Dr. Lloyd Minor: Why we shouldnt panic about coronavirus, and should start taking precision medicine seriously
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Show Dot Com to learn more and to register for a free exhibits. Pass use the code recode. This free offer expires April fifth. That's an ABC show dot com and use the Code Rico for a free exhibits pass. Hi I'm Tara. Swisher editor at large recode. You may know me as someone who could probably be a very good neurosurgeon. I'm used to getting into people's heads but in my spare time I'm just a reporter and you're listening to Rico decode a podcast about power change in the people you need to know. Were part of the VOX media podcast network. Today in the Red Chair is Dr Lloyd. Minor the dean of the Stanford University School of Medicine. He's also the author of a new book called discovering precision health predict prevent and cure to advance health and wellbeing which comes out March twentieth. We'll talk about the big public health issue. That's on everyone's mind right now. Which is the corona virus outbreak as? Well as how tech is changing the study and practice of healthcare doctor minor. Welcome TO RICO. Decode for your. I'm going to start going to go into your background. But let's talk about right now. The Corona virus anyone who has any ability to talk about it intelligently? We love to talk about having tomorrow having Ron Kline. Who was the? Bolas are you're under the Obama Administration. Talk a little bit about where you think we are. And how Stanford is handling this because I think every probably every major medical center is discussing this at length. I think this is a serious public health concern. But it's not a cause for panic specifically to your question about Stanford we're prepared None of us knows the extent of the spread but we just opened two wonderful new inpatient facilities children's hospital. We opened about two years ago. A new adult hospital. We open just this past November. They're equipped with private rooms rooms. That are ready to take care of patients with infectious diseases Our staff are trained. We have supplies of personal protective equipment. So we've been in preparation for this or an event like Cove in nineteen since before the current problem with this virus began. So when you say not panic what. People are panicking. Although the stock market's getting affected people are canceling things. What do you how do you? How do things like this player? We just don't know because everyone talks about this idea of the big one. I've been reading stories but some day. There's even big when this may not be the big one but tunnel but what. How do people not panic. What is the thing to do? What is the responsible thing to do? I think the way not to panic is to focus on the things that we know. Prevent the spread of the virus number one. We should wash your hands. Twenty seconds With soap and water. Also we should avoid touching our face Something that we do commonly But that we know that The spread of the virus by largest through mucous membranes. On our face nose eyes mouth so those are two relatively straightforward but requires some intention and planning Things that we can all do that have been shown to curtail the spread of viruses like Cova nineteen and specific virus. Exactly what about this cancellations quarantining because it shows shown up? Now it's a New York. I guess this is the viruses spreading and this one seems to seems to stealthily. Stay somewhere for a while right. We we I think other organizations are watching carefully recommendations from the CDC from local and county health departments with regard to how we advise our employees with regard to how we plan events the CDC did last night issued a recommendation that education's look at abroad programs consider bringing students back from those programs. So that's something. We began to look at immediately as well as determining where we have. Students will watch carefully the recommendations coming from national organizations local organizations and act accordingly right and and so people should not be hoarding masks. This is something that This surgeon general said. I've heard lots of doctors talk about it. This idea that that will protect you. That's not the case correct. That's correct the Specific recommendations from the CDC and other organizations is that just wearing a mask if you're not infected if if you're just wearing it because you're thinking it's going to prevent you from getting infected that's not likely to be effective and also it's likely to prevent the mass from getting to the places they need to get matches and taking care of patients who do have the effect y will not prevent that because the microbes get in. Is that correct right? What we what we know so far. And this is changing by the hour Not to mention by the day Is that this virus like other virus. Specific viruses in the family of Corona viruses is spread by droplets so the virus gets into particles of Saliva or other bodily fluids and then it's transmitted either Through a cough or a sneeze or through close contact with a surface that is had droplets on it a mask. Although you know in some sense it might be effective. It's not the principal way we prevent the spread of the yourself. It would prevent the cough from going outward. Actually sick it does right. But if you're trying to prevent the infection again it's handwashing avoid touching your face right because membranes right so the mass to be used for healthcare workers and people who are sick who actually want to prevent from coughing on a table or or more of that is central to. That's what it should be used for. If you're actually sick so screw you should wear. If you're not. You should not correct