Stanford Medicine Dean Lloyd Minor on Apple Heart Study, Biomedical Revolution and Precision Health

Lloyd Minor

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Mark Masselli: This is Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Well, Margaret we’re in the month of February already and surely spring
isn’t too far around the corner.

Margaret Flinter: Hope springs return, well Mark but it is February the month that we
celebrate Valentine’s Day and we want to remind folks this is a month where we like to
promote all matters of the heart including healthy hearts.

Mark Masselli: Heart d isease remains the leading cause of death for men and women
in America, 610,000 deaths per year Margaret. We have to do better.

Margaret Flinter: It comes down to a few basic rules, what we eat, our diet and how we
move our exercise are the best weapons in battling and preventing heart disease.

Mark Masselli: Also smoking remains the number one cause of preventable illness and
premature death from heart disease. It just go to the American Heart Association’s
website heart.org lots of great information t here.

Margaret Flinter: Well you know Mark there’s a new weapon we can leverage in the
war against heart disease and that’s the explosion of wearables. That brings us to our
guest today.

Mark Masselli: Dr. Lloyd Minor is the Dean of the Stanford School of Medicine that is
overseeing a long term strategy to advance what he calls the biomedical revolution in
precision health.

Margaret Flinter: Dr. Minor has earned a lot of attention for a recently announced
partnership with Apple and the telemedicine comp any American Well to launch the
Apple Heart Study to track A trial fibrillation in thousands of participants.

Mark Masselli: Lori Robertson also checks in. She’s the managing editor of
FactCheck.org.

Margaret Flinter: No matter what the topic you can hea r all of our shows by going to
chcradio.com.

Mark Masselli: As always if you have comments please email us at
[email protected] or find us on Facebook or Twitter we love hearing from you.

Margaret Flinter: Well ge t to our interview with Dr. Lloyd Minor in just a moment.

Lloyd Minor

Mark Masselli: First here is our producer Marianne O’Hare with this week’s headline
news.

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Mar ianne O’Hare : I’m Marianne O’Hare with these health care headlines. Indiana gets
the green lig ht from HHS to be approved for a work requirement for those receiving
Medicaid coverage in their state. This on the heels of Kentucky’s recent approval for a
similar Medicaid coverage rule, the measure approved by newly sworn in Health and
Human Services Secretary Alex Azar will require a so called able - bodied Medicaid
recipients to be required to work towards earning their health benefits. Recipients must
pay a monthly premium to gain benefits and if they miss a payment they’re kicked off
health coverage for at least six months. Since 2015 roughly 90,000 Indiana Medicaid
recipients were kicked off coverage for either not paying their premium or not filling out
their proper paperwork at one time or another.

It’s not longer just hide this year’s flu seaso n is officially the worst in a decade according
to statistics from the CDC. Officials of the Centers for Disease Control and Prevention
th
say that in the week ending January 27 one in 14 visits to providers offices was flu
related, straining resources at many of the nation’s hospitals who must bring in extra
staff to treat the influx of flu cases. At the time when the current administration is
considering big cuts to the CDC de mocratic Massachusetts Senator Ed Markey is
calling for a billion dollar fund dedicated to finding a universal flu vaccine. This year’s flu
vaccine has had a very limited efficacy against the prevalent strain of the flu.

Speaking of the CDC now that Brend a Fitzgerald is out resigning last week as director
due to her post - appointment investment in a large tobacco company. Investigation
published in Stat News have revealed a few more law makers with questionable
investments in similar entities. Two ranking members of the senate health committee
have been found to have tobacco company investments in their portfolios. Utah
Senator Orrin Hatch had investments in Philip Morris International, while the husband of
democratic senator Patty Murray had invested in Reynolds America. Tobacco
consumption is the leading cause of preventable death in this country and worldwide.
I’m Marianne O’Hare with these health care headlines.

