F125 Amazon in Healthcare, AI Related Disparities and the Microbiome Challenges (Erin Brodwin)
Three segments of the digital health market are worth keeping an eye on: big tech, digital pharmacy, and retail, says Erin Brodwin, Health Tech Correspondent for STAT News.
While every healthcare market in the world is different, the United States' healthcare system is probably the most diverse and fragmented one due to its size and the principles of the free market. Patients are seen as consumers, which contributes to perverse incentives. It is fair to say, though, that the intense competition also encourages innovation.
Digitalization has created many hurdles in the EHR space, giving innovators an opportunity to create user-centric solutions to fill the cracks in the healthcare system. For example, a huge challenge for patients in the US is the lack of medication price regulation. Pharma has the power to change prices based on their judgment, and prices can vastly differ between Pharmacies an individual goes to. Startups such are GoodRx, Rx.Revu and others have been addressing price transparency for years. Now, Amazon Pharmacy launched in 2021, is offering that as well.
Amazon is building an impressive track record of successful projects that, combined together, are catering more and more healthcare needs.
In light of Amazon's development of healthcare solutions, many providers of narrow health and wellness products are trying to strengthen their position on the market by becoming full-scale telehealth providers.
Digital Pharmacies and Walmart
Companies such as Hims or Ro, started out delivering very narrow product ranges such as erectile dysfunction and hair loss. "They are now branching out into brand new conditions, chronic conditions, and seeking to brand themselves more as full-scale or full-stack telemedicine companies. At this point, rather than calling them digital pharmacies, we can call them telehealth companies," Erin Brodwin says, pointing out that these companies are trying to leverage their customers’ loyalty to become the digital front door for healthcare consumers in the long run.
None of these players, however, is addressing the market of the 30 million uninsured and underinsured Americans. Brodwin is therefore looking closely at players that might tap this market: Walmart and Best Buy. "We know Walmart has a lot of physical retail clinics, and there was some reporting recently that they may have been tapping the brakes on that endeavor. So I think, regardless of what that may or may not mean, I think it could be a potential signal that they're going to be investing more in virtual and telehealth capabilities."
Amazon = pharmacy + primary care + … interoperability?
In 2018 Amazon announced its entry into healthcare. It's 2021 and Amazon offers Amazon care, Amazon pharmacy, physical clinics via a partnership with the Crossover health startup. All Amazon’s efforts taken together cover many healthcare needs, which is a telling sign of the role tech giant could play in the US healthcare market, says Erin Brodwin.
Three years ago, Amazon, Berkshire, and JPMorgan established a venture to disrupt health care. Haven was disbanded but individual involved companies are further developing the efforts from the venture. "One project at Haven was a project called project Starfield. It was supposedly one of their major efforts, and it involved creating a primary care delivery system that was primarily digital. Each employee was set up with a designated group of clinicians and nurses who would follow the individuals and get to know them over time. That could essentially provide prevention and continuous care. As it turns out, Amazon care appears to be doing something not too dissimilar. At first, they were in urgent care. Now they are also primary care. And if you look at their website, they have this whole section on what they call a care team. This is essentially a group of clinicians and nurses who get to know each person, follow them over time, and essentially act as what seems to be a care partner. They are providing potentially preventive care."
Amazon - Cerner integration
A seemingly trivial but potentially significant Amazon's endeavor is its health and wellness band Halo. "Normally, I'd say, that's not a big deal. It's a feature. It's nice to have. It's like a Fitbit - people might pick it up and then put it in a drawer and forget about it. But there are two interesting things about the Halo - it offers an integration with the Cerner EHR provider. Right now, you can only share some limited data with it, but that integration is going to be pretty important in the future. If you want to really make moves in the health tracking space, you have to connect all of the pieces. One of the reasons many people pick up a Fitbit and forget about it is because it's not connected on the backend with many services. Another interesting thing about the Halo is it has voice tracking. And right now, we know that the science behind voice tracking for detecting things like mental illness is pretty limited. But there is a lot of science in that space. And it could be really interesting to see whether they turn that into some kind of wellness. If they transition it beyond wellness, which is what they're doing right now to some kind of actual healthcare device and then of course offer integration with an EHR - that'll be really interesting to see."
