What is the state of healthcare innovation in 2020? In the episode, we explore exponential medicine with Daniel Kraft, one of the world's foremost medical innovators.

Daniel Kraft is a Stanford and Harvard trained physician-scientist, inventor, entrepreneur, and innovator and is serving as the Chair of the XPRIZE Pandemic Alliance Task Force.

With over 25 years of experience in clinical practice, biomedical research and healthcare innovation, Kraft has chaired the Medicine for Singularity University  since its inception in 2008, and is founder and chair of Exponential Medicine, a program that explores convergent, rapidly developing technologies and their potential in biomedicine and healthcare. Following undergraduate degrees from Brown University and medical school at Stanford, Daniel was Board Certified in both Internal Medicine & Pediatrics after completing a Harvard residency at the Massachusetts General Hospital & Boston Children's Hospital, and fellowships in hematology, oncology and bone marrow transplantation at Stanford.

Transcript

This transcript was edited lightly for clarity.

Background

Dr. Daniel Kraft:   A theme has been, how do we think differently about health, medicine, and technology and the convergence? How might we reimagine the near future and the distant future of healthcare?

Michael Krigsman: Daniel Kraft is a physician and an inventor who wants to transform healthcare.

Dr. Daniel Kraft:   Well, the term "exponential" is usually referred to think about the pace of change. Most of us know linear thinking: one, two, three, four five. Exponential thinking is when you double every step: 2, 4, 8, 16, 32, 64, et cetera. By 15 steps, you're about 32,000 but, by your 30th exponential step, you're at a billion. That would be, if you were taking a step, by a meter, that's 26 times around the planet.

That's usually something hard for our brains to kind of grok how quickly technologies can accelerate. The one most folks are familiar with is Moore's law, which is why our supercomputers in our pocket are pretty incredible in terms of what they're able to do. They're better than a Cray supercomputer by many orders of magnitude.

This is my antique iPhone 2 from 11 years ago when, 11 years ago, it seemed amazing and now it still works. It feels slow and clunky and a low-resolution camera. In 10 years, my iPhone 11 will feel slow and clunky or be embedded in my Apple AR glasses.

Part of the theme of exponential medicine, in general, is not about any one technology accelerating from not just digital and Moore's law and computation, but what's happening in synthetic biology and low-cost genomics to big data, AI, nanotech, and virtual reality. Some of them are just moving quickly. Some of them are moving exponentially.

The most exciting part, which I love to kind of curate, is the convergence. When you mash things up that are getting faster, cheaper, better, how do you use those to reformat how we do virtualized care, cancer diagnostics, or contact tracing? That's a bit of the theme. It's not just about pure exponentials but getting people to think a couple of clicks of Moore's law forward because that has huge implications about how we want to set up our healthcare systems for today and what's coming next.

Convergence across healthcare industry disciplines

Michael Krigsman: You mention the term "convergence," so I'm assuming that an important part of this—and correct me if I'm wrong—is the bringing together of folks from different medical disciplines. Would that be an accurate way of describing it?

Dr. Daniel Kraft:   Yeah, absolutely. I found out when we were starting Exponential Medicine ten years ago. I'm trained as an oncologist, hematology/oncology, I'll go to the ASH, American Society of Hematology, meetings and the cardiologists go to the American Cardiology and the gastro folks go and the pharma folks go. Things get very, very siloed and it's very rare that you bring clinicians, researchers, technologists, investors, patients, nurses, and healthcare administrators together to kind of go, "Wow, what really is cutting edge? What's happening now?" Many folks have no clue what's already here let alone what's coming and, again, that sort of blending.

Also, at Exponential Medicine, we had, I think, last year, 45 countries, so a lot of things happen asynchronously in different parts of the world and we can learn from things that are happening in the NHS, Israel, China, or even Latin America and vice versa and cross-catalyze. To open up the thinking and mindsets as well.

It's not often about the technology. It's how we blend those with incentives and the often misaligned incentives in the healthcare systems around the planet.

Michael Krigsman: If we go to a hospital today, the bastions of traditional medicine, a patient comes in is seen by the oncologist and then various specialties. It seems to me that we already have that blending, so how is what you're describing different from what's taking place now, everywhere?

Dr. Daniel Kraft:   What takes place today, most everywhere, is not really health care or the care side. It's really the sick side of the equation, sick care. That's based on our traditional model where you go to see the oncologist or your doctor in the primary care clinic or, God forbid, the emergency room or intensive care unit. That's where care happens. That's where your data is collected, whether it's your vital signs or your labs.

We end up with very intermittent, reactive, sick care. We get the data in a siloed way. The 0.0001% of the time you happen to be seeing a clinician of some sort, and that leads to our reactive system where we wait for the patient to show up with a heart attack, stroke, or late-stage cancer, or the pandemic to arrive.

Where that hopefully is starting to shift is now starting to leverage some of the more Internet of medical things, the connected data, the continuous healthcare exhaust that can be picked up from our wearables and our environments to then being much more proactive, to identify problems early, to optimize your health and wellness, to diagnose something early or then to manage a disease if you have it, whether it's diabetes, hypertension, or cancer.

There's been a shift, I think. There's amazing technology in individuals and systems, but they're very disparate and the data often is disconnected. Even though we're in this exponential age, the data doesn't talk to each other. It's still stuck on fax machines as a bottleneck.

I went to have a cardiac study a few months ago. The only way I could get my results at home was on a CD-ROM. I don't even own a CD-ROM player anymore, so we have a lot of old technologies, whether it's a fax machine or CD-ROM and paper forms still in the cogs of our sick care model.

Michael Krigsman: Why are we stuck using fax machines and CD-ROMs?

