
tools available, to help other athletes
improve their performance. He’d thought
of calling his new business the Quantiﬁed
Athlete, but eventually chose the
Optimized Athlete. Much better from a
marketing perspective! He’s been helping
many athletes prepare for the Olympics.
We’ll see, over the next couple of weeks,
whether he’s had an impact.!
!


25

The Quantified Self … or rather the self-
tracking movement it exemplifies … and
the potential impact it may have for the
future of healthcare is the focus of my talk
today.!
!
To frame that potential, let’s go back nearly
40 years, to another meeting in Silicon
Valley, to another group of hobbyists. It
was March 1975, and it was the first
meeting of the Homebrew Computer Club.
These computer hobbyists had a mission. !
!


26

At a time when only elite universities and
large corporations could afford computers,
when only professionals in lab coats
ensconced in special rooms had access to
computers, they dreamed of making
computing personal. They dreamed of
liberating computing for the masses.!
!
One of the attendees at that ﬁrst meeting
was Steve Wozniack. Three months later,
inspired by what he saw and heard that
day, he had built a working personal
computer. Ten months later, he and a
friend named Steve Jobs founded Apple
Computer.!
!
The Homebrew hobbyists foresaw and led
a movement to change computing from
the province of a limited elite to a tool for
the masses.!
!
And they changed the world.!


27

There had indeed been a lot of innovation
in the past from the centers of computing,
from the academics at universities like
Princeton and Stanford, and researchers
at corporations like IBM and Bell Labs.!


28

But, the personal computing revolution
unleashed the power of creativity
everywhere. Lone geniuses and creative
students the world over have dramatically
increased the pace of innovation. In
addition to Jobs &Wozniack, here are
some other companies started by
innovators outside the centers of power.!
!
Not everything can be done in a garage or
in a college dorm room of course. Some
things require the ﬁnancial resources that
only large institutions can provide. But
those companies, which started as fringe
projects, have become very mainstream.
And the innovation occurring at the edge,
where millions of people are
experimenting, continues to have a
powerful impact.!
!
Similarly, the self-tracking movement is
liberating health science, moving health
science from professional lab-coats to the
masses.!


29

Innovation in ideas and tools that further
health and well-being has come, for much
of the last century, from centers of the
healthcare profession. In the US, that’s
been from the 150 medical schools, !


30

from the 7,000 hospitals and clinics, !
!


31

from the 700,000 doctors, !
!


32

from the 7,000,000 health professionals.!


33

By contrast, in the US there are roughly
300,000,000 people who, by design or
otherwise, are constantly experimenting
with their health. We might all learn a lot
as people like Jeremy and Sky experiment
and as others invent.!
!


34

Yoni Donner is an inventor. Yoni is
pursuing a PhD at Stanford, studying
machine learning and artiﬁcial intelligence,
while also working at Google. !


35

A few years ago he became interested in
the topic of cognitive performance. He
surveyed the tools that have been
developed over the past 50 years for
measuring cognitive performance and
found that nothing quite addressed what
he wanted to do. The existing tools were
good for comparing groups, for developing
population norms, but weren’t good for
measuring small changes, for intra-
personal and day-to-day variation.!
!
He wanted to understand his mental
performance at a much more granular
level. He didn’t simply want to know
whether he was smarter than average. He
wanted to know the impact of different
meals or different hours of the day on how
well his mind worked.!


36

So, he spent a couple of years designing
and developing such tools. He has made
them available to all at a website called
Quantiﬁed Mind. Think of these tools as
short simple video games. His challenge in
creating these tools was to balance
competing goals. The games had to take
very little time, so that one could ﬁt them
into normal life, but they also had to
generate meaningful data. They had to be
simple to play, but also had to minimize
learning effects, so that they are useful
through frequent and ongoing use.!
!
Yoni has developed about 25 such games
so far, and is constantly working on more.
A wide variety of cognitive domains —
processing speed, motor function, context
switching, memory, visuo-spatial acuity,
etc. — are tested through simple games. !


37

One tool is “choice reaction time”. There
are three circles on the screen. The circles
randomly light up in green, and you press
the appropriate key 1, 2 or 3. This goes on
for a couple of minutes. At the end of
which you get some statistics on your
performance — how quickly you
responded and how many mistakes you
made. It’s quite simple, but do it at the end
of a long day and you’ll ﬁnd it is also quite
effective at detecting your tiredness.!


38

Another
tool
is
“sor-ng”.
There
are
four

images:
one
red
snail,
two
green
jelly
ﬁsh,

three
blue
whales,
and
four
yellow
dinosaurs.

