Best of 2018: AI, CRISPR, Telemedicine, and Emerging Health Care Trends

Best of 2018

[Music]

Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter, a show where we speak to the top thought leaders
in health innovation, health policy, care delivery and the great minds
who are shaping the health care of the future. This week Mark and
Margaret take a look back at some of the best shows of 2018 and the
amazing guest who joined us from Dr. Lloyd Minor Dean of Stanford
School of Medicine and Dr. Steve Klasko CEO of Jefferson Health and
the Jefferson School of Med icine both of whom talk about the need to
recruit more creative thinkers in health care and training for team
based approach to health care. Intermountain Health’s Dr. Charles
Sorenson talks about their integrated care delivery model,
telemedicine and a le adership institute he directs. CareMore Health
CEO Dr. Sachin Jain discusses the high tough approach they apply to
their Medicaid and Medicare patients yielding much better results.
Aetna President Karen Lynch discusses the merger with CVS.
Microsoft’s No e lle LaCharite talks about the future of voice and AI in
health care. As always you can find us wherever you listen podcast or
ask Alexa to play the program. Now, let’s listen back to some of our
favorite guest from 2018 on Conversations on Health Care.

Mar k Masselli: Well, Margaret we made it through another interesting year here on
Conversations on Health Care. 2018 has brought us some dramatic
twist and turns, we’ve seen the big vertical mergers between entities
like Aetna and CVS and the rise of tech inn ovation like CRISPR gene
editing technology and so many other interesting trends are
emerging, voice technology like Alexa has started to be explored as
tools to address some of health care’s biggest challenges. Some really
terrific guest though this year Margaret.

Margaret Flinter: We’ve also seen a real growth this year in the development of
coordinated care delivery models like CareMore Health and Cityblock
Health. Systems that seem to have really get that they can leverage
technology and team based appr oaches to bring care into the homes
and really the lives of patients, so that’s an approach I think we’re
going to hear a lot more about in the coming year.

Mark Masselli: Indeed, and there have been some really promising developments in
genomics and in bi oscience. One of the more fascinating stories to
emerge in this past year is the rise of CRISPR technology targeted
gene editing technique that is going to revolutionized the way we
treat and prevent disease. CRISPR scientist Samuel Sternberg joined
us ear lier this year talking about the promising potential of this tool
really just quite remarkable.

Samuel Sternberg: For so long we’ve been limited by relying on random mutation as a
way of being, the work stuff at evolution. Now, tools like CRISPR
scientist have the capability to go into the genome which is made up

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of DNA and make pinpointed precession changes to that genetic
material. That can really change the way that scientist think about
treating disease in human patients in editing the DNA of plants and
animals that we rely on for food and other kinds of industrial
biotechnology. Already, we’ve seen a complete transformation of the
way that biomedical research is being done because of the ability to
now go into the genome and make changes of the way of d esigning
better experiments and really virtually any sector of biological
research can be now studied better with tools like CRISPR.

Margaret Flinter: S cientists have set their sights on another daunting task t he H uman
C ell Atlas is a global scientific eff ort to map every single cell in the
human body . Co - chair Aviv Regev joined us on the show, talking about
the dramatic technological advances that are now allowing scientists
to pick up where the H uman G enome P roject left off .

Aviv Regev: J ust like the Huma n Genome Project was a project to find the genes
which are one part of the periodic table of elements of the human
body. The human C ell Atlas aims to find all the cells which are another
set of elements of the human body, except that there are 37.2 trillio n
of them together with the huge size of the human body, I think really
underscores how difficult this can be. Until recently, we could only
really analyze multiple cells at once, maybe millions or tens of millions
of them together. Now , we have new techni ques that allow us to look
at individual cells. You can think of it as new microscopes that allows
us to l ook at cells . We can really take on this challenge of the trillions
of cells that are different from each other and are organized
throughout the body .

Mark Masselli: Her co - chair on the Human Cell Atlas Dr. Sarah Teichmann elaborated
on the complexities of this process and how many disciplines are
involved .