right okay. So do all spent a lot of time thinking about this idea of the big one. The idea that there is there is a virus or or a play. That's going to affect humanity. We now want to get into position because medicine's changing too at the same time exactly. I think what's happened over the past month. Period past couple of weeks with regard to corona virus really underscores the importance of needing to focus much more attention on infectious diseases. Those emerging in those. That are already here. There's been very little work done. A new vaccine development In recent years. There's lots of reasons for that In terms of the business model in terms of the amount of R. and D. Cost Required to develop new vaccines. We need to rethink that and we need to learn a lot more about human immunology and how it is that we four vaccines how it is that we can mobilize the immune system in each of us to fight off infections like the infection from corona virus. Our knowledge of human immunology in the human vaccine response is still fairly primitive. That's an area. We focused on a lot at Stamford. And we'll continue to focus on in addition to the work. That's going to go on an industry. I hope To develop a vaccine for cove in nineteen and also better vaccines for the flu and and other related viral illnesses. Hi this is a good segue into talking about the yearbook described precision medicine. The idea that can help us in this way. I mean I wrote a column about about the things obviously working from home and things. There's a lot of technologies now that prevent people from hitting each other. But you're talking about something else. Explain precision medicine but what you mean and where How it's going to help our health. We are strategic vision in Stanford Medicine we describe as precision health and we call it health whether the medicine for the following reasons in the United States. We have a great sick care system. In terms of organ transplantation the latest treatments for cancer for goodness sakes. If one of our family members has a disease like severe heart disease or cancer. We want to get the very best individualized treatments and we do relatively well within the United States. But shouldn't we be taking those same enablers of genomics and data science and applying the much earlier on to predict and prevent disease precision health? Therefore for is about healthcare. It's about learning how to keep us healthy. Get Sick we want precision medicine which is about sick care which we for sure do at Stanford but the way we know we'll be successful a decade. We'd been successful a decade from now and our vision for precision health. Is that a lot of the severe acute diseases we treat today. Like cancer and heart disease will either be prevented in the first place or they'll be less severe because we will have detected and treated them earlier therefore they're three components. The precision health predict prevent and cure. But really in that order. Because we're if we're able to predict The likelihood that you are I will get a disease. We're much better equipped to prevent it from occurring in the first place and we can't prevent it if we diagnose it much earlier we'll be able to treat it more effectively than if it was diagnosed at a very late stage. Cancer provides a good example. Knowing are risk factors is going to be increasingly important and advanced diagnostic tests that are focused on detecting cancers like pancreatic cancer ovarian cancer much earlier. Should have an effect on the outcomes because today those two cancers in particular pantries and ovarian cancer are classically diagnosed very late in their course and therefore have a relatively poor outcome if we detect them earlier we should be able to treat them much more effectively. Talk about how that comes gets. Precision medicine is defined as individualized medicine. Correct is that. Am I wrong about that? You're right and really. The term precision medicine began right here in San Francisco Back Two thousand thirteen two thousand fourteen when sue Desmond Hellman was chancellor UCSF? She hosted a national conference on precision. Medicine is the first time I'd heard those terms us. Then President Obama pick that up as being an overall national goal and precision medicine is about using genomics and data science to personalize the treatment of the best example. Is Cancer Today for example? Our Treatment Outcomes in breast cancer much better than they were a decade ago because no one with breast cancer gets off the shelf treatment. Everyone with breast cancer has a treatment protocol. That's individualized to the disease works. Because I think people in our city that they medicine has been sort of a a kind of I. Don't see spray and pray but off the shelf. This everyone gets the same thing in this. Testing is done. Everyone is not the same let so the idea of precision medicine. Is that you tailor. The medicine to the individual person based on their genomics and other thing. That's right we can continuing Example of breast cancer there three very important receptors that are tested in every breast cancer. Patient that therapy for that patient is determined based on whether or not the person has receptor or not also the status of any notable any involvement of lymph nodes impacts the choice of therapy so whereas in the past like maybe fifteen to twenty years ago the treatment would have been you know. Mastectomy dissection radiation therapy same thing. That's not the case today. And as a result the outcomes are better because we are able to tailor the treatment to what we know will work best in the patient with that particular disease right and not and not treat every person the same so that has been a big boom for cancer what other