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Mark Masselli: We’re speaking today with Dr. Lloyd Minor the Carl and Elizabeth
Naumann Dean at the Stanford School of Medicine where he established a strategic
vision to lead the biomedical revolution in precision health. He’s also Professor of
Otolaryngology and Head and Neck Surgery as well as Professor of Bioengineering at
Neurob iology at Stanford University. Before coming to Stanford Dr. Minor was provost
and Senior Vice President for Academic Affairs at the Johns Hopkins University where

Lloyd Minor

he served as Chair of the Department of Head and Neck Surgery at the Johns Hopkins
Universi ty School of Medicine. Dr. Minor earned his bachelor’s and medical degree
from Brown University and completed his residencies at Duke University’s Medical
Center and the University of Chicago Medical Center. Dr. Minor welcome to
Conversations on Health C are.

Dr. Lloyd Minor: Thank you very much Mark it’s great to be here.

Mark Masselli: Yeah as you know Stanford School of Medicine is one of the most
recognized medical teaching institutions in the world which is also supported by some of
the best scienti st at Stanford University across a number of disciplines. You’ve
launched a very bold strategic vision at Stanford to break down the barriers between all
of these disciplines to accelerate the pace of biomedical discovery to bring us closer to
the promise of true precision medicine. I’m wondering if you could share with our
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listeners more about the 21 century strategic vision and your goals in this endeavor.

Dr. Lloyd Minor: For years we’ve been treating disease after the fact making diagnoses
far too late to achieve the outcomes that we would really like to achieve. Certainly,
when we have a severe acute disease like cancer we want precision medicine. We can
think of precision health as encompassing precision medicine but very importantly
focusing on health. There are really three components to our vision of leading the
biomedical revolution in precision health. First is to predict and then prevent and then to
cure disease precisely. Using the same levers of genomic medicine, big data science,
rege nerative medicine, but applying those in a predictive, preventive and proactive way.
The way we know we will have succeed it say a decades from now precision health is
that the instance of those diseases requiring precision medicine will be far less. I m ean
isn’t that what we all seek is to have healthy lives? When disease does come up to
either diagnose it much earlier so we can treat it more effectively or prevent it all
together.

Margaret Flinter: Well, Dr. Minor it reminds me that we had one of your colleagues on
with us a few years ago Dr. William Newsome who’s head of the Stanford
Neurosciences Institute and as you know he’s co - chair of President Obama’ s brain
initiative. He said to us then, that in order to unlock the secrets of the human brain t hat
long siloed scientific disciplines would have to come together and start working
collaboratively, computer science, neurology, biomedical engineering, physics,
advanced mathematics, everybody had to work together to tackle this enormous
challenge. Tal k with us if you will about how the academic landscape is being
fundamentally restructured to facilitate this new approach that will help you realize that
grand vision?

Lloyd Minor

Dr. Lloyd Minor: This is the century of biomedicine and we’re seeing so many
disciplin es from science and technology converge on biomedical problems. Biology is a
discipline it’s grown up, it’s now firmly a quantitatively rooted discipline and therefore the
techniques from the physical sciences from engineering, the techniques has been so
successful and other areas can now be applied in biology and medicine. At Stanford we
do have the advantage of everyone being on the same campus, our academic medical
center with the school of medicine and Stanford Hospital and Lucile Packard Children's
H ospital . We’re on the campus at Stanford University, my office sits literally across the
street from the chemistry department, a biology department and the engineering school.
There’s a very fluid interchange of faculty and students between and among the various
different disciplines at the university.

Also I think Stanford and our peer institutions as well are moving towards a more
collaborative interdisciplinary culture, how do you do that? Well, we provide incentives
like seed grants. In some of our seed grant programs we require that faculty from
d ifferent disciplines collaborate in preparing the grant proposal. Often times the catalyst
that brings laboratory groups together is the student who has expertise and is gaining
expertise in related the complimentary field, it really brings the faculty to gether. All
those are mechanisms that are being used to encourage and promote interdisciplinary
scholarship and research.