Dr. Sarah Teichmann: S ingle cell genomics is one of them and the excitement there is really
the r e s olution r evolution that ’ s taking place in genomics where we
can now study DNA and RNA nucleic acid in individual cells . T hat ’s an
incredibly exciting and that resolution revolution is also going to the
spatial level where we can study cells in their spat ial context. T he
technologies are genome bio I would say technology developers .

Margaret Flinter: S peaking of advances in all of these areas Dr. Eric Topol of the Scripps
Translational Institute joined us on the show a gain . Eric is a world
renowned cardiol ogist, as well as an expert in genomics, and he is a
personal medicine evangelist, I think we can say . H is institution is
providing vital support to the National Institutes of Health, all of us
p recision m edicine i nitiative .

Dr. Eric Topol: I t ’ s called the P articipants Center, which is all the participant facing
technologies like their apps, the website , data going back to them that

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they generate through their sensors or through their DNA . A lso we ’ re
responsible for enrolling hundreds of thousands of partic ipants. W e
have a lot of responsibility at this P articipant C enter , b ut moreover,
it ’ s to keep the engagement throughout decades ahead for each of
the million and likely much more than a million people . W e ’ re going
to be getting a lot of the folks who want ed a various sensors like we
already started a pilot with blood pressure watches, trying to find out
what is really promoting engagement along with useful data
collection .

Mark Masselli: 2018 seems to have been the year of the vertical merger. Large
indust ry players coming together to address cost and the inefficiency
in health care . P harmacy giant CVS acquiring insurance giant Aetna,
Aetna President Karen Lynch joined us on the show and predicted
mergers such as this are going to change how patients interf ace with
their healthcare experience.

Karen Lynch: Clearly, this is a transformational merger a nd it gives us the
opportunity to reshape the health care industry. T he way I think
about it for too long and far too often we ’ ve been practicing sick care,
not health care. T he potential of a CVS Aetna merger is really to
organize around the consumer and around the consumer experience.
CVS has over 10,000 stores across the United States, which means
t hat 70% of Americans live within five miles of a CVS. H ow this will
help facilitate improved access is really to understand that your zip
code is more important than your genetic code , a nd what that means
is your individual behaviors and your environment clearly have
meaningful impact on health care costs. I want you to imagine a local
CVS being an interactive hub where individuals can come in and learn
more about their health care . T hey can have further assistance in
navigating the overall health care systems where we might point
people to different providers and poin t them to social services in their
communities to address the social determinants of care. O ur overall
goal is to achieve affordable high quality care for the individuals that
we serve.

Margaret Flinter: Technology is poised to have a big impact, H arvard M edical School ’ s
Chief Information Officer D r. J ohn Halamka talks about the enormous
potential of artificial intelligence as well as genomics driven insights .
B ut he also sees a huge untapped potential in developing
telemedicine protocols throughout health care and advancing them.

John Halamka: I do 900 telemedicine consultations a year. I am credentialed by
Harvard to practice telemedicine , telecare and malpractice insured .
W hat do I do? I am the nation ’ s expert on poisonous mushrooms and
plants a nd so when ever a child or an adult has poisonous mushroom
or plant problem, p oison c ontrol gets involved. I get typically an image
sent to my iPhone , h ere is the mushrooms , he re is the symptom , a nd

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then I will say, a h, that is this particular variety, a nd this is th e solution
and we treat the patient . B ut here ’ s a 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 framework. Can I use my Massachusetts licensure to
ensure a medication is given in North Dakota? Well, at the moment,
no. But think about it , at low cost in real time, you ’ re getting to the
nation ’ s expert with the best advice and that is clearly something we
want to do more of.

Mark Masselli: Margaret Dr. Halamka is also a big fan of the potential for Alexa’s
voice technology application for the future of health care
demonstrating one of the skills he ’ s creatin g at Harvard and Beth
Israel Deaconess Medical Center in Boston.

John Halamka: Alexa, what is my care plan for today?

Alexa: H mm, I ’ m not sure .

John Halamka: W ell, here , you know, I must have been a little too close to the phone
and the mic. We ’ ve done 30 Alexa skills such things as when ’ s my next
dose of medication ? W hen will my doctor see me and they work really
quite well. But Alexa at the moment isn ’ t covered by a business
associate agreement. Amazon does by the end of the year plan to
have business ass ociate agreement coverage, so you can actually
transmit protected health care information over Alexa but huge
potential for the technology .