areas cancer being. Probably the most notable one but also in heart disease today a lot of advances in predicting and preventing heart disease and also intriguing severe heart disease and heart disease points out how we can make progress in reducing the incidence of a deceased quite a bit and of course last twenty twenty five years. It was a study begun now sixty years ago. The Framingham study in a suburb of Boston. That defined the risk factors for heart disease high cholesterol high lipid levels the relationship of high blood pressure as a result drugs like lipid lowering drugs were developed and we also had a renewed attention reducing the incidence of smoking. Better control of blood pressure. All those factors coming together have reduced the incidence of heart disease. Should we be able to do the same thing for other types of disease? I swear the risk factors may be a little bit harder to deduce than they were for heart disease but still now particularly with data science with the ability to aggregate large amounts of data. We should be in a much better position for each one of us to know what our likelihood of developing a disease is and how we can best prevent that disease. Let's talk about that idea. So the you take a patient precision health that would be to to figure out. I've heard lots of these companies now and a lot of tech people are going to them what they're going to die off. They're going to find out what they're probably going to die of. Based on this this idea of what your risk factors talk about how that works individually and then we can talk about it for everyone out for for lots of people are genome plays a big role in determining what we're at risk of It's not everything though you know. It's a sad fact in America today. The best predictor of life expectancy is not our genetic code. It's Zip Code in which we live and I think that's something we're going to have to see the social environmental behavioral determines. I write about them in. The book are going to be areas that we have folks a lot more attention on in academic medicine in the US healthcare delivery system than we have in the past that being said our genome does give us insights into our risk factors for variety of diseases. That's a starting point. But it's really only a starting point as we look at the interaction between the genome and things in the environment. That's where we're going to get a much more. Robust picture of what risk factors are and what we can do about it all right when we get back. We're talking about how you do that. How you do that. And how you spread it out to most people in this country and we'll talk a little bit about for not Medicare for healthcare for all in doing that when we get back. We're here with Dr Lloyd Minor. He's the Dean of the Stanford University School of Medicine. We'll be back after this. This episode is brought to you by command line. Heroes a podcast about the tech. You're probably using right now. Mainframes personal computers floppies smartphones everyone. Some of these machines succeeded while others failed or hardware got smaller and smaller while processing faster and faster command line heroes. The award. Winning podcast from Red Hat is back for its four season and this one is all about the history of hardware host Ceron Youth Barak. Brings you the story of the people who attempt the extraordinary and persevered in the face? Major obstacles head over to the podcast platform of your choice to listen and subscribe to command. Line Heroes. You'll find the first episode of this latest season which begins with a look back at the mini computer and features interviews with some of the subjects of Tracy kidder's classic books. The soul of a new machine. 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Indeed gives you smart tools to help you make hiring decisions quickly and be confident that you're making the right hire for your team. Post your job today at indeed dot com slash decode and get a free sponsor job upgrade in your first hosting that's indeed dot com slash decode terms conditions and exclusions apply offer valid through March. Thirty first twenty twenty. We're here with Dr Lloyd Minor. He is the dean of Stanford University School of Medicine. We're talking about. His new book called Discovering Vision. Health predict prevent and cure to advance health and wellbeing. Getting precision also talk about you. Were talking about certain things vision medicine which is when there's certain illnesses you zero in on them. After you know about at this is before you know about it. Correct is that is that the way would put it or not. That's correct Matt. It's about developing is about the science of prediction prevention which classically hasn't received as much attention as the science directed at curing disease. After the fact right but for example after it's been diagnosed as Everson diagnosed oftentimes at a very late stage for example. There's a revolution going on right now and diagnostic testing with the application of data science and analytic methods to detecting a small signal in the midst of a lot of noise. We should have in the not too distant future an array of diagnostic tests. That will give us better insight into whether or not we have an early stage of a disease that I think could be revolutionary. We talked before about cancers. We classically diagnosed late payments and ovarian cancer. We should be able in the future through blood tests to see and diagnose those conditions much earlier at Stanford. We've been a leader in the revolution in Molecular Diagnostics. Goes back more than a decade. When Steve quake and his colleagues were the first to use micro fluid ix to do a chromosome analysis of a fetus from a simple blood test in the mom