Mark Masselli: Dr. Minor the notion of precision medicine and certainly taking hold
across the health care landscape. We have the N ational Institute of Health all of us
precision medicine initiative, but we’re also seeing this explosion of targeted drug
development in the world of pharmaceuticals. For the first time we’re harnessing
personal health data from wearables to gain better understanding of population health.
I wonder if you could tell us what are you most excited about?

Dr. Lloyd Minor: Several things, there’s explosion in terms of basic biological
biomedical discovery. Our knowledge of receptors on the surface of sales o ur
knowledge of the ligan d s interact with those receptors, that knowledge is increasing at a
prodigious pace. In the past a scientist makes a discovery, and that scientist thinks, you
know that might be a drugable target. Then there’s a big gap between that fundamental
discovery of high biological significance and answering the question whether or not this
is a target, and if it is a target then making the compounds that interact with it as a
target, that’s been a big gap.

Classically what people would d o, would file for the intellectual property then at the
appropriate time they might seek to get commercial funding and work it up from there.
That’s easy to say in two or three sentences, it turns out it take a lot of time and effort
and years. We’re try ing to shorten that lag time in a number of different ways through
partnerships with industry to bring the benefit of medicinal chemist on campus to

Lloyd Minor

provide incentive funds that will help a faculty member to cross that first valley of death
and really dete rmine if that receptor or ligand is indeed a target. Another area relates to
this rapid development of the field that’s known as digital health. I think of digital health
as having two components, a consumer facing components wearables and other
devices, and second an ana lytical artificial intelligence, machine learning enabled
component which is extracting information from the treasure troves of data. Data that
are locked in our electronic medical record systems, but being able to decipher
relationships and therefore develop better care delivery pathways based upon this
enormous amount of data, so getting from basic discovery to therapeutics. Second,
being able to more meaningfully gather data about health and then extract information
from those vast qu antities of data.

Margaret Flinter: Well, I’m thinking listening to you it’s change everywhere, but it’s
change in the way we train our next generation of health care professionals too if we’re
going to be successful. You’re certainly one of the most ren owned campuses for
training of health professionals, a physicians specifically they need to work with other
health care professionals as well. What are you seeing in the changes in the education
and training of future physicians and other health care prof essionals at Stanford?

Dr. Lloyd Minor: One of my friends in the venture capital world will usually turn to me on
the penal and say, you know we’re going to put you out of business and your medical
school out of business in the next decade. There won’t b e a need for physicians,
everything will be handled by data scientist. Now I worry about a lot of things in life,
that’s not one thing that I tend to worry about. The need for physicians and other health
professionals to understand what can be accomplish ed through data science, that need
is increasing prodigiously. During the first two years of medical school we basically
follow the same calendar as the rest of the university, so we have first and second year
medical students taking courses in computer s cience and engineering as well as in the
humanities and social sciences. Medical students get combine degrees in law or in
business as well as in more traditional scientific disciplines.

Today more than ever the need to train physicians to be valuable mem bers of teams,
we also want to have physicians graduate from our medical school that have
competencies in other areas as well. I like to think of what we’re moving into and health
care as being high tech enabling high touch I don’t believe that health car e
professionals are going to be put out of business by high tech. When we ask people in
our health care delivery system, do you want to receive all of your care virtually or do
you want to have a primary care health provider and be able to access others v irtually?
No one elects to eliminate a primary care provider, but they also want the immediacy
that virtual interactions and digital health provide today. Those of us who are
responsible for training the heal th care workforce of the future, that’s what I think we
want to focus on.

Lloyd Minor

Mark Masselli: We’re speaking today with Dr. Lloyd Minor dean of the Stanford School
of Medicine where he has established a strategic vision to lead biomedical revolution
and precision health. We have Apple’s Chief Operating O fficer Jeff Williams on the
show who talked about their plans for entering in the health care space. Now Stanford
is partnering with Apple in the telemedicine company American Well on the Apple Heart
Study to accelerate research in population health. I’m wondering if you could talk to our
listeners about this collaboration, how might it inform the future of population health
research?