Mark Masselli: Try Alexa one more time.

John Halamka: Sure. Alexa, ask BI DMC w hat ’ s my care plan for today?

Alexa: Y our care plan for today include at 8 AM , a blood test to measure
glucose level and blood count . A t 1:30 PM an X - ray , at 4:45 PM your
doctor will be checking in .

John Halamka: Well, there you go.

Margaret Flinter: Mark that also speaks to the interesting wo rk being done by yet and
other outstanding guests that we ’ ve had on the show. No elle
LaCharite is the principal developer for Applied AI at Microsoft. After
leading a team of developers building hundreds of voice skills for
Alexa s he sees enormous potentia l for machine learning to evolve
dramatically in the health care arena.

Noelle LaCharite: T he nice thing is you go to Alexa today and there are dozens of
blueprints . I ’ m a huge fan of learning by doing , a nd so these code
snippets are fully functional , righ t. T hey ’ re not about the content, but
all the code is there. I always encourage people, like, just go and --

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you ’ d be shocked with zero technical skills i f you know how to follow
instructions . Y ou could build a skill for the first time , publish it to 10
mi llion Alexa users and have never built code before. E ven Alexa
today will even host your app, so you don ’ t have to worry about
infrastructure or how to do it. The most important thing today is
thinking about how can you create content and create an experie nce
on Alexa that your users will wa nt. B ut another place to see speech
and voice integrated with other technology kind of more holistically is
in the AI school. T here ’ s this free online school called AI S chool at
Microsoft.com and it infuses s peech, w e ha ve skill development . A ll of
these technologies kind of coming together to create scenario based
applications. The b lueprint s you can do in an hour , these are more like
eight our projects . B ut you end up with a portfolio of work that you
can literally clai m that you ’ve built so it helps you refine your resume.
Add these skills to your toolbox , a nd of course, I ’ m always trying to
share all of this with C hannel N ine on YouTube w ith the AI show ,
anything you can do to immerse yourself in this. You have a desir e to
build the technology is definitely available and ready for you to do it.

Mark Masselli: We loved her energy, enthusiasm and her knowledge for this space
Margaret .

Margaret Flinter: R eally insights , it ’ s really advance t he field .

Mark Masselli: Yeah, t echnology is great, but health care at its core is about
interfacing with human beings. W e ’ ve become really interested in
innovative care models that focus not only on high tech but h igh
touch as well. Dr. Sachin Ja i n is the CEO of C are M ore H ealth , a healt h
entity deploys teams of community workers, health coaches , traveling
doctors and nurses to meet vulnerable patients where they are . They
are really focusing on re ducing hospitalization and chronically ill
patients and improving the quality of their lives .

Sachin Jain: O ne of the key enablers of the CareMore model is the fact that the
chassis on which we ’re built is not a fee for service chassis. We are
built on, with a notion of full delegation of risk , meaning , we get paid
a per member per month risk adj usted payment for the care of our
patients. So, because we have a high level of loyalty, our patients
don ’ t leave us . O ur average member stays with us for nine years .
W e ’ re investing with the idea that long term, our patients will have
fewer medical compli cation, the slower progression of disease . T he
average acute episode of illness when somebody in the hospital and
cost 12 or $15,000, if you were to take that money and actually
reinvest it in prevention, which is what we do , you get phenomenal
outcomes a n d that ’ s how we ’ re able to provide transportation to our
members because we know that that ’ s one of the barriers to access to
care. That ’ s how we ’ re able to provide post discharge meals for
patients who don ’ t have food at home. That ’ s how we ’ re able to

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d el iver a togetherness program, which focuses on providing social
interaction and engagement for our most socially isolated members .
T hose are expensive interventions , b ut they ’ re far less expensive than
sending a patient to the hospital for an ICU admission.

Margaret Flinter: All of this reminds me of yet another guest. Iyah Room, t he founder of
C ityblock H ealth, which is a venture with Google ’ s parent company
A lphabet. He ’ s building a tech enabled ecosystem that embeds deeply
within urban communities where s ocial determinants of health pose
real challenges to good health outcomes and trying to empower
whole household and perhaps hold neighborhoods to improve their
health .