and as a result of that technology and related technologies today the use of amniocentesis which an invasive procedure to take flu right today. The use of amniocentesis dramatically reduced. Because we can get a comparable amount of information from a simple blood test. That's one of the mother of the mother right Which for those who have not had it. It's very invasive it's not a little invasive amniocentesis right exactly because it has a risk to the fetus The blood test works because there's a lot of DNA from the fetus. That circulates in the MOM. But you can apply that principle other conditions. Dna from a tumor from a cancer. That circulates in the blood. And then how do you detect that DNA? It's not as much of it as there is DNA from the fetus but still with with advanced analytic techniques. We have today. We still should be able to perfect these diagnostic tests and roll them out. So how this is not the way. Our healthcare says it is about sick care. It's about the cure. It's about finding out you have a disease and being surprised by it because most people die of something right you know talk about the way it set up and then later I want to get into the question of data like what do you do all this data but talk about the way we think of healthcare because it is about cures after the fact essentially several reasons for that one is the way we finance healthcare in America which still at his base is fee for Service System. That is we pay for units or increments of care we pay for the doctor's visit the Blood Test The radiology study increments of care that are not necessarily. Our payments system is not necessarily linked to outcomes therefore there has been a move which continues today and I think needs to continue even more in the future a move towards linking payments outcomes and move towards bundled payments and ultimately a move towards being responsible for the health and wellbeing of people who were in a health plan or in a delivery system. What are the reasons that there hasn't been as much focus on early stage diagnostics or prevention? Is that those. Don't necessarily translate into increments of CARE. There is a code for every office visit for every blood test There's not necessarily the same type of code to doing the type of nutritional counseling that perhaps could help to better control their diabetes or lower. Their Blood Glucose level. It's in that area that I'm really excited about advances in digital health. A lot of those going on right around us here in the bay area and that is we know that technology has disrupted pretty much every aspect of our lives except for health and healthcare tarnishing. Yes finance would be the other one right right. Oh you know we we. We do online banking today but the way we order goods and services. Everything's different but still by and large you know. Pick up the phone and call to make a point of doctors. We still transmit health records by fax machines. I can't believe it but we do Where the only industry that really still uses fax machines. We need to move beyond that. We need to leverage the benefits of technology. And bring them to people. But we have to do that while being cognizant of the security of the data and the privacy. That's most when I talked to doctors as most of the excuse for it is that is hippo or whatever talk a little bit about that explain hippo for those they they. They were protecting health records. Essentially that's right. Hip is making sure that a doctor healthcare delivery system doesn't go out and sell your data to someone else and reveal your health status to ensure something like that without your permission it also requires doctors dated and delivery systems to maintain the security of data. So that it can't be hacked or or stolen. The intentions of hip are absolutely correct. We also have to figure out ways to combine and aggregate data defying it but to extract information from the data. We have to bring it together and I think a lot of the work. That's going on now through the national coordinator of Health Information Technology moving forward with regulations. That will require more open architecture. Still protecting the security of data and and the role of patients decide how their data is being used but to require that when I want my health data shared with someone else or when I want to access it I can in the way I want to access it. Those types of requirements need to move forward when they do they will enable us to share data in an appropriate and safe way better than we can today. Whatever the reason is because of this. What is the reason given all these other changes across society and sharing of data? What is this just this or or what? What is the problem? Is that the payment system. If you had to point to it there are lots of factors but one is that there haven't been the incentives in place to make data interoperable interchangeable in the way that there have been the incentives and other industries for example. You mentioned Fintech before you and I can use. Atm Card Pretty Much any team on the planet today right. Imagine a financial services organization that said. Well we'll give you every customer a card but you can only use it at our. Atm's would we stick with that organization. No I think there's a strong role for consumers to really be pushing our doctors our delivery systems that I would access my data when I want to access and I wanted to be portable in the ways that I wanted to be portable. I want to be the person in charge of making those decisions. I think consumers pushing for that will help ultimately to drive the regulatory changes and also this shift more towards bundled payments so that there's there aren't as many incentives for delivery systems to prevent their