Digital doctoring
The digital revolution can spur unprecedented advances in the medical sciences, argues Eric Topol in "The Creative Destruction of Medicine."

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  • It is only the beginning of a transformation in medical innovation @ScottGottliebMD

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  • US government’s version of health care reform has little or nothing to do with innovation

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  • No single innovation in #medicine will have a more profound effect than the conversion of biological data

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Among the most common reasons why people come to an emergency room are bouts of heart failure or pneumonia. Sometimes they have a touch of both. When I was doing my residency 10 years ago, we often struggled to distinguish swiftly one illness from the other. We ended up treating a lot of people for both ailments, until we could sort out later which was the primary culprit.

Over the past decade, the way that doctors approach this common clinical dilemma has been transformed with a simple innovation. A blood test for B-type Natriuretic Peptide (BNP), which is secreted by weakened heart muscle, can help distinguish between the two conditions. Another improvement in recent years: Doctors are replacing their stethoscopes with inexpensive, hand-held ultrasound scanners that can detect a failing heart right in the ER.

Such innovations are just the beginning of a transformation of medicine, says Eric Topol in "The Creative Destruction of Medicine." Dr. Topol, a prominent cardiologist and geneticist, envisions a technology-enhanced future where new tools are integrated into diagnosing and treating patients, transforming the handling of common medical problems.

"The U.S. government has been preoccupied with health care 'reform,' but this refers to improving access and insurance coverage and has little or nothing to do with innovation," even though, as Dr. Topol notes, adopting new approaches would improve care and lower costs. Doctors still "render medicine by the yard," he says, and they follow insurance-mandated treatment guidelines that "are indexed to population rather than an individual."

Dr. Topol is known for not being shy about expressing his views on medical matters—he was a prominent critic of U.S. drug-safety oversight during the Vioxx episode, when the arthritis and pain-relief drug was pulled off the market in 2004 after tests showed that it raised the risk of heart attacks and strokes. But in recent years Dr. Topol has taken a lower profile and has focused his work on how new technology is making the delivery of care more effective, giving doctors the tools to target treatments in ways that can maximize benefits and minimize harms. As the chief academic officer at Scripps Health, Dr. Topol has studied how academic healthcare organizations like Scripps can collaborate with for-profit companies to accelerate technological progress in medicine. This book communicates what he has learned.

The author says that no single innovation will have a more profound effect than the conversion of biological data. With the aid of technology, Dr. Topol says, medical progress may well begin to resemble modern computers' own astonishing surge in processing power and data storage.

"The Creative Destruction of Medicine"—an allusion to economist Joseph Schumpeter's description of "creative destruction" as an engine of business innovation—is a venture capitalist's delight, describing dozens of medical technologies that show great promise. The book also provides colorful anecdotes about Dr. Topol's own sampling of these products, as both a doctor and stand-in patient.

He continuously checks his blood sugar with an implantable meter, and he goes to bed wearing a "Zeo clock" that monitors brain function to help analyze sleep patterns. When he tries to fake sleep so that he can disregard his wife's bedtime chatter, he learns that "it's hard to play possum with a sensor displaying your real-time brain waves."

Dr. Topol focuses much of his attention on the development of "theranostics," or the integrated use of treatments and diagnostics (especially genomic and protein information) to better guide therapy. These tools, he says, will enable treatment systems that combine the constant monitoring of a patient's biological information and the infusing of targeted medicines. The concept isn't new, but Dr. Topol does an admirable job of laying out the ways in which it will help transform medical practice.

Diabetic patients, for example, will be grouped and treated according to genes that reveal "those who have problems with making or secreting insulin and those who have problems with the action of insulin in the body's tissues." The technology for doing this is available, yet in today's medical environment—where patients are grouped into broad, crudely defined categories—these two kinds of patients aren't well distinguished, even though they have very different clinical needs.

The book can be dense with data, but it offers enough explanatory detail to make such information accessible to experts and lay readers alike. Its most important contributions are in portraying how medical innovation will coalesce to change clinical practice and what the coming changes mean for today's policy debates.

For instance, full adoption of the new tools will require the Food and Drug Administration to alter the way it evaluates products. The FDA, he says, should allow the testing of drugs on patients who are selected for their prospect of deriving a benefit. Right now, the FDA usually requires drugs to be tested in a scattershot fashion on large populations. With drugs being tested on cancer patients, he notes, the "FDA insists on a body count to be able to quantify how much and how long the new drug improves survival"—even though diagnostic markers can sometimes reveal in advance which patients are unlikely to gain a benefit.

Dr. Topol worries that doctors will resist technologies that empower patients because the tools will also diminish the doctors' gatekeeper role. The American Medical Association, for example, battled firms that provide genetic information directly to patients. "This arrangement ultimately appears untenable," the author writes, "and eventually there will need to be full democratization of DNA for medicine to be transformed."

In Dr. Topol's vision, innovation that enables real-time diagnosis and personalized treatments is a certainty, though not because reluctant or "sclerotic" doctors accept it or because Washington wills it into being. A seductive technology that works like a dream and improves lives will set off a consumer clamor, whether the new tool is an iPhone 4S or an implantable blood-sugar meter.

Dr. Gottlieb is a resident fellow at the American Enterprise Institute.

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