Dr. Daniel Kraft:   Well, there's a big layer. Again, some incredible things are happening but often our regulatory and reimbursement rules are stuck in our analog age and are just starting to catch up to our digital. How many of us had to fax and sign a medical release, get it to the medical records, get them to fax it to another hospital? That might be very time-sensitive.

There's always HIPAA laws that are well-meaning that are supposed for portability, but they've become overly layered and encumbrance in privacy. I would argue the patient would rather be alive than with their privacy intact. I've seen many examples where the fear and the inability to transmit data and information has had dire outcomes or hindered smart innovation. We definitely need to focus on smart privacy but sometimes there's an over-fear element in that regard and the regulations often haven't kept up.

That's why we're still stuck on fax machines because that's the old regs and some of that, again, is international standards and some are even state-to-state in the United States. Lots of challenges to do what we call often interoperability from one medical record system to talk to another or for your ability to get your chest x-ray or your labs to you in a sharable way where you own your data, can be much more empowered to make sense of that, and can be more of a copilot in your care if you're a patient.

If you're a clinician, to use this new connected world to gather not just the data but the actual information so you can use that and even get paid for it, aligning the incentives to use some of these new technologies to really amplify and improve what's called "value-based outcomes" where you pay for outcomes when they're better. The drug, the app, the digiceutical, the gene therapy are increasingly only going to get paid for when they work. It's about the technology, also aligning incentives; that means follow the money, in most cases.

About exponential medicine

Michael Krigsman: You have this conference that you've been running for a number of years now entitled "Exponential Medicine" and you bring together a very interesting cast of participants. What's the underlying set of decisions that you're making in terms of how you bring these folks together and how does this relate to what you were just describing?

Dr. Daniel Kraft:   I think I'm fortunate I live here in Silicon Valley, despite our current fires and earthquake risk, to see a lot of things hopefully a little bit early, whether that's next-generation VR or 3D printing, or in travels around the world, when we used to travel, bump into very interesting people, technologies, and ideas.

My favorite thing in terms of curating exponential medicine and, if you go to exponentialmedicine.com/videos, you can see a tremendous array of amazing thought leaders, technologies, and ideas. But often, it's finding not the obvious folks, not the folks who are famous scientists, investors, or technologists, but to find things that are a little bit early.

One example of a technology that's at the convergence of exponential—and I have it over here—is virtual and augmented reality. I've got my Oculus Quest here that some of you might have at home now. Incredible amounts of technology for $300, $400. That starts as a gaming platform and it's wonderful for gaming. I've done 100 days straight of VR-based exercise, as an aside.

A few years ago, I met a young surgeon who had built the first VR training platform for orthopedic surgeons. You go into the VR headset and you're now in the operating room with the actual instruments from Stryker or a different company. You can practice a procedure, whether you're an orthopedic surgeon or not, and learn how to do that. Just like a flight simulator for pilots—I'm a pilot as well—you can drain for very difficult circumstances, bad weather, bad outcomes, and you're seeing that early and bringing that to the stage, you know, four years ago.

Now, it becomes sort of obvious. That company is advanced, called Osso VR, to the point where they've now done randomized trials showing physicians training on VR getting much better, much faster with their outcomes. It's finding things a bit early and then also showing examples that are not always traditional medicine, things that are outside of the norm to some degree, like psychedelics being used for treating PTSD or end of life care, and that's going through MAPS, going through phase 3 clinical trials with dramatic input, so those are fun.

We also blend in music and art, and everything from mindfulness, which relates to neuroscience, to music, to chakra shaman ceremonies. We get people a little bit out of their usual headspace, and that's where some of the interesting blending and connections happen outside of your usual button-down kind of conference.

Michael Krigsman: As I was looking at the attendee list from some of the past years. I found it striking that you have, among those folks, senior executives from traditional healthcare as well as senior execs from major pharma companies. Given the state of healthcare today, how can we start to integrate the things you're describing into our healthcare system? It seems like an enormous gap and pretty hard to do.

Dr. Daniel Kraft:   Particularly in the United States, there's no one healthcare system. There are thousands of types of systems, many of which are designed differently, and some are sort of aligned as a payor player. I mean Kaiser, Geisinger, or VA, the clinicians there or the system is not paid per procedure or per admission. They're aligned with, hopefully, being proactive and preventative.

Big healthcare systems, just like big companies, often have trouble innovating, innovating at scale. One of the nice things about coming to Exponential Medicine or getting in the mix is, it opens your mind to what's here or what's coming.

Often, again, it's not about the technology but how you integrate it in. Design thinking, how you might redesign your clinic so the waiting rooms, the patient stays in one room; the medical team comes to them. How you think about the design elements of how you communicate differently to a baby boomer versus a millennial and learning from others.

When you're coming from big pharma, especially, those are big ships and slow to move. No one wants to be the disruptee. You want to be the disruptor. No one wants to be the next Kodak or Blockbuster.

We always overuse the phrase, "You want to Uber yourself before you get Kodaked." We hopefully open the eyes and sometimes scare folks a bit, like, "Wow. If we don't get ahead of the curve here or start thinking a little more proactively and innovatively, we're going to be left in the dusk by the next generation payment models or virtualized care systems, et cetera." It's often a challenge for people to get out of their silos and that's what we try and do is break open the silos and connect the dots.

Transformation and traditional healthcare

Michael Krigsman: When you're speaking with, again, senior folks, decision-makers, innovators from traditional medicine and healthcare and pharma, what's the reception that they have to the things that you're describing?

Dr. Daniel Kraft:   Sometimes, it's a bit of shock and awe, like, "Oh, my gosh. We're behind the curve." Others are trying to do things like a chief innovation officer or someone who is very forward-thinking inside of a larger organization and it's hard to bring their folks along.

