I am interested in the progress of “personalized medicine,” so I participated in TCGC — The Clinical Genome Conference in San Francisco this week. It is a small conference, mostly academics and scientists. The biology and statistics were over my head, nonetheless, I’m glad I went.
The core question is — is NGS (next generation sequencing or whole genome sequencing) ready to be used (and how) in clinical medicine? We all hear about the $1000 genome is around the corner (that is your whole genome sequenced for ~$1000) — but having this test done, will it enable a physician to a) better diagnose what is wrong with the patient and b) will it enable the physician to better treat the patient?
My quick observations are:
- I was surprised by the number of teams working on various elements of the problem around the world. Prior to the conference I was familiar with several efforts, but there must be literally hundreds of teams working on tools, pipelines, proprietary data sets etc. Clearly many see the science and market opportunities and they are pursuing them.
- Many of the presenters talked about the same problems — lack of clear interfaces across the pipeline, lack of a complete or gold reference standard, need different tools for different parts of the genome/exome, still lots of manual curation required etc. Then there were some new problems raised like patient consent, patient/physician reporting and education, clarity around things like sensitivity and specificity of the results and recommendation. Many of these issues were raised in the CLARITY challenge I posted about earlier.
- Lots of teams/companies are going after building an end-to-end pipeline of tools, dbs and knowledge. Most of the existing tools are open source, as are many of the knowledge sources. Given the immaturity of the industry — perhaps a vertically integrated solution is the right business approach. There seems to be a some “build it and they will come” thinking around business models.
- Few talked about what I think a central problem re: faster adoption of NGS in clinical medicine is — namely the lack of new, targeted, identified or approved treatment options. The “test” potentially improves the physician’s ability to diagnose the problem or understand the root cause of the disease — but for many conditions there are no treatment options. The science is learning faster around the diagnosis side of the equation, which is good — but the lag time around finding, building and approving treatments may be the rate limiter for growth of the sector.
- There are some interesting ideas around sharing knowledge and “crowdsourcing” solutions to the tough problems that should accelerate growth and adoption. I found this one intriguing www.bioplanet.com/gcat — trying to build truth sets.
The sector is super exciting for its potential and filled with really smart, interesting and passionate people. I will continue to monitor and stay involved.
Last week, David Brailer’s Health Evolution Partners (where I’m currently an Operating Partner) held its annual conference in Laguna Nigel, CA. What makes this conference really interesting is they get leaders from major companies across the health economy — health delivery system, research, big pharma, payers, tech — and add in a bunch of disruptive, small companies in the same setting which stimulates a diverse variety of interesting dialogs. Folks are both inspired and enabled to take some concrete actions to either collaborate, do business or simply be smarter for having participated.
The first night had a quick fireside chat with David Agus and then a later panel which had Eric Topol and Bob Galvin on it. Agus and Topol are leading researchers in genetics — but have a pretty different perspective on where to focus. It would have been fun to see them on the stage at the same time. Both have books out (I’ve finisherd Agus’, started Topol’s). Here are my takeaways:
- Agus is promoting a ‘systems biology’ approach to understanding and treating health and disease. Genes are important — but we won’t find the answer by just improving our understanding of the genetic variations. Our body is a complex system — which has many redundant capabilities and adapts to inputs. We really don’t know why certain treatments work — but we should follow the evidence even we don’t understand the causal pathway. I initially learned about ‘systems biology’, P4 Medicine and the challenges of building computational models of our body from Lee Hood in Seattle. You can watch Agus at the KhanAcademy here.
- Topol appears to be more firmly in the camp of truly understanding our genes will lead to the ability to treat and prevent disease. This focus is similar to Frances Collins head of NIH. In addition, Topol’s focus in his book (and other talks) is that technology convergence and consumerism will necessarily drive medicine through the digitial revolution that will unlock value. Naturally I share his enthusiasm for consumerism and technology — but so far I’m in the ‘systems biology’ camp as the more likely framework to right.
- Galvin made a key points about our need to be skeptical about technology as the solution to our cost problem and that we needed to focus on consumer/patient behavior. He described the need for incentive systems and feedback loops to consumers to drive better outcomes.
Jeff Trent (founder of TGEN and whose team is doing some great work) later characterized the differences between Topol and Agus in a way I found interesting as:
- Agus believes common sense trumps technology
- while Topol believes technology will trump common sense.
The discussion matters (one is not right and the other wrong) because it should impact where our research dollars and programs go. While average citizens don’t get involved in understanding and caring about our research priorities — they should. In his book, Agus also shows how a ‘systems’ approach really should influence our health regimen and approach TODAY. I agree.
Last week ‘health reform’ was in the news because of the three days of hearings in the Supreme Court. I believe the Obamacare law raises some very fundamental questions about the scope and role of the Federal government. I was delighted that the country is finally having a conversation about the core issues raised by the law – a debate that should have happened during the legislative process.
Here are some of my favorite posts:
- George Will on why it violates centuries of contract law.
- Glenn Reynolds on division of powers necessary to protect liberty.
- Grace Marie-Turner cautioning about reading too much into Justice Kennedy’s questions.