Their enroll leased from looking at other opportunities when it comes to preventative health. You don't have that that's not done. And why is that from your perspective? The idea given and then we'll get into people carrying devices and knowing what they're walking and things like that but the idea that the system is more oriented towards the end versus the beginning of couple of reasons why prevention hasn't received the same attention as treating and curing disease one is. That is fundamentally about behavior. I mentioned avoiding. Oh seventy percent of the determines health or social environmental and behaviorally related. I moved here from the East Coast over seven years ago and when I was getting to meet people in the ecosystem I met with prominent biotech venture capitalists and I said well. Is there something they've if you hear a pitch about something you say thank you? I'm not interested. You know you're wasting my time. And he said Yeah anybody who comes to me saying that they have an idea for how to change behavior. I'm not interested in it. Became very discouraged because it is fundamentally about be up. Now fortunately we've seen Startups that are doing that. Particularly in the diabetes space. This is where we need to go it. It isn't easy but what we know is that technology can help in creating communities and communities can help support behavior change so one reason it prevention has not received as much focus first of all it's hard and insist viewed as being soft because it is so closely linked to behavior and social environmental factors. We need to get over that. And focus a lot more of our time and attention on the science of prevention and a leveraging digital technologies to help prevention about those digital technologies. Because they've been a boom in them everyone's carrying in carrying different fitbit's whether it's that or there's all kinds of groups That and companies. That have started to do that. To be constantly monitoring people how do you look at that trend? Well I think the opportunities are great. The risks are also significant. And we have to figure out how to leverage the opportunities but also always protect the privacy of individuals and the security of data. We we collaborated with Apple. Using Watch to detect the most common arrhythmia atrial fibrillation area. There was there was a number of companies that that's right A. Fib oftentimes goes undiagnosed until it causes a big problem stroke. Now this is a a a hardy retired. The heart beats irregularly right and The coordination between the top chambers of the heart and the bottom chambers is distorted and as a result people can form blood clots which can go on 'cause strokes and other problems since it isn't a rib mea. Th you measure heartbeat if you measure measure rhythm you should be able to detect when it occurs we conducted a clinical study a clinical trial enrolling over four hundred thousand people and using watch as an alert and then for people who got the alert that they might have a Fib. They were given the opportunity to receive a patch. Ekg where that for about six days. Send it back in. And then we could coordinate and and compare what the watch says to what the watch was saying. There was a strong concordance about eighty four percent of the time when the watch said the person has a fifth the EKG said that that's the case also so that was encouraging apple's going to extend that study with other collaborators Johnson and Johnson and others every time you and I fly on an airplane. Those jet engines are being monitored hundreds thousands of times. A minute why can't we have the same sort of thing for our health particularly for those who are at risk of something. Like a major heart rhythm abnormality. We should be able to do that. It's within our grasp today and we don't do it because it because I think Cost one thing because when the iphone came out it was only a small segment of the population had access to a smartphone right. Mitt and that's not the case today Most people have smartphones. I think the same thing will occur digital health monitoring devices. There hasn't been. I think it gets back to. There's been less emphasis on prediction and prevention than there has been on cure. There's been less investment in that area but that's changing digital health startups now. There's a robust investment ecosystem. We have seen in the past year to some exits of those early stage. Companies in meaningful ways that should keep investors interest in digital health. But I think it's going to be a combination of the investor segment of getting us as consumers more comfortable with measuring things like our heart rate and and having that going in the background and also getting us is delivery systems really viewing ourselves as partners with our patients and helping our patients decide how they wanNA monitor their health and how we can help them do that. So when you're talking about all these digital companies they they're they're pretty widespread. Though they're I mean they're probably spend more widespread amount a group of people a wealthier group of people who are monitoring. Their health is obviously here. A lot of people. I've I've Whether they're carrying the fitbit's whether they have the things on the wrist whether they're doing all kinds of diabetic stuff. How does it get out to the larger group of people right? I think it it makes sense. Then you have a lot of data yes exactly. I think it will get out to a larger group of people just as smartphones got out to a larger group. They started with a small segment of the population as they began to deliver more and more useful information the adoption of smartphones grew. I think we'll see the same thing with personal monitoring devices also. I