Medicines future Theres an app for that Daniel Kraft

a couple of years ago when I was

attending the TED conference in Long

Beach I met Harriet now we’d actually

met online before you know not the way

you’re thinking we were actually

introduced because we both knew Linda av

one of the founders of the first online

personal genomic companies and because

we shared our genetic information with

Linda she could see that Harriet and I

shared a very rare type of mitochondrial

DNA haplotype K 1 a 1 B 1 a which meant

that we were distantly related we

actually shared the same genealogy with

Ozzie the iceman so Ozzie Harriet and me

and being the current day of course we

start our own Facebook group you’re all

welcome to join and when I met Harriet

and person the next year at the TED

conference she’d gone online and ordered

our own happy haplotype t-shirts

now why am I telling you this story what

does this have to do with the future of

health well the way I met Harriet is

actually an example of how leveraging

cross-disciplinary exponentially growing

technologies is affecting our future of

health and wellness from low cost gene

analysis to the ability to do powerful

bioinformatics to the connection of the

internet and social networking what I

like to talk about today is

understanding these exponential

technologies you know we often think

linearly but if you think about it if

you have a lily pad and it just divided

every single day 2 4 8 16 15 days of

32,000 what do you think you have in a

month or at a billion so if we start to

think exponentially we can see how this

is starting to affect all the

technologies around us and many of these

technologies speaking as a physician and

innovator we can really start to

leverage to impact the future of our own

health and of healthcare and to address

many of the major challenges that we

have in healthcare today ranging from

the really exponential costs to the

aging population the way we really don’t

use information very well today the

fragmentation of care and often the very

difficult course of adoption of

innovation and one of the major things

we can do we’ve talked a bit about here

today is moving the curve to the left we

spend most of our money on the last 20%

of life what if we get spend and

incentivize physicians and healthcare

system in our own self to move the curve

to left improve our health leveraging

technology as well

now my favorite technology example of

exponential technology we all have in

our pocket so if you just think about it

these are really dramatically improving

I mean this is the iPhone 4

imagine what the iPhone 8 will be able

to do now I’ve gained some insight into

this I’ve been the track chair for the

medicine portion of a new institution

called singularity University based in

Silicon Valley and we bring together

each summer about 100 very talented

students from around the world and we

look at these exponential technologies

from medicine biotech artificial

intelligence robotics nanotechnology

space and address how could cross train

and leverage these to impact major unmet

goals we also have seven-day executive

programs and coming up next month is

actually future mat a program to help

cross train and leverage technologies

into medicine now I mentioned the phone

these mobile phones have over I think

20,000 different mobile apps available

to the point where there’s one out of

the UK where you can pee in a little

chip connect it to your iPhone and check

yourself for an STD and

I try that yet but that’s available

there other sorts of applications

merging your phone and diagnostics for

example measuring your blood glucose on

your iPhone and sending that Prudential

e to your physician so they can better

understand and you can better understand

your blood sugars as a diabetic so let’s

see now how exponential technologies are

taking healthcare let’s start with

faster well it’s no secret that

computers through Moore’s law are

speeding up faster and faster we have

the ability to do more powerful things

with them they’re really approaching in

many cases surpassing the ability of the

human mind but what I think

computational speed is most applicable

is that of imaging the ability now to

look inside the body in real time with

very high resolution is really becoming

incredible we’re layering multiple

technologies PET scan CT scans and

molecular diagnostics to find and seek

things at different levels here you’re

going to see the very highest resolution

MRI scan done to date reconstructed of

Bartho - the curator of TEDMED and now

we can see inside of the brain at a

resolution and ability that was never

before available and essentially learn

how to reconstruct and maybe even

re-engineer or backwards engineer the

brain so we can better understand

pathology disease and therapy we can

look at side with real-time fMRI in the

brain at real-time and by understanding

these sorts of processes in these

connections we’re going to understand

the effects of medication or meditation

and better personalize and make

effective for example psychoactive drugs

the scanners for these are getting

smaller and less expensive and more

portable and this sort of data explosion

available from these is really almost

becoming a challenge the scan of today

takes up about 800 books or 20 gigabytes

the scan of just in a couple years will

be one terabyte or 800,000 books how do

we leverage the information let’s get

personal I won’t ask you here’s how to

colonoscopy but if you’re over age 50

it’s time for your screening colonoscopy

how would you like to avoid the pointy

end of the stick well now there’s