Back to the Kodak example, Kodak invented digital photography. It was invented there, but they didn't want to cut into their film sales because maybe the VP of film was blocking things out.

Sometimes, it's a matter of sparking leadership inside of a traditional organization and getting them to think about how do you accelerate some of these things internally with their five- or ten-year plan because, if you're doing your ten-year plan with the mindset of 2020 and not thinking about where AI, robotics, 3D printing, nanotech, genomics, and crowdsourcing are going to be, you're not going to be making a very good plan. Plans change, but you need to be somewhat, again, not on the linear track but the exponential.

I think sometimes it spurs some new thinking. A lot of the cross-fertilization that happens, we've had the head of innovation from National Health Service come for several years. He got spooled up and built a young entrepreneur physician or clinician program in the U.K. and that started a bunch of their docs and clinicians starting to go, "Wow! Here's a problem. I might be able to solve that and then role that out at the scale of the NHS."

Part of what I love about Exponential Medicine is it's catalyzed a lot of next-generation innovations that I don't even know about all of them. Part of it, again, is about understanding technology, where it's heading, their convergence, what's possible today, and what's coming next, and how to see a pain point and solve for that not just with what's in your pocket today but what you'll be able to do with next-gen systems, and those next-generation systems are coming quickly.

Digital transformation in healthcare

Michael Krigsman: Are we talking then about healthcare, technology, or business disruption?

Dr. Daniel Kraft:   I think it's a bit of all of it, right? It's also psychology. Again, moving the cheese is sometimes hard. If you create a new app, service, or platform that a good example might be virtualized angiograms where you can now do a 30-second CT scan, send the data to the cloud, it'll reconstruct your coronary blood vessels. It's gone through the FDA, et cetera. A company called HeartFlow.

But is that going to be exciting to the interventional cardiologist who gets paid to do those procedures or the hospital itself that makes a lot of money from doing diagnostics in the cath lab? That's a business model meets technology meets mindset. I think it's a blend of all those.

Frankly, the old models of healthcare were medical devices and drugs. Now, in the last decade or so, we have AI-based drug discovery. We have robotic surgery. We have digiceuticals. We have virtualized care. We have fields that have built at the interface that didn't even exist, in some cases, 10 or 20 years ago, and so it's business models meets innovation.

Then where the money hits the road, how do you pay for these things? There are a lot of great apps, devices, platforms, gene therapies that just don't ever get out of the gate because of misaligned incentives.

Michael Krigsman: From that standpoint, this is really not much different than any other business innovation problem where you're looking at disruptive technologies and trying to figure out how do we bring those into the market.

Dr. Daniel Kraft:   Except that you've now got the added layers of lives are at stake and it's not like you can just ship a new software version or print a new widget. You've got to go through regulatory.

To their credit, the FDA has now been getting out of their linear mindset. We've had Bakul Patel, Head of Digital for FDA, come to Exponential Medicine several times and, through workshops and other outside elements, go, "Well, what's coming and how do they now build a software and medical device platform for speeding up how you might think about the app controlling your insulin pump using AI machine learning?" or a precheck platform. If you're a well-established startup or company, you don't have to go through every hoop every single time and send in PDF books of your trials.

I think it's about bringing all these folks together, including the patient population. My friend Lucien Engelen calls it Patients Included or Nurses Included. You need to bring often the caregivers and the patients who are the need-knowers when you're solving a problem.

When I was a fellow at Stanford in hematology, oncology, and bone marrow transplant, I was part of the very first year of a program called Stanford Biodesign, which brings together medical folks, engineering, and law. In the first third of the year, you're just looking for problems to solve and really understanding them because many folks will build it and no one is going to come because it doesn't work with a nurse or fit into the medical records system or the payment model.

For anybody out there, many of you are nonmedical, you've got incredible skills in platforms and blockchain, gaming, design, IT, or apps that may have never been applied to healthcare. But if you find a pain point, particularly when you collaborate with clinicians, patients, and caregivers, a lot of things can move quickly. But you also have to understand and engage the regulatory process at the same time.

Michael Krigsman: It's bringing together of the technology, addressing the economic aspects, addressing the patient experience, the regulatory aspects, the business model aspects, and these are the kind of building blocks, could we say, who are driving healthcare change, essentially.

Dr. Daniel Kraft:   Right, and all those are moving parts. Now we're in the setting over COVID. We're speaking now in August of 2020. A lot of things have been catalyzed in sometimes good ways by the COVID pandemic. Virtualized care is an obvious one. I think, in April of 2020, the number of virtual visits when up by 1000% and maybe have come down a bit.

Now, because HIPAA got relaxed so you could do Zoom-based virtualized calls that weren't against the law and reimbursement models matched so you could get paid to do a virtual visit, those have exploded and the genie is out of the bottle and I don't think it's ever going to go completely back in because now we're able to see the value of not just a Zoom call for business but, in many cases, for a clinical encounter because you don't often need to lay on hands for every follow-up visit.

The ability to add connected devices is the future of virtual visits so it's not just the doctor or nurse on the screen. You can look at your Fitbit or your Apple Watch data or you're connected to a stethoscope or home ultrasound and use that as part of your care. Asynchronous chatbots, which can do early triage. Is that cough related to COVID or the flu? Bring in-home diagnostic platforms that could do labs or use your voice to diagnose conditions.

Lots of things are converging and being accelerated is a bit of the silver lining, as well as the speed and pace of taking all this data and moving it from data to information, actionable information. Then narrowing the gap from knowing that actual information the clinic, like, how do you manage a sick COVID patient in the intensive care unit?

Lessons from Wuhan, China, and from Italy, and from the ICUs in New York City are now distributed across the U.S. and the world. There is an acceleration of collaboration as well because it often is a long journey between something becoming known and being standard of care.