With successful stories under its belt, Amazon still needs to address privacy concerns and make sure employers cannot use the healthcare data for discrimination, says Brodwin.
AI in healthcare
Erin Brodwin.
Apart from covering health tech companies, Erin Brodwin has been covering AI-based clinical decision support systems in healthcare since 2019.
While AI is promising, it's becoming clear that data collection and diversity in samples is of huge importance when a tool is put in place for a broad population. At the moment, most algorithms are trained on write populations. Regulators require companies to train and deploy tools on diverse datasets.
One example of how problematic is a homogenous sample was discovered during the pandemic. Measuring oxygen levels with pulse oximeters is an important part of care for COVID patients. It turned out, not all oximeters work on black population as they do on the white population. "It took us a global pandemic to recognize that pulse oximeters, the little devices that go on your fingertip, don't work as well when they are used on black patients or patients with dark skin. Essentially the lights are trained in a way that works better on skin that is extremely light and transparent. They weren't developed on skin that has higher levels of melanin," says Erin Brodwin based on her research.
Transparency is a prerequisite for AI adoption
Stories like this add to the hesitancy around the use of AI tools and stress out the need for transparency around AI development. In a report published in December 2020, Brodwin wrote an insightful story about the reasons behind the lack of trust doctors have in AI systems and how these systems negatively impact clinical practice. The problem often lies in the poor implementation process. In some cases, clinicians are literally only informed, possibly over email, that a new tool will be present in their clinical practice. There are, of course, also better examples of technology implementation. "Duke Institute for Health Innovation is bringing in anthropologists and sociologists to review how the tools impact workflows and social interactions within a health system. They've found interesting downstream effects of tools that seem to improve patient care. When they were looking at a sepsis algorithm, they found it was working great for patients. However, it was making nurses feel completely alienated. The algorithm changed the workflow at the hospital and directed nurses to have to cold call clinicians that they didn't have a previous working relationship. The doctors on the other end were reserved and surprised by being contacted by the nurses they didn't know or heard of. The algorithmic tool put a whole lot of emotional labor on nurses. They tried to time their calls when the doctors would be in a good mood, they tried to figure out creative ways of introducing themselves, and getting doctors to trust them. This shows that creative and inclusive efforts to develop these tools more inclusively and transparently are going to be really important," comments Erin Brodwin.
Tune on for the full discussion.
Some questions addressed:
Due to the pandemic, the digital health space really took off. While there's hope that the pandemic will slowly get under control with vaccinations, telehealth and telemedicine players are working hard to make some changes permanent. What is known about this so far?
One of the ideas is that more medicine offered in the comfort of our homes would mean more prevention and in the long run a reduction in admits and emergency room visits hence healthcare saving. Are most patients who end up in the ER really the patients who would have time and money to invest in wellness and preventative care?
What are your memories of the first announcements that Amazon wants to enter healthcare, more specifically Pharmacy?
There were many doubts that Amazon could succeed because healthcare and drug management are complex etc. Its 2021 and Amazon offer a competitive online Pharmacy and expand its Amazon Care and telehealth offer. Do you think the significance Amazon is gaining in healthcare is worrisome?
Among other things, you cover AI-related trust issues and the implementation challenges of AI solutions. Perhaps we can touch upon reservations clinicians have due to a lack of information about how AI tools work and what datasets they are based on?
Your reporting often reveals which tech startups are overpromising. You broke the story about a seemingly promising startup in the microbiome space uBiome, which filed for bankruptcy and the founders have recently been charged with fraud. Can you take us through your research process and what triggers you to doubt claims made by companies?