Another
image
appears
below
and
you’re

asked
to
match
something
—
the
color,
the

number
OR
the
species
—
and
press
the

appropriate
key
1,
2,
3,
or
4.
In
this
case

you’re
asked
to
match
the
color,
so
you’d

press
3.
It
turns
out
that
this
is
much
harder

than
it
seems.


39

He decided to use his own tool to prove
something about himself that he was quite
conﬁdent about: that his work
performance, the quality of his
programming, was much better when he
skipped lunch. He wanted to prove that he
wasn’t being unsociable; he was being
smart.!


40

Turns out he was wrong. He performed
more poorly when he fasted. This chart
shows the results of a simple motor-
function test — how rapidly he could tap
the space bar. Faster tapping means a
higher bar. Blue is when he had lunch;
green is when he did not. He did the
exercise with both left and right hands. For
his right hand, on average he did 7.1 taps
per second with lunch, and about 6.7 taps
per second without. The difference is
slight, a fraction of a second slower, but
consistent, as you can see from the error
bars.!
!


41

Here are the results from the “choice
reaction time” test — the one with the
three circles. A faster response time is a
shorter bar. Again blue is with lunch, and
green is without. This metric also shows
that he was slower when he fasted.!


42

But there’s more. The tools measure a
variety of cognitive functions, not just
speed, and it turns out that his
performance — fasting versus eating —
depended on the type of task to be
performed. If the work involved critical
thinking, something complicated that he
had to think through carefully, fasting was
detrimental. On the other hand, if the task
was mundane and monotonous he would
actually perform better if he fasted. Now,
he is able to tailor his lunch to the work he
has to do.!
!


43

Others are now taking advantage of Yoni’s
tools to conduct their own experiments,
evaluating the impact of sleep, diet,
exercise, and many other things on their
cognitive performance.!


44

Alex Grey is another young inventor. At an
early age he became familiar with surface
electromyography, a noninvasive method
of quantifying muscle activity by
measuring the muscle’s electrical output.!


45

This technology is used widely. Sensors
are placed on appropriate muscles, and
the electrical activity is recorded. It is used
to study muscle movements large and
small, and to treat injuries for everyone
from athletes to musicians.!


46

Alex’s parents ran a clinic which used such
technology to help treat people with
repetitive strain injury and other such
muscular chronic pain. This diagram
shows the amount of muscle energy used
for hand writing and using a computer
mouse before and after treatment. He
personally beneﬁted from his parent’s
expertise when he himself developed an
issue as he was growing up.!


47

Years later, Alex decided to start a
company to broaden the use of sEMG
technology. Current sEMG systems are
expensive, and they’re conﬁned to lab use
— you saw all those wires. He believes
such technology could have a much bigger
impact if we can get it out of the lab and
into everyday use. !
!
Alex set himself a challenging goal: to
design an sEMG system that would be
usable in the real world — something that
could readily be worn while going about
normal life, something that was small,
light, comfortable, and without wires. And,
it had to be inexpensive. His company
Somaxis has created such a sensor. !
!
The quality of data his sensor collects isn’t
as good as the laboratory equipment, but it
is proving to be more than adequate. Most
importantly the data is obtained in real-
world conditions.!


48

In this simple example, Alex put a sensor
on his left and right thighs and went for a
run. As he got tired, the change showed
up clearly in what the sensors record.!


49

With more sophisticated experiments, he
has learned interesting things about
himself. For example, he wondered for a
given running speed, what cadence or
stride rate would use the least amount of
energy, and so delay the onset of fatigue.
He created an audio track of snippets of
ever faster music, and then ran on a
treadmill at constant speed. As the music
got faster, he would have to take shorter
steps to match his cadence to the rhythm.
He wore sensors on the quadriceps,
hamstrings, and calves of both legs, and
combined these measurements for an
overall score on the amount of energy he
was expending. He discovered that when
running at 6.5 mph, a comfortable speed
for him, he used the least energy at a
cadence of 130 bpm.!


50

Alex’s technology has attracted the
attention of professional athletes. They
want to discover their own particular
efficient motions to improve their
performance. Alex is also starting to apply
his technology to the very same people his
parents treated, people such as office
workers who hurt themselves from too
much typing or writing. These workers will
be able to learn directly, sitting at their own
desks, how to minimize their strain.!
!
The technology is also starting to find
interest in unexpected places. I’ll tell you
more about that in a moment.!


51

Alex and Yoni and Jeremy and Sky … just
a few of those whose efforts are currently
at the edge, at the fringes of healthcare.!
!
How are such efforts going to impact the
future of healthcare? !
!


52

For one thing, it will move us from talking
about “patient” empowerment, to
“personal” empowerment. !
!