Michael Krigsman: The other day, I was party to a conversation between two physicians discussing a patient and one physician said to the other, "Oh, yes. I have to get this information." A question was asked. "I have to get this information," and he was looking through the chart and couldn't really find it. The other physician said, "Oh, yeah. I also prefer the paper records." The first physician said, "Yeah, you know, well, that's what I'm used to using."

Dr. Daniel Kraft:   That's a great example. I'm sort of that digital, bridging the digital divide. I got my first mobile phone when I was a medical resident. When I grew up, we didn't have Twitter or Facebook, or email when I was an undergraduate. Now you have folks graduating medical school who completely grew up on all these platforms.

Yes, there are some benefits to just looking through a paper chart. I started in paper charts. Then you go to digital and that has pluses and minuses.

A great example, Dr. Bob Wachter, who chairs medicine at UCSF, gives a great example of when I trained. You go to radiology rounds. You go to the radiologist with the whole team and you look at the actual physical x-rays. You put them on the light board, you look at them, and you have a discussion.

Now, in the digital age, you can look at your x-rays on your mobile phone or a computer and you miss that sort of interaction piece. There's something that changes in this element of interaction and sometimes solving problems.

Then there's the issue of, you can digitize a medical record. Unfortunately, that's what the problem is with our EMRs, things like Epic, Cerner, Allscripts. They've become basically digital versions of a long list of what used to be written by hand and they don't really add to your cognition. They can get in the way. Too many clicks. There's burnout from trying to just enter data.

I'm hopeful, whatever solution, a lot of these exponential solutions need to be integrated into the workflow of the doctor, the nurse, the pharmacist because there's so much friction, whether it's fax machines or CD-ROMs, just to be able to synthesize.

My favorite example that most people kind of get is, 15 years ago, we all used to drive with paper maps and now you couldn't imagine driving without Google Maps or Waze where we're crowdsourcing our data. Our private speed and location build the driving map that's hyperlocal. Imagine our electronic medical record systems and our personal record systems are building a bit of our own personal Google Map or Waze to take us on our healthcare journey, whether it's for our patients or for ourselves, that is gleaning knowledge from other patients like me or patients like mine on the genomic level, on the sociome level, on the digital exhaust level. There are a lot of challenges to make the technology integrate with actual clinical care that goes all the way down to your medical record and eventually using AI, machine learning, et cetera to really upskill the doctor, the nurse, or the community health worker to use that at the point of care in much more impactful ways.

One of the points of exponential medicine in general is, how do we democratize healthcare and improve health equity? There's a lot of disparity and that can be definitely improved using something as common as a smartphone.

Exponential medicine and culture

Michael Krigsman: We have a question from Twitter. Exponential medicine isn't just about technology and science, but it's about ways of working.

Dr. Daniel Kraft:   Sometimes people tell us at the conference, which we have at the Hotel del Coronado in San Diego, when we're in real life, on the beach, it's sort of like Burning Man meets a medical conference. Sometimes it's, how do you work together out of the usual silos of title and rank all the way to how do you interact at a conference at a silent disco or doing an unconference where people are sharing things in new ways?

I think we do need new ways of working together. Part of that can be facilitated by the connection digital, virtual layer. In the cancer world, we can now think about doing virtual tumor boards where might bring the oncologist, the radiologist, the pathologist together, and then also look at the data from their digitized slide and using AI machine learning. Have a thousand experts around the table virtually in terms of learned information.

New ways of doing asynchronous care. We just did a series with UCSF called "Hospital to Home." I like to call it hospital to homespital. All these new ways of doing remote patient monitoring, so whether it's an Internet of Things type medical device or sensor in your underwear band that can track your respiratory rate and your steps and shows you if you're getting into trouble from a pneumonia or COVID. How do you connect the dots on that for managing folks outside of the clinical realm? Something else that's been obviously catalyzed by COVID and that means we need new definitions of who does what where and when.

Transformation and medical education

Michael Krigsman: We have another question from Arsalan Khan. "Doctors can benefit greatly from learning technology during their education not only as an end-user but perhaps even as developers. Why hasn't the education system emphasized this enough?" He is raising the broader question of medical education, which seems like a really important part of this.

Dr. Daniel Kraft:   Medical education has not changed dramatically maybe a hundred or so years. Things were set up in the early 1900s to hopefully make medical education much more regulated, which makes some sense. But we're still picking medical students based on their ability to do well at organic chemistry and physics and not maybe on their ability to have engagement, empathy, decision-making, and maybe even manage apps and services because you need your memorization muscles less now than synthesis, potentially, going forward.

Part of this is who do we select for, let's say, medical school and how do you train them, not just for 2020, but they're going to be working into 2040, 2050? What skills do you need? How do you use some of these new platforms like virtual reality and augmented reality to vastly accelerate your ability to have a virtual patient in front of you?

There are several apps where you can pull up a virtual heart and play with it, learn its anatomy, walk through it, and add a heart attack, add a valve problem, or add a drug to treat it or a medical device. You can dramatically learn in new forums and even do that collaboratively. The opportunity reinvent continued medical education all the way back to how do we educate clinicians and, again, the ability, I think, to democratize and upskill folks.

If you're a nurse in a rural village in Rwanda, you can use one of the little tools, the Eko Stethoscope. It's a general stethoscope with an EKG. You can listen to heart sounds and potentially diagnose a heart murmur as good as a highly trained cardiologist. Blend in, again, the virtual coach that can come on your iPad and help you through sewing up a tough laceration or be inside the robotic surgeon surgery with you.

There are lots of ways we can do real-time, crowd-sourced, not just if you talk about a Waze or Google Maps for patients, but for clinicians as well to be always sort of virtually coached and seeing the map to a path forward clinically.