Dr. Lloyd Minor: One of the things that excites me the most about the Apple Heart
Study is it’s starting to put informati on about health into the hands of each of us as a
health care consumer. Technology has transformed every other aspect of our lives and
our economy except for health care. You and I can use our ATM card pretty much at
any ATM on the planet, the way we ord er essential goods and services has changed
dramatically, but the way we access information about our health has undergone very
little change. We still walk into doctor’s offices and we see fax machines that in other
sectors have gone out of business a lo ng time ago. One essential next step is to make
information about our health more accessible to us, and that’s exactly what the Apple
Heart Study is intended to do, it’s looking for the arrhythmia of Atrial fibrillation, we know
it’s the most common arrhy thmia . We really don’t know today the true incidence and
prevalence of Atrial fibrillation, and we have designed a study to look for Atrial fibrillation
working with American Well to be able to when the watch kicks up that there may be an
arrhythmia for t he consumer to contact American Well to screen further for the
possibility of Atrial fibrillation. This will first of all give us a treasure trove of data about
the true instance and pr evalence of Atrial fibrillation, and it’s an essential first step
towa rds ultimately designing a monitoring system that will enable people to know if they
have the arrhythmia, and enable physicians to make a much more informed judgment
about when it needs to be treated or when it can simply be observed.

Margaret Flinter: Dr. Minor I’d like to ask you if we can maybe focus for a minute on
prevention. You talk about the next big thing in health being precision health and you
believe it will be a game changer to population health in the future. Talk about this
precision hea lth system that you have it at Stanford and what would you like our
listeners to know about it?

Dr. Lloyd Minor: There are several components addressing the social environmental
and behavioral determinants of health. We look at health and health care as a pie. Our
traditional health care delivery system only addresses maybe a quarter of that pie,
social environmental and behavioral determinants account for 75% of the pie. One
project we’re doing here, obesity among Latino American children is very high in the
United States, prevalence is about 39%. We know that children who have obesity go on
to develop a very high instance of diabetes, heart disease, kidney failure, a host of

Lloyd Minor

complications associated and triggered by obesity. How do we combat that obe sity
epidemic? We have a group of our faculty who receive funding for a project called
SPHERE Stanford Precision Health for Ethnic and Racial Equity.

One component of that project looks at obesity among Latino American Children in
Santa Clara County. Yes , we’re doing the traditional scientific medical analysis of
genomics and other biological indicators and markers, but we’re also looking at how we
can encourage and enable activity. We’re doing very practical types of interventions
like offering to repla ce all of the cooking and serving utensils in a house hold, replacing
them with smaller utensils hopefully leading the smaller portions. We’re studying all of
these interventions to see what’s effective in specific patients according to their social
envir onmental and behavioral determinants, that’s a first step. I also think this
revolution in digital health, this revolution will help as well because each of us as
consumers is going to have a lot more information about our health than we’ve been
able to g arner in the past.

Mark Masselli: Well, Dr. Minor we have tens of millions of Americans who don’t have
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access to health insurance and yet on the other hand we’re talking today about this 21
century innovations and we’re facing this much larger concern a bout how do we bend
the cost curve. Then we have these announcements most recently by the collaboration
between Amazon, Berkshire Hathaway, and JP Morgan vowing to reduce the health
care cost burden to make health care more affordable using technology. T here’s seems
to be still lots of skepticism, so in your vision of the future where is the opportunity to
bring this desperate groups together to form a sort of a more perfect union for the health
care delivery system?

Dr. Lloyd Minor: Let me offer few tho ughts, to the extent that we can simply and make
more efficient the supply chain in health care delivery that will lower cost and
conceivably improve outcomes making what is today a rather fragmented supply chain
more cohesive and coherent. Also one can i magine that 10 years from now the way we
will access health care delivery services can similarly be dramatically different in a way
that adds value, lowers cost, improves outcomes and makes the entire system more
efficient for us to engage in healthy behav iors. For example, if we’re able to get
healthier sources of food in an accessible and affordable way that will promote health.
You can imagine it across the board with multiple aspects of economy relate to health
making those more accessible, more affor dable will help us to achieve a healthier
society.