essentially virtual colonoscopy compare

those two pictures and now as the

radiologist you can Sochi fly through

your patients calling and augmenting

that with artificial intelligence

identify potential as you see here a

lesion that we might have missed it but

using AI on top of radiology we can find

lesions that were missed before and

maybe this will encourage people to get

colonoscopies that wouldn’t have

otherwise and this is an example this

paradigm shift we’re moving to this

integration of biomedicine information

technology wireless and I would say

mobile now

this era of digital medicine so even my

stethoscope is now digital and of course

there’s an app for that we’re moving

obviously to the era of the tricorder

so the handheld ultrasound is facially

surpassing and supplanting the

stethoscope these are now at a price

point of what used to be a hundred

thousand euros or a couple hundred

thousand dollars for about five thousand

dollars I can have the power with very

powerful diagnostic device in my hand

and merging this now with the advent of

electronic medical records in the United

States we’re still less than 20%

electronic here in the Netherlands I

think it’s more than 80% but now that

we’re switching to merging medical data

making it available electronically we

can crowdsource that information and now

as a physician I can access my patients

data from wherever I am just through my

mobile device

and now of course we’re in the era of

the iPad even the iPad 2 and just last

month the first fda-approved application

was approved to allow radiologists to do

actual reading on these sorts of devices

so certainly the physicians of the day

including myself are completely reliable

on these devices and as you saw just

about a month ago Watson from IBM beat

the two champions in jeopardy so I want

you to imagine we’re in a couple years

we start to apply this cloud-based

information well we really have the AI

physician and leverage our own brains

and connectivity to make decisions and

diagnostics at a level never done RT

today you don’t need to go to visit your

physician in many cases only about 20%

of actual visits you need to lay hands

on the patient we’re now in the era of

virtual visits from sort of the Skype

type visits you can do with American

well to Cisco that’s developed a very

complex health presence system the

ability to interact with your healthcare

provider is different and these are on

being augmented even by our devices

again today here my friend Jessica sent

me a picture of her head laceration so I

can save her a trip to the emergency

room I can do some Diagnostics in that

way or might we be able to leverage

today’s gaming technology like the

Microsoft Kinect and hack that to enable

let’s say Diagnostics for example in

diagnosing stroke using simple motion

detection using $100 devices we can

actually now visit our patients

robotically this is the rp7 if I’m a

hematologist visit another clinic for

visit a hospital these are being

augmented by a whole suite of tools

actually in the home now

so imagine we already have wireless

scales you can step on the scale you can

tweet your way to your friends and they

can keep you in line we out wireless

blood pressure cuffs a whole gamut of

these technologies are being put

together so instead of wearing these

glue G devices we can put on a simple

this is developed by colleagues at

Stanford called the eye rhythm

completely supplants the prior

technology and a much lower price point

with much more effective ‘ti now we’re

also in the ear today of quantified self

consumers now can buy basically

hundred-dollar devices like this little

Fitbit I can measure my steps my caloric

outtake I can get insight to that on a

daily basis I can share that with my

friends with my physician

there’s watches coming now that I’ll

measure your heart rate Zeo sleep

monitors all suite of tools that can

able get a leverage and have insight

into your own health and if we start to

integrate this information we’re going

to know better what to do with it and

how better to have insight into our own

pathologies health and wellness

there’s even mirrors today I can pick up

your pulse rate and I would argue in the

future we’ll have wearable devices in

our clothes modern in ourselves 24/7 and

just like we have the OnStar system in

cars your red light might go on and once

a check engine light it’s going to be

check your body light and go in and get

and take care of and probably in a few

years we’ll check in to your mirror and

it’s going to be diagnosing you okay for

those of you with with kiddos at home

how would you like to have the the

wireless diaper that sir supports here

too much information I think that you

might need but it’s it’s gonna be here

now we’ve heard a lot today about

technology and connection and I think

actually some of these technologies will

enable us to be more connected with our

patients and take more time and actually

do the important human touch elements of

Medicine as augmented by these sorts of

technologies now we talk about

augmenting the patient to some degree

how about augmenting the physician we’re

now near super labeling the surgeon who

can now go inside the body and do things

with robotic surgery which is here today

at a level that was not really possible

even five years ago and now this has

been automated further layers of

technology like augmented reality so the

surgeon can see inside the patient

through their lens where the tumor is

where the blood vessels are this can be

integrated with decision support a

surgeon in New York and be helping a

surgeon in Amsterdam for example and