About patient experience and transformation

Michael Krigsman: Do clinicians even have the time and anything beyond a very broad, abstract interest in patient experience? Even to go further, if it's true that the body is essentially a set of mechanistic equations and chemical reactions, then why do you have this focus on design thinking, patient-centeredness, and everything else? Why don't you just train people and force them to learn better? That'll lead us to better healthcare and life will become simpler. We don't have to worry about all of this other stuff you're talking about.

Dr. Daniel Kraft:   We can always try and learn better and even how you can flip classroom education to gamifying education. There are now video games where you can learn, as a nonmedical person, do a full operation and do a heart transplant.

I think now there is just so much data. You have your digitone from your wearable devices like an Apple Watch or a Fitbit. Remember, Fitbit has only been out for 11 years. It's pretty new to the point we can measure almost every element of physiology and behavior from our wearables or insideables or our invisibles. Wi-fi can measure our data now.

That creates exponential data sets, including our genomics, our microbiome, our sociome, and the challenge in terms of learning is we can't learn it all. You can't read every paper. The amount of medical information is going up fast, so we need to leverage—it's over buzzwordy—AI, machine learning, and big data because AI is not going to be replace a doctor but the doctor using AI will replace those who don't – or the healthcare system. Pick your favorite specialty or any field. It's when you blend those together to give us the best insights.

A simple example would be: Okay, Michael. Let's say you have high cholesterol. Normally, I would just pick the standard dose of Lipitor. Hopefully, I could look at your microbiome because that might impact how you absorb Lipitor. I could look at your genomics from something as simple as 23 and Me to look at your pharmacogenomics to know that Lipitor is not the best drug for you because you're at high risk of muscle myopathy or inflammation. We need to skip to Simvastatin.

How do we then combine that with your blood pressure medicines that are personalized to you? What if we could 3D print those in a single medication so that, every morning, you take your combined blood pressure med, your statin, and the right amount of aspirin for you and even print that every morning, which is something I'm doing with a new startup called IntelliMedicine? We need to start to pull this together in ways that isn't just learning but is continually learning and, hopefully, surfacing the best information at the point of care to the patient and the system around them.

Healthcare policy and transformation

Michael Krigsman: Dr. Rasu Shrestha makes this comment. He says, "Policy has always been a big catalyst for tectonic shifts in healthcare in the United States. With the elections around the corner, do you see opportunities to exponentially move forward with the right policy catalysts?"

Dr. Daniel Kraft:   Yeah, you can't get a lot of this out of the gate. We can just look at our current predicament in COVID. A lot of our challenges in testing, et cetera, were based on bad regulatory or policy decisions that slowed up testing or other elements.

Exponentially changing things might be always difficult in healthcare, but I'm hopeful. I'll show my biases that we have a new administration come January that's much more forward-thinking, can align what we need to do next in policy to reward not just healthcare, but sick care. We're paying for prevention, for public health, thinking about new models.

I like the idea I came up with a colleague of mine of a global public health corps where you could volunteer, just like an EMT or fireman, to be your local public health servant and use all these technologies to do contact tracing and address social disparities. A lot of that does come from the policy level and how we pay for things at the NIH level, the NSF level, and beyond.

We need smart, exponential mindsets to shift policies so that these exponential technologies can come together and really shift things because we have so much room to go. We spend more per capita in the United States for an individual that have 20th in terms of lifespan, so we have a long way to go to align our technologies and our capabilities, and that requires leadership and smart policy.

Michael Krigsman: We have another question from Twitter. You can see I prioritize the questions from Twitter over my own. Very often, the questions from Twitter are better than the ones that I have because they are from practitioners in the field such as Shawna Butler, RN. Shawna says, "How is exponential medicine catalyzing cross-disciplinary teams and making health innovation a team sport that has a variety of new and unexpected players?" She also is asking, "How are we innovating for the "bottom billion" that don't have access to high-tech healthcare?" Two questions, the cross-disciplinary teams and innovating to help the remainder of the world that doesn't have access to all of this high-tech.

Dr. Daniel Kraft:   It's not just about the traditional doctor or health administrator. We need to, as Shawna has proposed, accelerate nurses being involved, physical therapists, the team element so that we're all upskilling the nurse practitioner to do what a primary care doctor did and was assured to primary care docs, to being part of innovation.

There are several examples. It started as MakerNurse where nurses see challenges in the clinic and they solved them with macgyvered systems and now can scale them through 3D printing and democratized platforms, which also leads to democratizing healthcare. There are good examples now. A community health worker with a $50 or $25 smart tablet can collect data, can do diagnostics, might have a pocket ultrasound or other device that are coming to market, and can give them the ability to interact with the community and do smart diagnosis and triage. Then when they need care, may not need to send them 100 miles walking to the city or central village. They can mediate some of that with an AI assist or with telemedicine type visits.

Tremendous ability to democratize healthcare and I think that's one of the great potentials of the fact that we all now have smart apps that can integrate our data, show us when we're off track, and make us, each as individuals, empowered to be on top of our health, not waiting for the problem to happen. That can be globalized and can play a key role in preventing the next pandemic as well. That means it's patients included, nurses included, doctors included. All of us can be helping create the future of healthcare.

XPRIZE Pandemic Alliance Task Force

Michael Krigsman: What about things like COVID testing? The word that came to mind starts with cluster and ends with something that we probably shouldn't say, although why not? I will say it. You know it's been such a clusterfuck. What can be done about that? I bring that up because it's just such a practical problem that affects every person who is listening.

Dr. Daniel Kraft:   Absolutely. The key thing to getting ahead of a pandemic or stopping one is to have smart identification, isolation, and quarantine. Contact tracing is the key term, but that's driven by testing. Some of our regulations have slowed down. Better tests, the ones we have now that often take several days to come back, are over $100.