Margaret Flinter: We’ve been speaking today with Dr. Lloyd Minor Dean of the Stanford
School of Medicine. You can learn more about his work by going to
Medicine.stanford.edu or follow on Twitter @Stanfor d Med. Dr. Minor thank you so

Lloyd Minor

much for the pioneering work that you are doing and for joining us on Conversations on
Health Care today.

Dr. Lloyd Minor: Thank you Margaret it’s been a pleasure talking to you and to Mark.

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Mark Masselli: At Conver sations on Health C are, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy . Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org, a non -
partisan, nonprofit consumer adv ocate for voters that aim to reduce the level of
deception in U.S. politics. Lori, what have you got for us this week?

Lori Robertson: The new GOP tax law abolishes the Affordable Care Act’s individual
mandate in 2019. The president mention this in his state of the union address saying,
quote, “We eliminated an especially cruel tax that fell mostly on Americans making less
than 50,000 dollars a year.” That may sound surprising but the IRS statistics backup
the claim that the mandate fell mostly on those with less than 50,000 dollars in adjusted
gross income. In 2015 IRS data show that 6.7 million tax filers paid the mandate
penalty, of those 6.7 million people who paid it 5.3 million or 79% had adjusted gross
income of less than 50,000 dollars. 27,000 of them had AGI less than 10,000 dollars
and about 3700 had AGI of less than one dollar.

Why would some people with so little taxable income pay the tax? The IRS has
reported in the past that some people appear to be mistakenly paying the tax. Back in
20 14, eight million people paid the tax and the IRS commissioner said that an estimated
313,000 low income filers likely should have filed an exemption. He said the IRS had
sent letters to those tax payers about the apparent mistake. Exemptions are availab le
for those with short gaps in coverage, citizens living abroad, those with personal
hardship, those who would have qualified for the Medicaid expansion but their state
didn’t expand it, and those for whom available insurance is unaffordable. Some low
in come tax payers are automatically exempt because their income is below the tax filing
threshold. About 10,000 dollars for a single person and 20,000 dollars a couple. That’s
my fact check for this week, I’m Lori Robertson Managing Editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you ’d like checked, email us a t
CHCradio.com we ’ ll have FactCheck.org’s, Lori Robertson check it out for you, here on
Conversations on Healthcare.

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Tinnitus is vaccine condition

Lloyd Minor

that afflicts millions of Americans, a condition for which there is really no viable
treatment to date. A University of Michigan researcher may have found a solution, Dr.
Susan Shore says tinnitus mark by a constant ringing i n the ears is really the results of
misfiring brain signals. Her team has developed a device aimed at getting to the root
cause of tinnitus neurons in the region of the brain stem. When those cells become
hyperactive they create a signal that is transmit ted to the part of the brain where hearing
perception occurs and the constant ringing can wreak havoc on sufferer’s lives. The
device works on two fronts, it uses weak electrical impulses target to the brain’s region
responsible for the problem and also s ense time sound to interrupt the auditory
sensation cause by the tinnitus.

Dr. Susan Shore: We develop this treatment for a particular class of tinnitus in which
the person who has the tinnitus is able to modulate either the pitch or the loudness of
the t innitus by pushing on their face.

Mark Masselli: The study group has been relatively small so far but the results had
been quite promising. Dr. Shore says that the severity of the tinnitus was greatly
reduced in most of the participants and some got to t he point where they no longer
interfered with their daily lives. A relatively simple targeted device that could potentially
help millions of tinnitus sufferers from the worst affects of their condition. Now that’s a
bright idea.

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Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark Masselli: I’m Mark Masselli, peace and health.

Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health Center.