Alexa and Telemedicine in Health Care: Harvard’s Dr. John Halamka on Promising Health Tech Trends to Watch

Dr. John Halamka

[Music]

Margaret Flinter: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter a weekly show where we speak to the top thought
leaders in health innovation, health policy, care delivery , and the
great minds who are shaping the h ealth care of the future. This week
Ma rk and Margaret speak with Dr. John Halamka, Chief Information
Officer at Beth Israel Deaconess Medical Center and Harvard Medical
School advancing technologies that will facilitate true personalized
medicine through w earable s, genomics , artificial intelligence , and
health IT.

Lori Robertson also checks in the Managing Editor of FactCheck.org
and looks at misstatements spoken about health policy in the public
domain separating the fake from the facts, and we end with a bright
idea that ’ s improving health and well - being in everyday lives . If you
have comments , please e - mail us at [email protected] or f ind us on
Facebook , Twitter , iTunes or whe rever you listen to podcasts . You can
also hear it by asking Alexa to play the program Conversations on
Health Care . Now stay tuned for our interview with John Halamka
Chief Information Officer at Beth Israel Deaconess and Harvard
Medical School.

Mark Masselli : We ’ re speaking today with Dr. Jo hn Halamka, Emergency Room
Physician , Chief Information Officer since 1998 at Beth Israel
Deaconess Medical Center in Boston and International Health Ca re
Innovation Professor at the Harvard Medical School, where he
oversees all educational research and ad ministrative computing for
18000 faculty and 3000 students. He ’ s also chairman of the New
England Health Care Exchange Network and is co - chair of the HI T
Standards Committee . Dr. Halamka writes extensively on Health
Information Technology in his popular bl og Life as a Healthcare C I O.
He earned his Bachelor s of Science at Stanford , his medical degree
from UC San Francisco School of Medicine and h is MS at Harvard
Medical School . Dr. Halamka , welcome to Conversations on Health
Care.

Dr. Halamka: Well , good mor ning.

Mark Masselli: Yeah , you recently launched this new venture called Health
Technology Exploration Center which is seeking to leverage emerging
technologi es like artifici al intelligence, telemedicine, b lockchain in the
h ealth care industry ; and I ’ m won dering if you could share with our
listeners about the new incubator center and your plans to bring
some of these tech innovations more rapidly to scale.

Dr. Halamka: Well , so h aving been in the Harvard system for 25 years , what you see
is an ultimate lear ning laboratory. Thousands of faculty and wonderful
students , patients , and data and a sense that we n eed to make health

Dr. John Halamka

care better ; and you see today in private industry wonderful
technologies and deep learning and mobile and Cloud, but very often
these larger companies don ’ t have the domain expertise to actually
test out their products in real health care environments and make
sure they ’ re useful. T his notion of the health technology exploration
center is to provide that learning laboratory. It ’ s not as if we ’ re going
to create technologies to sell to the outside world , it ’ s taking
technologies from the outside worl d and bringing them into a lab.

Margaret Flinter: Well Dr. Halamka , you ’ ve said that if data interoperability is to
improve than the sta ndards have to improve first and as the coacher
of the HI T Standards Committee , you have s aid there are three key
areas where we should be able to meaningfully i mprove the standards
in health IT . I wonder if you could share those with us on what you ’ ve
learned t hrough your experience developing standards within your
network , which standards you see as having the power to improve
health data liquidity as well as data intelligence ?

Dr. Halamka: The s tandards are built by consensus so that means a vote of a
thousand to one is a tie. I t can be very challenging to get international
consensus. A s I ’ ve worked over the last 15 years on these particular
issues , I ’ ve tried to move us from what used to be something very
specific and slightly arcane to something that would be more the
standard that a Google or an Amazon would use to c reate an
ecosystem of products . T oday if you ’ re an engineer working with
Google or Amazon environment , you ’ re using a set of standards called
the Javascript Object Notation or J SON . That particula r technique has
no w been incorporated into health care data interoperability using
the Argonaut Project . The Argonaut Project basically says we ’ re going
to take the com mon kinds of data use in health car e and make it so
easy that a 26 - year - old in their gar age without health care domain
expertise can write novel apps b ut there must be security. There are
certain ki nds of standards OAuth and OpenID that help us with
security and making sure that only the right actors get access to your
data. Then finally we c ontinue to work on vocabularies. When I say
high blood pressure, hypertension , and elevated blood pressu re they
all mean the same thing, but yet we need to make sure that our data
flow i s such that we actually understand what data we receive based
on what the doctor or patient meant.