I've been chairing the XPRIZE Pandemic Alliance Task Force and have worked with Jeff Huber, who is the founder of GRAIL, and started OpenCovidScreen. With XPRIZE, we've now launched an XPRIZE for rapid or fast, frequent, cheap, and easy, FFCE. Fast, frequent, cheap, and easy, that's the hashtag #FFCE. To be apprised to make tests under $5 in an hour or less that can be done multiple times a week at a school or workplace to get us back to normal life and to identify cases when you're asymptomatic. That's an example of leveraging an innovation prize to get things to move and scale faster.

There are some pretty exciting, fast, frequent, cheap, and easy tests that are coming to market now as well. That blends with our regulatory needs. To get out of our cluster, we need to have the ability to do fast, frequent, cheap, and easy testing. You can go to xprize.org/testing to learn more about the prize.

We've had over 450 teams already enter the preliminary registration and we're going to hopefully then find, test the tests, and scale the winners very quickly. That might play a role for this pandemic but, hopefully, if we need it in the next ones, to have those sorts of tests, molecular or otherwise, spit in a tube, have the result fast and easy. That's critical as part of our cluster. Part of it, again, is going to be smart public policy, funding, and mindset.

Michael Krigsman: There has been so much attention and resources paid to the problem of testing by so many different companies and governments without a lot of, as far as I can see as a layman, a lot of apparent success given how screwed up everything is right now. Why will your approach with the XPRIZE produce results that are better and faster than just what's going on in out there in the marketplace today?

Dr. Daniel Kraft:   Well, prizes can often help speed things up. One of the early prizes was to cross the Atlantic, which Lindbergh won. That incentivized steam. That opened up transatlantic travel.

The first XPRIZE, the Ansari XPRIZE, was the first rocket to space that was privately done. That's catalyzed SpaceX and many other endeavors.

Part of what it does is sets some rules out there for fast, frequent, cheap, and easy testing. It gets people to compete and then often collaborate. Then we help support the teams from the regulatory perspective, from the scale perspective, from the funding perspective so that the best tests that meet the criteria can accelerate into market and get the attention and funding they deserve.

If we move up the ability to get 50 million tests in the United States every day up by a month, that will definitely save lives, shorten the pandemic, and have economic impact. Sometimes, it's about aligning. It's $5 million of prizes. It's not a lot in the big picture, but it gets a lot of people really thinking and motivated. Again, often teams combine.

I helped come up with the medical Tricorder XPRIZE a few years ago that was won. A lot of teams converged and now we have, coming to market soon, the equivalent of a medical tricorder to do home-based diagnostics and triage. It's often about setting audacious but achievable goals and helping speed them up when the market could use a little bit of a nudge.

Michael Krigsman: We have another question from Arsalan Khan who asks, "We talked about connected healthcare but the change has been so difficult since connected means across borders and tech is not the same across different countries. How do we develop some type of baseline healthcare technology that's available more broadly?"

Dr. Daniel Kraft:   We have challenges even state-to-state let alone hospital-to-hospital. Telehealth is required usually to be licensed in every state you're practicing in. That's hopefully going to get shifted in the United States, let alone different countries.

I think we need a baseline. I like to call it moving from quantified self where you can collect your heart rate data in your sleep, which is all great to know and can change your personal habits. Quantified self to quantified health where connected data can start to flow to your clinician in meaningful ways that aren't overwhelming and integrate with their workflow.

I've just been building out a new platform called Digital.Health. That's the website. It's still very early. A place for, eventually, clinicians to find and prescribe connected health technologies, whether it's a connected blood pressure or an app to quit smoking or a mindfulness app or a diabetes prevention program. But I think we can democratize some of these around the planet and learn.

We don't need to keep building lots of widgets. It's a matter of building the ones that work and having a data flow, closing the loop because most clinicians—we talked about this a bit—don't want to see your heart rate data or every little hiccup or sleep information. They want to see the actionable information in a way that integrates in.

"Oh, I've got a thousand patients in my panel. There are the three that the blood pressure or blood sugar are out of whack. We need to call them proactively." That needs a lot of smart not just technology but policy and folks like Russ, Sue, and others building that into their healthcare systems for the nurses, the doctors, and patients together.

Michael Krigsman: The other day, I had a test denied by my health insurance provider and I pay these guys. I won't say how much, but it's literally over a few tens of thousands of dollars a year. I mean it's insane. I said to them that I will pursue this to the ends of the earth until the day I die, because I felt I needed this test. I did and it took me a long time and they finally agreed. How is it that this is happening and what can we do about that? I realize you're not a healthcare economist, but what do we do?

Dr. Daniel Kraft:   Oh, it's so crazy. Even in my own personal and family health, the smallest things, it's just so hard to even understand your medical bill let alone your insurance plan, gold versus blue, and what's reimbursed and not. We need health education as well as financial education.

I think part of what we need to almost think about is—it's overused—the uberization of healthcare, which is starting to happen. It used to be a hassle to get a taxi and then flag them down and have a paper receipt. Now it's connecting the dots between things that these companies didn't invent: mobile, GPS, online payments.

Some of the winners that are coming to market are redesigning that experience for you as an insurance member, so it makes it more streamlined that you're not stuck on the phone or looking at fax reports and battling. I don't know. Your particular challenge of getting something approved is very, very common and it's so hard to get through all those phone numbers and emails to get an answer. I think we need to uberize that platform. That means smarter chatbots better designed to match you and your personality and education rather than one size fits all, but a huge conundrum.

I think the more we can streamline the rails and get rid of the friction in healthcare, the better we can spend time on the actual care part. A lot of that is not from future technologies but what we have now. Just putting them together in ways that are smart, engaging, and value-driving, and not crazy-making.