we’re entering era a really truly

scarless surgery called notes where the

endoscope robotic endoscope can come out

the stomach and pull out that

gallbladder all on a scarless wedding

and robotically and this is called notes

and this is coming basically scarless

surgery is mediated by robotic surgery

now how about controlling other elements

for those who have disabilities

the paraplegic there’s the ear of brain

computer interface or BCI where chips

have been put on the motor cortex of

completely quadriplegic patients and

they can control a cursor or a

wheelchair or initially a robotic arm

and these devices are getting smaller

and going into more and more of these

patients still in clinical trials but

imagine when we can connect these for

example to the amazing bionic limb such

as those of the DECA arm

built by Dean Kaman and colleagues which

has 17 degrees of motion and freedom and

can allow the person who’s lost a limb

to have much higher levels of dexterity

or control than they’ve had in the past

so we’re really entering the era of

wearable robotics actually if you

haven’t lost a limb you’ve had a stroke

for example you can wear these augmented

lambs or if you’re a paraplegic like I

visited the folks at Brooklyn bionics

they’ve developed a legs I took this

video last week here’s a paraplegic

patient actually walking by strapping on

these exoskeletons these otherwise

complete world’s you’re bound and now

this is the early era of wearable

robotics and I think by leveraging these

sorts of technologies we’re going to

change the definition of disability to

in some cases be super ability or super

enabling this is Aimee Mullins who lost

her lower limbs as a young child and

Hugh her who is a professor at MIT who

lost his limbs in a climbing accident

and now both of these can climb better

move faster swim differently with their

prosthetics than us normal abled persons

now how about other Exponential’s

consider the obesity trend is

exponentially going in the wrong

direction including with huge costs but

the trend in medicine actually is to get

exponentially smaller so a few examples

we’re now in the era of Fantastic Voyage

the eye pill you can swallow this

completely integrated device it can take

pictures of your GI system help diagnose

and treat as it moves through your GI

tract we need to even smaller micro

robots that will eventually autonomously

move through your system again and be

able to do things that surgeons can’t do

in much less invasive manner sometimes

it might have self-assemble in your GI

system and be augmented that reality on

the cardiac side pacemakers are getting

small are much easier to place so you

don’t need to train an interventional

cardiologist to place them and they’re

going to be wirelessly to limit it again

to your mobile devices so you can go

places and be monitored remotely these

are shrinking even further here’s one

that’s in prototyping by Medtronic

that’s smaller than a penny artificial

retinas the ability to put these arrays

on the back of the eyeball and allow the

blind to see again in early trials but

moving into the future these are going

to be gained changing or for those of us

who are sighted how about having the

assisted living contact lens Bluetooth

Wi-Fi available beams back images to

your eye now if you have trouble

maintaining your diet it might help to

have some extra imagery to remind you

how many calories are going to be coming

at you

how about enabling the pathologist to

use their cellphone again to see at a

microscopic level and tell ember that

data back to the cloud and make better

diagnostics in fact the whole era of

laboratory medicine is completely

changing we can now leveraging micro

fluidics like this chip made by Steve

quake at Stanford micro fluidics can

replace an entire lab of technicians and

put it on a chip enable thousands of

tests to be done at the point-of-care

anywhere in the world and this is really

going to leverage technology to the

rural and the underserved and unable

what used to be thousand-dollar tests to

be done at pennies and at the

point-of-care if we go down the small

pathway a little bit further we’re

learning the era of nano medicine the

ability to make devices super small to

the point where we can design red blood

cells or micro robots that will monitor

our blood system or immune system or

even those that might even clear out the

class from our arteries now how about

exponentially cheaper not something we

usually think about in the era of

medicine

that hard just used to be $3,400 for 10

megabytes expletive cheaper in genomics

now the genome cost about a billion

dollars about ten years ago when the

first one came out we’re now approaching

essentially a thousand dollar genome

probably next year in two years about a

hundred dollar genome what are we going

to do with hundred dollar genomes and

soon we’ll have millions of these tests

available and that’s when it gets

interesting when we start to crowdsource

that information and we enter the era of

true personalized medicine the right

drug for the right person at the right

time instead of what we’re doing today

which is essentially the same drug for

everybody so two blockbuster drug

medications many cases which don’t work

for you the individual and many many

different companies are working on on

leveraging these approaches and I’ll

just show you a simple example from 20

through me again

my data indicates that I’ve got by

average risk for developing macular

degeneration two kind of blindness but

if I take that same data upload it to

decode me I can look at my risk for