think we'll see more and more delivery systems working with patients who wish to use a device to enable them to do that in a way that it's not interfering with their life so we know that the most useful devices the ones that actually have the greatest stickiness are the ones that don't require a lot of effort on our part because most of us don't want to spend a lot of time and effort on it and that ability to operate in the background and monitor our health in the background should increase. As time goes on a couple of things I write about in the book that are encouraging still early. Stage not available for general use. Today is a Smart Mirror for example. Most of us in the morning. We're looking at a mirror. We tell a lot about our health about how. How're facial? Appearance? May Change over time so that we have you look in the mirror and for example. If you're becoming jaundice that'll show up in your is The amount of adipose tissue fat that you have in your face is an indication of your overall health. There's lots of different things that if you're making a measurement repeatedly over a long period of time very subtle changes can become significant. And that's the notion behind a smart meter smart toilet also operating in the background. That can look for early indications that is going on with our health brought by measuring this. We're going to get back talking about this when we get back. Especially around the data implications and the privacy implications where here talking to Dr Lloyd. Minor? He's the head of the Stanford Medical School Essentially And he's written a book about precision healthcare. We'll talk about that and more when we get back. This episode is brought to you by. Us Cellular. There's never been a better time to switch to US cellular. 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Mar APP is designed to work with most new. Hp Printers Beach P. Smart APP is available in Google. Play or the APP store visit. Hp DOT com slash. Get real to shop compatible printers. That's HP DOT com slash. Get Real or here with Dr Lloyd. Minor his book is called Discovering Precision. Health predict prevent and cure to advance health and wellbeing. We're just talking about smart mirrors and smart toilets. People make fun of people for doing that. In Japan there there was always like. Oh they have these independents. The do you imagine people will embrace. Those are the idea that they should be constantly monitored to see how they're doing you know in order to prevent something further on down the line. I think some will and some won't to adoption I believe will be determined ultimately by how useful it is if it if if we're able to win my say when we're able to show that this really does have an impact on health that you can detect diseases earlier and treat them far more effectively than I think. There'll be more people adopted smart mirrors smart toilets which again They Monitor your evacuation essentially of all kinds to look for what? What does that looks for? And look for early indications of Cancer. you can look for Indications of other diseases of the metabolism Monitoring Diabetes will be enhanced by that but a lot of diseases that progress should be able to be detected much earlier right as well as for example a decade ago. Not many people monitor their activity level. We know that twenty minutes of moderate exercise a day has an enormous effect on our overall health and well being now more people are either closing their circles or doing something to look at their activity level and can serve as a nudge And back to behavior change these micro nudges or or reminders or small indications during our day that if we do something might change our how we feel our well being those have been shown over and over again to be the most effective ways to To actually impact behavior and by monitoring things like our steps other things in the background will be able to live. More informative nudges when we want to receive them. If we don't then we don't have to write this all sounds great the idea of monitoring all the time but us being monitor and social media is being monitor movements Geography everything else has been become controversial Recently just this week. Walmart is getting into healthcare working On a prime competitor Walmart. Plus it's an idea They're trying to That you pay a certain amount to get different things. But one of them is Walmart. Healthcare the piloting a health clinic with services. Hubs against rivals. Health hubs and things like that At the same time Amazon is also Getting into healthcare. That's what everybody thinks that they will do a lot of stuff like that and obviously they will focus on preventative. Because I would imagine. That's exactly what they'll focus on. This idea of these big companies and apple is is in here Probably the most privacy friendly the protective of privacy friendly company talk about what this happens because when these companies get in obviously prevention will be an important part of this because they are going to try to try to up end in disrupt the healthcare system as it is. I'm encouraged because I think each in. Its own way can bring new ideas new approaches to health and healthcare. I mean let's take Walmart as an example. I think roughly seventy four hundred stores Walmart stores in some of the most underserved health areas of the country. Walmart is opened a as you mentioned. Health clinics at a couple of stores in the Atlanta. Suburbs I think they'll study those intensively but bringing primary care and vision services and dentistry in an affordable way in an easy to access way to communities should go a long way and identifying predicting and preventing diseases and and those clinics are going to be focused on doing