Michael Krigsman: Getting rid of the friction and that would require then aligning financial incentives in a way that is completely out of whack today.

Dr. Daniel Kraft:   Well, there's this payments chart of the number of doctors, let's say, doubling over the last couple decades but the number of administrators going up like this. You get rid of that friction; you're taking away someone's paycheck because that's how a lot of the money is made.

Companies like Amazon, they're famously getting into healthcare. Still with their challenges, are able to sometimes get rid of the middlemen. That's threatening to a lot of providers.

We're seeing the CVSs and Walmarts and others build healthcare hubs at their local pharmacies. That's disruptive because you can get care done at lower prices. People are going to go where it's easy and where it feels connected and it feels that it's entered the Fourth Industrial Age. You know, how we get our banking done and get our movies feels pretty natural. Healthcare, again, is still stuck on waiting on hold.

I even had my own tele-visit follow-up for a primary care visit but I still had to get four phone calls from my local healthcare team to set up the voice call. Those little layers will get improved. It's starting to happen and it's all about, again, not being stuck in our old mindsets, thinking at least accelerating things, not just always exponentially, and solving for the actual pain points, not just first shiny new object, app, device, or wearable.

Michael Krigsman: I love that, solving for the actual pain point. Combine that with patient experience all across the board throughout the patient lifecycle and, boy, that would sure revolutionize our healthcare system. We're just out of time. Any final thoughts, Daniel, that we haven't spoken about? There's been so much. I wish we did have a few more hours. Any final thoughts?

Dr. Daniel Kraft:   Maybe back to your pain point. All experienced pain points, whether it's challenges getting a test approved or tracking your mother's health or medication adherence, to better forms of detecting cancer. Many folks listening out there have built incredible technologies and platforms and see their own personal or other problems, whether it's in their own life or friends, family, or business members. I think we can all start to work collaboratively.

Platforms like Exponential Medicine are open to everybody, so it's a team sport. Again, we have a lot of power in our hands to reshape things if we align the incentives, the technology, the people, the design, the workflow to kind of talk healthcare and advance it to where it can be and where it should be.

Michael Krigsman: Daniel, if people want to look you up, what's the best URL or the best place to find you and learn about your work?

Dr. Daniel Kraft:   I try and put everything at danielkraftmd.net. You can follow me on Twitter, @daniel_kraft. If you go to exponentialmedicine.com, sign up for the newsletter, or exponentialmedicine.com/videos for lots of great content from a prior year. We're hoping to have a virtual ExMed, Exponential Medicine, later this fall, so keep your eye out for that. We've always live-streamed those and made those open to everybody because we don't want to have different tiers of access. We want to have a big tent for healthcare catalyzation and improvement.

Michael Krigsman: All right. I would like to thank Daniel Kraft. Daniel, thank you so much for being here today.

Dr. Daniel Kraft:   Thank you.

Michael Krigsman: Okay. Everybody watching, thank you for watching and particularly to those folks who asked questions. Before you go, I must ask a favor. Subscribe to our YouTube channel and hit the subscribe button at the top of our website so you can get our most excellent newsletter. Thanks a lot, everybody. We have awesome shows coming up. The fall season is amazing. Check out CXOTalk.com and we'll see you again soon. Have a great day, everybody. Bye-bye.

This transcript was edited lightly for clarity.

Background

Dr. Daniel Kraft:   A theme has been, how do we think differently about health, medicine, and technology and the convergence? How might we reimagine the near future and the distant future of healthcare?

Michael Krigsman: Daniel Kraft is a physician and an inventor who wants to transform healthcare.

Dr. Daniel Kraft:   Well, the term "exponential" is usually referred to think about the pace of change. Most of us know linear thinking: one, two, three, four five. Exponential thinking is when you double every step: 2, 4, 8, 16, 32, 64, et cetera. By 15 steps, you're about 32,000 but, by your 30th exponential step, you're at a billion. That would be, if you were taking a step, by a meter, that's 26 times around the planet.

That's usually something hard for our brains to kind of grok how quickly technologies can accelerate. The one most folks are familiar with is Moore's law, which is why our supercomputers in our pocket are pretty incredible in terms of what they're able to do. They're better than a Cray supercomputer by many orders of magnitude.

This is my antique iPhone 2 from 11 years ago when, 11 years ago, it seemed amazing and now it still works. It feels slow and clunky and a low-resolution camera. In 10 years, my iPhone 11 will feel slow and clunky or be embedded in my Apple AR glasses.

Part of the theme of exponential medicine, in general, is not about any one technology accelerating from not just digital and Moore's law and computation, but what's happening in synthetic biology and low-cost genomics to big data, AI, nanotech, and virtual reality. Some of them are just moving quickly. Some of them are moving exponentially.

The most exciting part, which I love to kind of curate, is the convergence. When you mash things up that are getting faster, cheaper, better, how do you use those to reformat how we do virtualized care, cancer diagnostics, or contact tracing? That's a bit of the theme. It's not just about pure exponentials but getting people to think a couple of clicks of Moore's law forward because that has huge implications about how we want to set up our healthcare systems for today and what's coming next.

Convergence across healthcare industry disciplines

Michael Krigsman: You mention the term "convergence," so I'm assuming that an important part of this—and correct me if I'm wrong—is the bringing together of folks from different medical disciplines. Would that be an accurate way of describing it?

Dr. Daniel Kraft:   Yeah, absolutely. I found out when we were starting Exponential Medicine ten years ago. I'm trained as an oncologist, hematology/oncology, I'll go to the ASH, American Society of Hematology, meetings and the cardiologists go to the American Cardiology and the gastro folks go and the pharma folks go. Things get very, very siloed and it's very rare that you bring clinicians, researchers, technologists, investors, patients, nurses, and healthcare administrators together to kind of go, "Wow, what really is cutting edge? What's happening now?" Many folks have no clue what's already here let alone what's coming and, again, that sort of blending.