Mark Masselli: You know I ’ ve been thinking about the change that we ’ ve witnessed
since the passage of the High Tech Act which allowed many members
of our health care system to switch from paper to electronic health
records in a fairly short time and the obligation her e was to meet the
standards of meaningful u se. You ’ ve said that ’ s place d too heavy a
burden on clinicians who a re overwhelmed by data requirements in
their daily workflow and that to spur innovation that is truly go ing to
be helpful. We need to scale back on some of the regulatory

Dr. John Halamka

restrictions and let the market dri ve the next way of innovation, but
also, you ’ re looking in terms of these regulatory requirements that
have been foisted upon the health care industry and you ’ re quite
concerned a bout it. Talk to us about that.

Dr. Halamka: Well certainly and so let me just tell you how it happened. A s I was
chairing these committees in Washington , the FDA says we ’ re very
concerned about implants and things with batteries t hat fail so we
better at every visit have a doctor key in a universal device identifier
for w hatever implants you have and al l o f us said wow that sounds
great . T hen the Centers for Disease Control says Ebola is ba d .
T herefore we better document your trave l history on every single
encounter. Before you know it at the end of all of these deliberations ,
we ended up with 140 data elements that every clinician must record
on every encounter while seeing a patient in 12 minutes , being
empathetic , and never commi tting malpractice. It ’ s not possible.
H ence this sense that we need better technology it isn ’ t just more
clicks. What if Alexa with appropriate security listen s to what a doctor
and patient said and then recorded a chart. Okay well that would
reduce burden , or what if we recognize that there are certain
technologies emerging natural language processing that can help us
look at text and get data from text. T here are fewer check boxes and
things for doctors to enter. I mean this is the sort of direction we ne ed
to go in getting to a result without having to t ell the doctors how to
do it gi ving the vendors the latitude to innovate.

Margaret Flinter: Well Dr. Halamka , I understand that your genome was only the
second to be fully sequenced by the Human Genome Pro ject. I believe
you ’ re known as patient number two, but as we strive towards more
personalized medicine with efforts such as the All of Us, Precision
Medicine Initiative at N IH , the Cancer Moonshot ; describe the
importance of the role of genomics.

Mark Mas selli: We often hear these terms used today personalized medicine and
precision medicine. Well , let me distinguish between those two for a
moment. Now , if you read the New England Journal , what it says is
stop doing prostate speci fic antigen testing on 56 - year - old males
b ecause the last 10 years have not shown a reduction in sickness or
death. But my genome suggests that I ’ m going to die of prostate
cancer someday. W ait a minute , for me absolutely do that every year.
T hat ’ s a bit more precise. I hope that a s we move forward with more
and more people getting sequenced , the care plans and not just
you ’ re a 56 - year - old male but it ’ s here ’ s what your genome says your
risks are and therefore this is what we ’ re going to do.

Mark Masselli: We ’ re speak ing today with Dr. John Halamka, Chief Information
Officer at Beth Israel Deaconess Medical Center in Boston and
International Health Care Innovation professo r at the Harvard Medical

Dr. John Halamka

School. Dr. Halamka , you are big proponent of telemedicine which is
starting to gain tr action as payers increase their willingness to
reimbu rse providers for such service, and yet you say there are still
challenges when it comes to clinicians practicing across state lines .
Y ou say the fastest route to realizing telemedicine promises to
facil itate the clinician to clinician connection. I wonder if you could
talk about the power of telemedicine as we imagine a more high
functioning health system and how do we scale it up across the
country to all regions within the country.