exactly that I mean. How can we identify High Blood Pressure or high glucose levels and and treat those people now as to whether or not it's Walmart or it's Amazon or it's apple I mean each of course comes at it from a bit of a different angle given their core business model but I think that's going to be good for consumers now what we have to make sure in all of this is that the interests of the patients have to be? I interested in consumer has to be first and that is that I hope we never get to a situation where health related data is viewed as simple social media data. There may be some people who want their health data accessible in that way but I think most people will not. We're to make sure that it's protected. Privacy is protected and but when they when have a big these big tech companies get into it has changed the current environment is? That's what's necessary to change this because it isn't really working under the current insurance system with big giant insurance companies where nobody's concerned with prevention essentially now as much as they need to be That's one thing that I think. One of the many things that I think can come in a very constructive way from the focus of these large companies on Health Walmart began many years ago. They are the largest employer in the United States and for their employees who need a series procedure like heart surgery. Or maybe they have back pain. They began establishing centers of excellence and they monitor the health outcomes of those centers of Excellence. Very very closely. That's a win win situation. It's a win for the company because they're getting the best outcomes and in usually better outcomes are associated with lower cost showers for sure a win for the employees because when they go for and maybe they have to travel one hundred two hundred miles to get heart surgery. Walmart pays for that but they can be sure that they're getting it done by by surgeons in delivery system with those outcomes being very very closely monitored so they're going to get the best care that's available that spirit needs to permeate more of the healthcare delivery space in I think we'll we'll see more of this linkage to outcomes to payments both in government insurance plans and increasingly commercial plans as well all right. It's a win these big getting one of the things that's Problematic is getting healthcare to everyone and obviously one of the issues in this election is Medicare for all whether there should be a single payer system all kinds of things. How do you get And it makes perfect sense that we should have precision health. It should be early. It should be preventative How do we get to that with all this political rancor around healthcare in general there are two principles that I believe are fundamental to revamping the US healthcare delivery system one is? I believe that every American needs health insurance now how that's finance where that's medicare for all or the exchanges. I mean they're variety different ways to do it but everyone needs a basic form of health insurance. That's number one number two or health plan. That's right the way we think of it. True true a health plan but something that provides them with a basic level of care and it also takes care of them if they develop a major illness that provides for the care they would need nutrient that. Ls because what we see today. Is that people all people who either have no insurance or they have very poor insurance. They delay the delay and delay and delay and getting something addressed and then they only encounter. The healthcare delivery system after that collision has progressed. That's just bad. It's bad for the patients. It's bad for the delivery delivery mechanism because their care is going to be much more expensive in have much poor outcomes when without delay. So that's why everyone needs some form of health plan health insurance but something that provides basic care second is that we need to continue this. Move Away from fee for service medicine and more towards bundled payments and towards alternately. All of us on the delivery system side being responsible for outcomes and by moving away from the incremental payments or to pay for each unit of care and more towards outcomes based reimbursements. That will help us to drive value. That is better outcomes for lower costs and we'll also align the financial incentives with what we want the incentives of the delivery system to be which is keeping US healthy. And when we do get sick providing it's the best treatment that will give us the best outcome sue to finish. What are the key? I want to understand from you? What the key things in the next five years. That are happening. Some of the key. Tha especially technology trends. That are happening. That will bring us to this the diagnostic tests. And then how you would look at it twenty years from now if if we had had the ability to know was coming down the Pike and do something about it before it got the worst possible you know. We're in the worst possible situation on the technology side. I think we'll continue to see the development of of monitoring device bartering devices. Also we'll see much better electronic health record systems today. Electronic health record systems don't provide much decision support. They don't furnish you and me. With data and the forms we would like it to be a lot of entrepreneurial activity going on in that regard and I think we'll see a lot of improvements in the way they function in the future. Also I think technology will enable us to monitor our health in ways. We've never been able to in the past. Not everyone will want to do that. Those who do will be able to do so without a lot of friction without having to the most is having something on