Iyah Romm: A n average hospitalization which is going to shift a little bit market by
mar ket accounts for those sort of four hours of the communi ty care
worker, but also accounts for significant transportation or one of my
favorites, which is two and a half years of food stamps for a family of
four . W e think about the opportunity for meaningfu l investment of
those factors that underlie the health of the population. I think it ’ s
very clear that we have opportunity to reinvest . W e believe that you
can reduce emergency department spending an d an inpatient hospital
spending on the order of 35 to 40 %. O ne thing that ’ s worth noting
about individuals who have significant health challenges, they a re
significantly more likely to be admitted from an emergency
department into a n in patient setting. On the pharmacy side there are
variety of pragmatic factors here that I think are really important to
consider. We had a member recently who had recurrent emergency
department utilization, who made really smart choices to access the
emergency department at the end of every month to get a 30 day
refill of insulin b ecause they knew that the emergency department
would ration that out at the end of every month. The reason for that
is because they had a $350 copay on that insulin medication . B eing
able to find ways to intervene around the cost of pharmacy services
drive s recurrent and preventable emergency department spending I
think it ’ s really powerful .

Mark Masselli: A ll of this change in tech enabled care delivery means that the
nation ’ s t eaching institutions have to rethink how they ’re training t he
n ext g eneration o f health care professionals like Dr. Lloyd M inor,
Dean of Stanford Medical School, who says they ’ re taking a much
more interdisciplinary approach to medical training.

Lloyd Minor: During the first two years of medical school, we basically follow the
same c alendar as the rest of the university. W e have first and second
year medical students taking courses in computer science and
engineering, as well as in the humanities and social sciences. M edical
students get combined degrees in law or in business as well as in
more traditional scientific disciplines. Today, more than ever, the

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need to train physicians to be valuable members of teams , I like to
think of what we ’ re moving into in health care as being high tech
enabling high touch. I don ’ t believe that health care professionals are
going to be put out of business by hi gh tech. No one elects to
eliminate a primary care provider, but they also want the immediacy
that virtual interactions and digital health provide t oday .

Margaret Flinter: W e gained some similar insights Mark from Dr. Steve Klasko who is
CEO of Jefferson H ealth which oversees the Jefferson School of
Medicine. He says we must train the clinicians of tomorrow to be
absolutely comfortable collaborating in teams, something that hasn ’ t
been traditional ly done in medical schools, but of course, is part of
the air we breathe here in community health.

Steve Klasko: We were the first medical school in the country that thought seeing
humans would be a good idea. We had the first center for inner
professional education. W hat we ’ re doing here at Jefferson is from
the first time that a medical student literally starts their studies . T hey
are basically surrounded by nursing students and pharmacy students .
B efore we have a chance to teach them to be arrogant or qu ote, give
orders. They ’ re learning to be a teammate , s o we believe t hat that
makes a difference. What I hear from residency directors all over the
country is that our students understand teamwork better. I think the
combination of using simulation to creat e great teammates before we
start to look at ourselves as captain s of the ship, and to recognize that
you ’ re go ing to have to continue to get your technical and teamwork
competence assess like pilots or folks in nuclear power plants makes a
lot of sense. I think Jefferson ’ s leading the way .

Margaret Flinter: W e want to particularly call out the work of Dr. Don Warren. He is a
physician and director of the program called Indians Into Medicine at
the University of North Dakota, both recruiting Native American s into
medicine where they ar e very disproportionately not represented, but
also doing research and educating people to the impact of history and
historical trauma on the future health of generations really just doing
terrific work.

Mark Masselli: Such imp ortant work .

Don Warren: A s a nation we need to come to terms with t he American Holocaust,
the American Indian population was almost completely wiped out. If
we are ever going to get to health equity, where we can actually raise
health to appropriate statu s for every population, we have to contend
with the truth. I see a reluctance to do that because it makes people
feel bad. T he truth is, there was deliberate attempt at genocide of
American Indians. People may have heard of Amherst, Massachusetts
or Amhers t College. It ’ s named after Lord Jeffrey Amherst who was a
colonial governor, and he is the one who ordered the distribution of
blankets from a smallpox hospital to the northeastern tribes with the

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purpose of killing them. O ur first documented case of biot errorism is
our own colonial government , b ut that ’ s not in our history books. I
think that what I see is that people blame the victims , you don ’ t
understand why we have such high rates of addiction or diabetes or
cancer. Well from my perspective if you wan t to get to equity you
have to walk through truth.