53

A patient only exists as a client of a health
professional. A person exists on his own,
whether or not a health professional is in
the picture. Much patient-oriented health
innovation assumes a professional
presence, professional supervision. Tools
for personal health empowerment assume
that the person himself leads and chooses
who else he brings into the picture.!
!


54

Similarly, we talk about “personalized
medicine” as something in which the
health professional has detailed data
about his patient that he uses to make
better decisions. !


55

In contrast “personal medicine” is about
the person himself having detailed data
about his condition that he uses to make
his own decisions.!
!


56

Much health research aspires to know
what works, what makes a statistically
signiﬁcant difference, to some group of
people. !


57

In contrast self-tracking is about
discovering what works for me, what
makes a difference to me, in my life, right
now … whether or not it is good for
anyone else.!


58

We’re talking about health innovations
being developed for use by individuals by
themselves. !


59

Does this mean that healthcare
professionals are optional? Well, yes and
no. In all aspects of life we turn to experts
when we believe such expertise is
valuable. Most of us are unlikely to set a
broken bone, do surgery, or deal with
cancer by ourselves. But, for day-to-day
health there will be less and less
inclination to “consult your doctor ﬁrst”.!


60

Some may argue that these people at the
edge, these so-called innovators are
amateurs, who don’t know what they’re
doing and whose work should have no
place in the health profession.!
!
Others might feel that their experiments
are risky. That without proper supervision
from health experts such experimenters
might hurt themselves.!


61

Many point out obvious and legitimate
concerns about the quality of such self-
experimentation. And they’re right. Many,
perhaps most, of the self-experiments I
come across are ﬂawed in some important
ways. And often the results are
inconsequential. But, to point out the
obvious, so is much formal science. Let us
hope that overall scientiﬁc-literacy is
higher in future generations.!
!


62

True breakthroughs are rare. Earlier in my
talk when I noted some of the very
successful technology companies that
were started by amateurs I neglected to
mention that there were tens of thousands
of similar efforts that failed.!
!
However, true breakthroughs do exist.
There are diamonds amongst the failures,
people such as those I’ve told you about.!
!


63

The arguments about the amateurishness
of much self-tracking efforts are also
besides the point.!
!
I believe it is inevitable that such tools and
such self-experimentation will become
ever more mainstream. Technology —
sensors, smartphones, web access —
continues to become cheaper, faster, and
more widely available. Information, and
admittedly mis-information, is everywhere.
And skepticism about expert knowledge
and bias is increasing. All leading to
greater self-experimentation, self-direction.!
!


64

With all this innovation going on at the
edge, how can the core healthcare
industry play a part? Even if these
changes are inevitable, what can you do to
inﬂuence the changes?!
!


65

First of all, you’ve got to follow, you’ve got
to know, what’s going on. Once upon a
time, huge IBM wanting to get into
personal computing turned to tiny
Microsoft for a key component. Today,
despite its tremendous size, IBM
continues to seek out innovation in tiny
startups. And those once-tiny startups and
now major players — Microsoft, Apple,
Google, Facebook — do the same,
constantly looking for innovation at the
edge.!
!


66

And, of course, you’ve got to get involved
…!


67

To have any credibility, you have to lead
from the front. Talking about the
opportunities or dangers of self-tracking
carries little weight unless you’ve tried it
yourself. Familiarity with academic
literature alone carries little weight. So,
learn about yourself. Track your sleep, or
your mood, or your ofﬁce tasks and their
relation to your stress, … anything really
— and see what you learn about yourself,
as well as the difﬁculty of doing, of
learning, and of making changes.!


68

You might ﬁnd that you have to remind
yourself of what constitutes good science.
Blindly assuming that the protocols of
large clinical trials are the only way to do
good science is as much “cargo cult
science” mentality as anything you might
ﬁnd to criticize of the amateurs.!
!
You might also come to appreciate that
messy data obtained in real-world
conditions is far more valuable than clean
data obtained in sterile laboratory
conditions or highly-circumscribed clinical
trials.!
!


69

Then you can use your clout to accelerate
widespread adoption of innovations for
personal health, to encourage and support
your patients to learn more about
themselves and to make their own
decisions.!
!


70

I’d like to close with two examples of ideas
from the edge that may be starting to
inﬂuence the mainstream. They are both
things I’m involved in.!
!
One has to do with seeing opportunities to
applying new tools to address major
problems.!


71

HIC2012 The Future of Healthcare: Innovation at the Edge

HIC2012 The Future of Healthcare: Innovation at the Edge

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HIC2012 The Future of Healthcare: Innovation at the Edge