your body right not so much. The smart toilets and Smart Mutual. Just one way but mostly is right. That's where most of the innovation is going on right now. That's right as well as in early diagnostics which are technology enabled but usually involve looking for very small amount of cancer cells or another Molecule in in the blood or urine that could be tested very easily and very inexpensively when it scaled all of that in the three or five year timeframe. Then looking more broadly once that's deployed. I see us moving away. From just after the fact medicine and much more towards the prevention and prediction that will enable us to drive better outcomes and that would include. What how would that? How would that look for a patient going in for example? And you wear a monitor device you so your your heart is being monitor. Your blood is being monitored a regular basis or you engage in other ways the healthcare delivery system where you don't come in for an appointment you have a virtual visit with Lifestyle coach or nutritionist. At night you know when you're at home rather than having to take off a work. We're doing that today. And our delivery system and many others are as well but we lower the friction. We lower the amount of effort. Each of us has to take in order to engage in our health. And if we make those methods of engagement better and more accessible than we increase the likelihood that everyone's going to take advantage of them right now and get. It gets back to these other determinants of Health. We still within miles of where we're sitting today. We have food deserts. We HAVE COMMUNITIES. That don't have access to healthy food. Technology can help with that to bring food into communities to identify the areas where there aren't shopping. Opportunities enable people for the same amount of money to get healthy foods. All of this should be much more robust as we apply technology. And the way that it can and when you think about The idea of advance healthcare. You talked about predict and prevent. How does that cure is it? The amount of data that we understand how things lead to things. Or what is where. Where's the curing part? The curing part I think is best. Represented. What's going on in cancer today. into roughly thirty years that I've been involved in some way or another with medicine. I've never seen anything like the past seven eight years in the advances in immunotherapy. And I really feel that we're still at the early stages the fact that you know former president. Jimmy Carter is alive and doing at least for the press reports. Relatively well today with stage four melanoma. That was diagnosed over three years. Ago is nothing short of amazing. That just would not have happened before the type of checkpoint inhibitors that we've been told he's taking that have arrested as melanoma. We're at the early stages of that. But but I believe that there is a revolution going on in the treatment of cancers. And we're going to be able to leverage it much more effectively because we have a foothold and how to engage the immune system in treating cancer. That does beg the question. Should we all be living that long? It does a lot of a lot about this and they're talking about health span rather than lifespan. And that you're healthy up until one hundred and two and then you die healthy. You know in a relatively healthy man. I want to end on that. The implications of that if we are able to keep ourselves healthy and obviously in Silicon Valley. There's a lot of people who just don't WanNa die Who are looking into all kinds. There's there's all kinds of concepts around that and you know you know whether it's Google and Calico and different things like that. How do you look at that? The idea I mean you're talking about having healthier lives until you die. But how do you look at the concept that a lot of people are talking? Which is not dying or doing other things to prevent push off dying. Certainly I hear that and in the environment we live in worked a lot. I think that's a relatively small sector of of society is thinking in those terms what I'm most excited about. Is that through what we've been talking about in this interview? The technologies we've talked about the other advances. We should be able to make health and healthcare much more gala -tarian than it is today in our country Coming back to statistics that I just find appalling that I think is a mandate for us to change in that. Is that our ZIP code? Which we live in is more of a determinative. Our life expectancy than our genetic code. We should be able to change that and make health and healthcare much more egalitarian. And yes some people are GonNa want to look at how they can extend that life span. Other people are going to be quite happy having a healthy life until whatever happens that in the life all right thank you so much. I really appreciate it. This is Dr Lloyd Minor. He's the Dean of the Stanford University School of Medicine Book is called discovering precision. Help predict prevent and cure to advance health and well being Thank you for coming on the show. You can follow me on twitter at Cara. Swisher my executive producer Eric Anderson an Eric America my producer. Eric Johnson is Hey. Es J. Dr Minor where can people find you online Dina Meyer Dot Sanford. Edu and the book will be out as soon as you can find that everywhere if you liked this episode. You really appreciate it if you shared it with a friend to make sure to check out our other podcasts pivot reset recode media and land of the giants just search for them in your podcasting. App of choice or tap the link in the show notes thanks also to our editor Joe Robbie. Thanks for listening to this episode of Rico Decode. I'll be back here on Friday tune in then.