- WSJ — on why today’s ‘health marketplace’ is perverse and the need for change
However, I found this WSJ article detailing the nasty battle between UPMC and Highmark to be way more telling about the future of the health delivery system. There are many dimensions to the battle over customers, physicians and dollars that are interesting. One paragraph in the article I found particularly fascinating: “Early talks between the companies hadn’t gotten far. Highmark has said UPMC initially sought a 40% increase in its hospital rates. Mr. Romoff doesn’t dispute that but says it was a fair boost to make up for inadequate payments under the old pact with Highmark.” Pricing power matters a lot in the health economy and having a good brand and substantial market share dramatically increases pricing power – which has been UPMC’s strategy. What is unique about the health marketplace is that there are limited checks and balances to this market power – at either the payer or provider level, because the consumer of the service is not engaged and empowered to ‘shop around’ for value.
My view is – without pervasive price transparency, ubiquitous quality reporting and material economic incentives for consumers to be smart shoppers (where applicable) – ‘health reform’ will unfortunately lead to neither increased ‘value’ in the health economy nor bend the cost curve.
p.s. update — Highmark CEO fired. Not germane to the discussion — but felt the update necessary.
Last fall my wife and I became empty nesters and last month I fulfilled my long held promise to her of retiring from the ‘start-up’ lifestyle we have lived during our 24+ years of marriage. I want to be engaged and making an impact on the health ecosystem – just with a different work-life balance. I am delighted to have joined David Brailer’s Health Evolution Partners growth equity fund as an operating partner to help identify and grow innovative companies in health. The health delivery system and overall ecosystem have a long way to go to become ‘digital’ and to benefit from the power of real-time data, ‘industrialization’, and consumer engagement. The economic health of societies across the globe needs the health sector to adopt these changes and tools and faster!
Closing comments on Microsoft and Health Solutions Group:
I went back to work at Microsoft for a second time in 2005 after a seven-year absence where I was the founding CEO of drugstore.com. One crucial lesson learned at drugstore.com was the role that government has in setting the rules of the game. So I decided I wanted to learn more about the government side of the business, and ended up on the President’s Information Technology Advisory Council. Because I was still chairman of drugstore, they made me co-chair of the health subcommittee. And at that time, I got to learn from the IOM, from HHS, and from a lot of experts around the country that people die every day in our health delivery system because of inadequate information systems. That just seemed wrong and that more needed to be done to change it.
I decided to go back to work and try to make a difference. I realized that to really make a difference in ‘digitizing the health economy’ required a company like Microsoft that would have the scale, tenacity, patience, and capabilities to build scalable health platforms. We formed a ‘start-up’ unit inside Microsoft to capitalize on the observation that health is a big and growing segment that’s been under-invested in information technology.
Interestingly enough, during my first week on the job in 2005, Craig Mundie and I went to a GE Healthcare 2015 workshop hosted by GE CEO Jeff Immelt and Sir William Castell. Sir William had actually helped motivate me to go back to work with his inaugural speech at the Pacific Health Summit the summer before that talked about the need for completely different paradigms around early detection and prevention. Then to be able to participate in this two-day conference of 50 leaders in Crotonville, New York, in my first week backed formed a set of impressions that were inspiring and valuable.
Health has always been a part of my life, as it is with everybody. Everybody has personal stories. Healthcare information technology became a passion for me when I observed that health is fundamentally an information management problem, and for whatever reason, there wasn’t the class of systems inside of health organizations that enabled users to leverage real-time data for insight and action. It’s not because the technology suppliers were bad; it’s because the economic infrastructure doesn’t reward the kind of innovation that is rewarded in other industries. It’s a complicated problem and I recognized it would take many steps and time to change it. My inspiration was to leave a better health system for my kids.
And that’s why most of my previous blog posts are centered around the idea that it’s not just about creating a better widget; you have to create a marketplace of incentive systems that allow and motivate people to adopt technology in a different way. I intend to maintain this them in my blog going forward – as I find so many people operate with unexamined assumptions about the role of incentives and policy frameworks in driving health outcomes.
I’m proud of many things we’ve accomplished since starting the Health Solutions Group. We’ve built a trusted brand in an environment where people would have bet against us. Five years ago, people thought we were crazy to talk about personally controlled health records. Today it’s the law. So we’re helping to move the world in the right direction. And the fact that we’ve done it in a way that’s cooperative and collaborative with the rest of the industry is great.
The benefit of the new joint venture between Microsoft and GE is that it allows us to move faster and accelerate our vision. I think it’s clear that customers expect Microsoft to play the role of platform, enabling a best-of-breed environment that allows them to choose from multiple vendors. It’s great to have GE, a first-tier application vendor, say, “Yes, I believe in an open environment, and I’m also going to invest in modifying my technology stack to go take advantage of this and to move forward.”
The vision of this joint venture — the vision that Microsoft has had of a connected, data-driven, health infrastructure — I see it happening. I think the only question is, “Does it take two years or 22 years?” It’s somewhere in between; it’s a matter of how fast reform can happen. I think more and more people will start to find ways to reap the benefits of bundling (as Zeke Emanuel wrote about in the New York Times), more prescriptive care pathways, and technology that lowers costs and improves patient outcomes.
So, it’s clear it’s going to happen. It’s just a matter of when. And whether the U.S. will be a leader or some other country leapfrogs the U.S. in capabilities. I am confident the JV will have a major role to play in liberating the data, driving insight, empowering users and the health system alike to improve patient outcomes.