Dr. Halamka: I do 90 0 telemedicine consultations a year. I am credentialed by
H arvard to practice telemedicine, telecare , and malp ractice insured.
What do I do ? I am the nations expert on poisonous mushrooms and
plants and so whenever a child or an adult has a poisonous measu re
or plant problem , poison control gets involved . I get typically an image
sent to my iPhone. Here is the mushroom , here is the symptom, and
then I will say that is this particular variety and this is the solu tion and
we treat the patient, but here ’ s the challenge. I am licensed to
practice in Massachusetts. What if I suggest that a medication needs
to be given immediately but I ’ m not licensed to practice in the state
where the medication is given. T his is where we just need to work on
the regulatory frame work. Can I use my Massachusetts licensure to
ensure a medication that ’ s given in North Dakota ? Well , at the
moment no . At the moment that ’ s where it ’ s a provider to provider
consultation and the person who ’ s licensed in North Dakota actually
gives the med ication but think about it at a low cost in real time
you ’ re getting to the nation ’ s expert with the best advice. That is
clearly s omething we want to do more of.

Margaret Flinter: I want to touch on another aspect of your work. You ’ ve -- as we ’ ve
noted yo u ’ re the International Healthcare Innovation Professor at
Harvard and you ’ re traveling the globe and you ’ re coming in contact
with disruptive innovations in care delivery , and then you get to come
back to that giant talent pool in Cambridge of students. Te ll us about
the kind of innovations you ’ ve brought back to your students at
Harvard that look exciting and promising to you.

Dr. Halamka: W hen you work in countries like Scotland or the Nordic countries
Denmark or Sweden , what you see is a whole new range of
possibilities. H ere we have 330 million people in the United States ,
but you go to Scotland there are five . How many emergency
department databases are there in the entire country of Scotland ?
One and so if you go to an emergency department , every docto r in
every emergency department immediately knows who you are , what
medications you ’ re on , what allergies you have , what laboratories you
have . So you look at the smaller countries and their agility and the
a bility to create data liquidity and you say can ’ t we do this here. If you
were born in Norway today , what would your medical record nu mber

Dr. John Halamka

be ? It turns out it ’ s 2018, 0813 0001 . It ’ s a date plus a birth order , and
every citizen has their entire record for life cons olidated around a
single number and ima gine the power for both ca re and analytics of
doing that. T hese are the sorts of things technology and policy you
see that you say I wish the United States would have as well.

Mark Masselli: You really have this incredible sandbox that you ’ re engaged in. Y ou ’ re
sort of at this intersection of so many of these emerging trends the
use of wearables , you have talked about the voice activ ation power
perhaps of an Alexa, but you ’ re also engaged in the w ork and the
capability of Blockchain Technology . Y ou ’ ve just launched a new
pu blication blockchain in health care today. Still it ’ s something that I
think it mystifies many of us in terms of how it will work in the health
care system and wondering how do you envision all these
technologies serving as game changers i n the health ca re landscape as
we move forward.

Dr. Halamka: I think b lockchain is a public ledger right . It ’ s not owned by a
corporation. It ’ s not owned by a government and it cannot be
changed. Think of it as a blackboard where you can write once and
nev er erase. A sk yourself well what if a patient sues a doctor and the
attorney says give me the medical record. Well , the attorney may say
that medical record ha s been altered or changed. It turns out we
could use b lockchain as a means of hosting not the med ical record
itself but an extract of the medical record. We call this a hash one - way
mathematical transformation that can actually prove the medical
record has never been altered or changed. Blockchain is g reat for
audit trails, b lockchain might be a good place to store patient
consent. I ’ m not putting my medical record on the b lockchain but
here are my consent preferences on this public ledger that is
unalterable , and we could all consult that ledger when ever your
medical record is exchanged. S ome good pos sibilities . On Internet of
Things on connected devices , I think increasingly as we move away
from fee for service , you ’ re going to get more home care. G etting
information from your home what ’ s your blood pressure , wh at ’ s your
pulse , what ’ s your glucose, ho w is your sleep and using that with your
consent to keep you healthy in your home is incredibly important. Y es
in my home , my sleep is monitored , my weight is monitored , my
blood pressure is monitored, and all that data is sent to my clinician
and use d as part of my total care program.

Margaret Flinter: Well Dr. Hala mka , y ou ’ ve said that the need for inpatient hospital care
is going to drop dramatically in the coming decades and that we ’ ll
have to start thinking about how we ’ re going to re purpose all those
hospital beds and very sophisticated organizations for a different use
in the future. Tell us what you ’ re seeing in that vision.