Margaret Flinter: T his of course was the year that the Theranos S candal broke wide
open . T ech startup that claim ed to be a revolutioni z ing diagnostic
testing able to test for hundreds of diseases with just a small drop of
blood , there are so much excitement about that . Wall Street Journal
writer J ohn Carreyrou conducted and in - depth investigation and
found that not only were these false claims but the company was
actually putting patients at risk for real h arm .

John Carreyrou: S he came to have this very powerful b oard of older men and that
gave her credibility with the investors th at co n she targeted
billionaires and billionaire families . A mong them R upert M urdoch who
invested on in $25 million family and Be tsy DeVos our current
Education Secretary which put in 100 million . The heirs of Sam Walton
put in a 150 million , so really that ’ s how it unfolded . T hen what ’ s
going on now , well , she ’ s been charged with fraud by the SEC and she
negotiated a settlement wit hout admitting wrongdoing. But there ’ s
also criminal investigation spearheaded by the US Attorney ’ s Office.

Mark Masselli: His exposure led to the shutdown of the company, which at one point
was valued at $9 billion. S peaking of corporate greed in real har m t he
opioid crisis has exploded in recent years. Long time New York T ime
journalist Barry Meyer had been investigating the role of Purdue
P harma in the rise of the opioid crisis. The maker s of the opioid pain
killer, Oxycontin discovered the company lied about the drug ’ s
potential harm and helping set the opioid crisis in motion.

Barry Meyer: I think it ’ s important to bear in mind that the FDA approval of
Oxycontin t he actual language that was used was that Oxycontin
because it was a time release form or l ong acting form is believed to
pose less abuse liability. That is believed was the language that was
approved by the FDA t hat is it might be less prone. What Purdue did is
basically took this unique claim, one that had never been given to any
drug before a nd ran with it. W hat they did was they train their
salespeople to basically go out and lie and tell health care
professionals that it would produce less abuse and addiction. T here
was an internal decision made by this company to basically deceive
doctors a nd lie to doctors .

Mark Masselli: His book P ainkiller is a cautionary tale of what happened when drug
manufacturers mislead the public.

Margaret Flinter: S peaking of writers, we had a delightful conversation with New York

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T ime science columnist Carl Zimmer whose terrific book S he H as H er
M other ’ s L augh examines the history of heredity and how our
growing understanding of genomics will only enhance our greater
understanding n ot just of health, but of humanity.

Carl Zimmer: I do think that clinicians just rea lly have to practically start over with
their education b ecause so much has changed so quickly. T he patients
are going to be coming to doctors with results they ’ re getting from
directed consumer services as customers, and they ’ re going to say,
l ook 23 mean s says I have this, what are you go ing to do about it?

Margaret Flinter: Yeah, they already are.

Carl Zimmer: Yeah, exactly. Y ou need to learn how to talk about, for example, risk .
There’s a big difference between a mutation that guarantees you ’ re
going to get Huntington ’ s disease and a mutation that ’ s slightly on
average increases the risk of heart disease . Clinicians are going to
have to really get to understand lots of very common diseases are
influenced by hundreds or thousands of different genes.
th
Mark Masselli: As we embark on 2019 our 10 year of doing the show w e’ ll be
keeping our eyes o n the continuing emerging trends, the Affordable
Care Act which is where we started Margaret with our show . We’ll
watch with interest a s such things as telehealth and precision
m edicine approaches begin to take hold in the health care arena.

Margaret Flinter: I f it ’ s making news in the health care arena, particularly innovations
and policy, technology and health care. You ’ ll hear about it right here
on C onversations on H ealth C are.

[Music]

Mark Masselli: You ’ ve been listening C onversations on H ealth Care, I’m Mark
Masselli.

Margaret Flinter: And I ’ m Margaret Flinter.

Mark Masselli: Peace and health.

Female: C onversations on H ealth C are is recorded at W E SU at Wesleyan
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