example type 2 diabetes I’m at almost

twice the risk for type 2 diabetes I

might want to watch how much dessert I

have the lunch break for example it

might change my behavior leveraging my

knowledge of my pharmacogenetics how my

genes modulate what my drugs do and what

doses I need are going to become

increasingly important and what’s in the

hands of the individual and the patient

will make better drug dosing and

selection available so again it’s not

just genes it’s multiple details our

habits our environmental exposures when

was the last time your physician asked

you where you’ve lived

geo medicine where you live what you’ve

been exposed to can dramatically affect

your health we can capture that

information so genomics proteomics the

environment all this data streaming at

us individually and as us as poor

physicians how do we manage it well

we’re now entering the era of systems

medicine or systems biology where we can

start to integrate all this information

and by looking at the patterns for

example in our blood of 10,000

biomarkers at a single test we can start

to look with these little patterns and

detect disease in a much earlier stage

and this is being called by Li hood the

father of the fear of p4 medicine we’re

going to be predictive we’re going to

know what you’re likely to have we can

be preventive that prevention can be

personalized and more importantly it’s

going to become increasingly

participatory through websites like

patients like me or managing your data

on a Microsoft Health fault or a Google

health leveraging this together in

participatory ways is going to become

increasingly important so I’ll finish up

with exponentially better we’d like to

get therapies better and more effective

now today we treat high blood pressure

mostly with pills what if we take a new

device and knock out the nerve vessels

that

me delayed blood pressure and a single

therapy basically cure hypertension this

is a new device that essentially is

doing that that should be on the market

within a year or two how about more

targeted therapies for cancer right I’m

an oncologist and I know today most of

what we give is essentially poison we’ve

learned at Stanford and other places

that we can discover it cancer stem

cells so once it seemed to be really

responsible for disease relapse so if

you think of cancer as a weed we often

can whack the weed away it seems to

shrink it often comes back so we’re

tacking the wrong target the cancer stem

cells remain and the tumor can return

months or years later we’re now learning

to identify the cancer stem cells and

identify those as targets and go for the

long term cure and we’re ending the era

of personalized oncology the ability to

leverage all this data together analyze

the tumor and come up with a real

specific cocktail for the individual

patient now I’ll close with regenerative

medicine so I’ve studied a lot about

stem cells embryonic stem cells are

particularly powerful we also have adult

stem cells throughout our body we use

those in my field of bone marrow

transplantation

Geron just last year start of the first

trial using human embryonic stem cells

to treat spinal cord injuries still a

phase one trial but evolving we’ve been

actually using adult stem cells now in

clinical trials for about 15 years to

approach a whole range of topics

particularly in treating cardiovascular

disease if we take our own bone marrow

cells and treat a patient with a heart

attack

we can see much improved heart function

and actually better survival using our

own bone marrow drive cells after a

heart attack I invented a bicycle the

marrow miner a much less invasive way

for harvesting bone marrow it’s now been

FDA approved and will hopefully be on

the market in the next year so hopefully

you can appreciate the device that are

curving through the patient’s body and

removing the bone marrow instead of with

200 punctures which is a single puncture

under local anesthesia but where stem

cell therapy really going if you think

about it every cell in your body has the

same DNA as you had when you were an

embryo we can have reprogram your skin

cells to actually act like a pluripotent

embryonic stem cell and utilize those

potentially to treat multiple organs in

that same patient making your own

personalized stem cell lines and I think

there’ll be a new era of your own stem

cell banking to you know have in the

freezer your own cardiac cells myocytes

neural cells to use them in the future

should you need them

and we’re integrating this now with a

whole year of cellular engineering and

integrating exponential technologies for

essentially 3d organ printing replacing

the ink with cells and essentially

building and

reconstructing a 3d organ that’s where

things are going to head still very

early days but I think as integration of

exponential technologies this is the

example so enclosed as you think about

technology turns on how to impact health

and medicine we’re entering an era of

miniaturization decentralization and

personalization and I think by pulling

these things together we can start to

think about how to understand and

leverage these we’re going to empower

the patient enable the doctor enhance

wellness and begin to cure the well

before they get sick because I know as a

doctor if someone comes to me with stage

one disease I’m thrilled we can often

cure them but often is too late and it’s

stage three or four cancer for example

so by leveraging these technologies

together I think we’ll enter a new era

that I like to call stage zero medicine

and as a cancer doctor I’m looking

forward to being out of a job thanks

very much