Dr. Halamka: Sure. I ’ m an emergency physician and so of course you ’ re going to

Dr. John Halamka

need emergency departments and ICUs for people w ho have heart
attacks or strokes or get hit by cars, but the kinds of treatments we ’ re
delivering in what are called the ward beds , the standard
unmonitored part of the hospital , can absolutely be delivered in the
home. Why do we need you in a hospital if you ’ re just getting a dose
of antibiotics a day or a couple of medications to reduce the amount
of water in your body if you have congestive heart failure ? That sort
of thing can be delivered in the home with appropriate monitoring. I
can imagine the organ izations of the future will have virtual lists.
These are individual clinicians that are monitoring patients in their
homes using appropriate technology and ensuring the kind of
interventions that would have been made in a hospital bed. W e ’ ll
have emergenc y department s, ICUs , and virtual lists.

Mark Masselli: Well that ’ s very exciting . I wonder if you could just pull the thread a
little. We talked a little earlier abou t the Alexas in the world a re, are
you doing any work in that area ? Do you know of anybody who ’ s
doing work both to supp ort patients, support clinicians or is it still too
new of an emerging field ?

Dr. Halamka: Well , here a little -- should we tr y something a little dangerous?

Mark Masselli: Yes.

Dr. Halamka: Alexa, ask BIDMC, what is my care p lan for today?

Alexa : I am not sure.

Dr. Halamka: Well here you know , I must have been a little too close to the phone
and the mike. We ’ ve done 30 Alexa skills and those are such things as
when ’ s my next dose of medication , wh en wi ll my doctor see me , ge t
a nurse ; these sorts of things and they work really quite well . Alexa at
the moment isn ’ t covered by a business associate agreement. Amazon
does by the end of the year plan to have business associate
agreement coverage, so you can actually transmit protect ed health
care information over Alexa b ut for the moment the experiments we
have done really aren ’ t transferring things like your name or things
that would be used to personally identify you. W e probably are safe
with the early experiments but huge potenti al for the technology.

Mark Masselli: Try Alexa one more time . It may have just been -- just waking up.

Dr. Halamka: Yeah sure.

Mark Masselli: Alexa, ask B IDMC what ’ s my care plan for today?

Alexa: Your care plan for today include s at 8 a.m. a blood test t o measure a
glucose level and blood count , at 1 : 30 p .m. an x - ray , at 4 :45 p.m. y our
doctor will be checking in.

Dr. Halamka: Well there you go.

Dr. John Halamka

Mark Masselli: Well that is perfect. That ’ s a great utility.

Margaret Flinter: Absolutely. We ’ ve been speaking t oday with Dr. John Hala mka Chief
Information Officer at Beth Israel Deaconess Medical Center in Boston
and International Health c are Innovation Professor at the Harvard
Medical School. You can learn more about his work by going to his
blog Life as a Healthc are CIO at g eek d octor .blogspot. com and follow
him on Twitter @jh alamka. Dr. Halamka, t hank you so much for your
contributions to advancing health information technology for your
creativity and your enthusiasm for the future and for joining us today
o n Conv ersations on H ealth C are .

Dr. Halamka: Well my pleasure , thanks so much.

[Music]

Mark Masselli: At Conversations on Health Care , 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 nonpartisan, nonprofit consumer advocate
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: Senator Bernie Sand ers and Alexandria Ocasio - Cortez the Democratic
nominee for New York ’ s 14th Congressional District seat are pointing
to a study they say shows Medicare for A ll would save Americans
money, but the author says those comments appear to show a
misunderstanding of his study. The study is based on the language of
a Medicare for all bills proposed by Sanders last year that makes
assumptions about reduced administrative and drug costs as well as
deeply reduce d reimbursement rates to health care providers under
Univ ersal Health Care System. T he study ’ s author believes those
assumptions about savings are unrealistic. The study is a working
paper written by Charles Blahous of the Mercatus Center at George
Mason University. The center gets some of its funding from the
l ibertarian Koch b rothers and Sanders and Ocasio - Cortez both
referenced that in their claims. The top line of the paper ’ s abstract
says that Sanders ’ Medicare for All bill “ would under conservative
estimates increase federal budget commitments by approximat ely
$32.6 trillion during its first 1 0 years of full implementation. ”

That ’ s wh at the government would spend, n ot total health care
expenditures . Sanders ’ office points to other figures that show that
between 2022 and 2031 , the currently projected cost of health care
expenditures in the U.S. of $ 59.4 trillion would dip to $ 57.6 trillion
under the Medicare for All plan. That ’ s how Sanders arrives at his
claim that the study shows that Medicare for All would save the
American people 2 trillion over a 10 - year period. The study ’ s author ,
however , told us he doesn ’ t think that ’ s realistic. One reason is that

Dr. John Halamka

Sanders ’ bill says health care providers will be reimbursed for patients
at Medicare payment rates projected by the Centers for Medicare and
Med icaid Service s to be roughly 40% lower than tho se paid by private
insurers . The study which used the text of Sanders ’ Bill to guide
assumptions cautions that the assumption is suspect. The report
provided an alternative scenario estimate that showed a net increase
in h ealth care spending. We ’ re not suggesting the assumptions made
in the Sanders Bill are wrong, but they aren ’ t t he assumptions of the
Mercatus Center study and 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 check ed, e - mail us at chcradio. com. We ’ ll have factcheck.org ’ s
Lori Robertson and check it out for you here on Conversations on
Health Care.

[Music]

Mark Masselli: Each week conversations highlight s a bright idea about how to make
wellness a part of our communities and everyday lives. C h arles
Slaughter learned the value of entrepreneurship from an early age
f irst as a paper boy growing up in Connecticut , l ater he took the
passion globally as a field organizer for micro finance company. Then
came his first successful venture Travel Smith a $ 100 million online
clothing supply company for serious global travelers. H is travels also
showed him another sta rk reality, the number of children dying in
third world countries from treatable diseases due to lack of access to
basic medicine.

Charles Sla ughter : There ’ s only three or four sort of major causes of this , the real disease
malaria and pneumonia. What is shocking is that all of those things
can b e addressed extremely low cost, but the barrier is effectively
delivering what we know works.

Mark Ma sselli: Chuck Slaughter speaking in a school foundation video highlighting his
work . He wondered how we could put the power of healing in the
ha nds of villagers themselves and he realized the su ccessful model
already existed.

Charles Slaughter : I ’ m thinkin g about that , I go wham and hold the phone i sn ’ t there a
business model that excels at that ? Y ou start to think about Amway
and Avon and Tupperware. F or the research I actually enrolled as an
Avon lady and tri ed to learn it from the inside.

Mark Masselli: He founded Living Goods a company that sells not makeup but
lifesaving essentials like drugs to treat malaria and diarrhea.

Charles Slaughter : We recruit , train , and support networks of community health

Dr. John Halamka

promoters w ho go door to door every day teaching fami lies how to
i mprove their health and wealth. Making a living by selling high
impact health products like simple treatments for malaria and
diarrhea , he althy fortified foods . Every agent works as an
entrepreneur under Living Goods brand and now they get a
S martphone . T hat Smartphone has a Living Goods designed
application on it that can help them with a guided diagnosis of
childhood diseases that enables them to register and support
pregnant women and reminds them to follow up.

Mark Masselli: There are now L iving Good sale associates serving the needs of some
5 million residents through S ub - S aharan Africa and the results are
quite impressive. In some cases , infant and child mortality is down
25% in the communities being served . Living Goods a simple
grassroot s business model facilitating the distribution of low cost life
saving materials generat ing income while saving lives. Now , that ’ s a
bright idea.

[Music]

Mark Masselli: You ’ ve been listening to Conversations on Health Care . I am Mark
Masselli.

Margaret Fli nter: I ’ m Margaret Flinter.

Mark Masselli: Peace and h ealth.

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University streaming live at CHC R adio.com , iTunes , or wherever you
listen to podcasts . If you have comments , please e - mail us at
[email protected] or find us on Facebook or Twitter . We love
hearing from you . This show is brought to you by the Community
Health Center.