Also, at Exponential Medicine, we had, I think, last year, 45 countries, so a lot of things happen asynchronously in different parts of the world and we can learn from things that are happening in the NHS, Israel, China, or even Latin America and vice versa and cross-catalyze. To open up the thinking and mindsets as well.

It's not often about the technology. It's how we blend those with incentives and the often misaligned incentives in the healthcare systems around the planet.

Michael Krigsman: If we go to a hospital today, the bastions of traditional medicine, a patient comes in is seen by the oncologist and then various specialties. It seems to me that we already have that blending, so how is what you're describing different from what's taking place now, everywhere?

Dr. Daniel Kraft:   What takes place today, most everywhere, is not really health care or the care side. It's really the sick side of the equation, sick care. That's based on our traditional model where you go to see the oncologist or your doctor in the primary care clinic or, God forbid, the emergency room or intensive care unit. That's where care happens. That's where your data is collected, whether it's your vital signs or your labs.

We end up with very intermittent, reactive, sick care. We get the data in a siloed way. The 0.0001% of the time you happen to be seeing a clinician of some sort, and that leads to our reactive system where we wait for the patient to show up with a heart attack, stroke, or late-stage cancer, or the pandemic to arrive.

Where that hopefully is starting to shift is now starting to leverage some of the more Internet of medical things, the connected data, the continuous healthcare exhaust that can be picked up from our wearables and our environments to then being much more proactive, to identify problems early, to optimize your health and wellness, to diagnose something early or then to manage a disease if you have it, whether it's diabetes, hypertension, or cancer.

There's been a shift, I think. There's amazing technology in individuals and systems, but they're very disparate and the data often is disconnected. Even though we're in this exponential age, the data doesn't talk to each other. It's still stuck on fax machines as a bottleneck.

I went to have a cardiac study a few months ago. The only way I could get my results at home was on a CD-ROM. I don't even own a CD-ROM player anymore, so we have a lot of old technologies, whether it's a fax machine or CD-ROM and paper forms still in the cogs of our sick care model.

Michael Krigsman: Why are we stuck using fax machines and CD-ROMs?

Dr. Daniel Kraft:   Well, there's a big layer. Again, some incredible things are happening but often our regulatory and reimbursement rules are stuck in our analog age and are just starting to catch up to our digital. How many of us had to fax and sign a medical release, get it to the medical records, get them to fax it to another hospital? That might be very time-sensitive.

There's always HIPAA laws that are well-meaning that are supposed for portability, but they've become overly layered and encumbrance in privacy. I would argue the patient would rather be alive than with their privacy intact. I've seen many examples where the fear and the inability to transmit data and information has had dire outcomes or hindered smart innovation. We definitely need to focus on smart privacy but sometimes there's an over-fear element in that regard and the regulations often haven't kept up.

That's why we're still stuck on fax machines because that's the old regs and some of that, again, is international standards and some are even state-to-state in the United States. Lots of challenges to do what we call often interoperability from one medical record system to talk to another or for your ability to get your chest x-ray or your labs to you in a sharable way where you own your data, can be much more empowered to make sense of that, and can be more of a copilot in your care if you're a patient.

If you're a clinician, to use this new connected world to gather not just the data but the actual information so you can use that and even get paid for it, aligning the incentives to use some of these new technologies to really amplify and improve what's called "value-based outcomes" where you pay for outcomes when they're better. The drug, the app, the digiceutical, the gene therapy are increasingly only going to get paid for when they work. It's about the technology, also aligning incentives; that means follow the money, in most cases.

About exponential medicine

Michael Krigsman: You have this conference that you've been running for a number of years now entitled "Exponential Medicine" and you bring together a very interesting cast of participants. What's the underlying set of decisions that you're making in terms of how you bring these folks together and how does this relate to what you were just describing?

Dr. Daniel Kraft:   I think I'm fortunate I live here in Silicon Valley, despite our current fires and earthquake risk, to see a lot of things hopefully a little bit early, whether that's next-generation VR or 3D printing, or in travels around the world, when we used to travel, bump into very interesting people, technologies, and ideas.

My favorite thing in terms of curating exponential medicine and, if you go to exponentialmedicine.com/videos, you can see a tremendous array of amazing thought leaders, technologies, and ideas. But often, it's finding not the obvious folks, not the folks who are famous scientists, investors, or technologists, but to find things that are a little bit early.

One example of a technology that's at the convergence of exponential—and I have it over here—is virtual and augmented reality. I've got my Oculus Quest here that some of you might have at home now. Incredible amounts of technology for $300, $400. That starts as a gaming platform and it's wonderful for gaming. I've done 100 days straight of VR-based exercise, as an aside.

A few years ago, I met a young surgeon who had built the first VR training platform for orthopedic surgeons. You go into the VR headset and you're now in the operating room with the actual instruments from Stryker or a different company. You can practice a procedure, whether you're an orthopedic surgeon or not, and learn how to do that. Just like a flight simulator for pilots—I'm a pilot as well—you can drain for very difficult circumstances, bad weather, bad outcomes, and you're seeing that early and bringing that to the stage, you know, four years ago.

Now, it becomes sort of obvious. That company is advanced, called Osso VR, to the point where they've now done randomized trials showing physicians training on VR getting much better, much faster with their outcomes. It's finding things a bit early and then also showing examples that are not always traditional medicine, things that are outside of the norm to some degree, like psychedelics being used for treating PTSD or end of life care, and that's going through MAPS, going through phase 3 clinical trials with dramatic input, so those are fun.

We also blend in music and art, and everything from mindfulness, which relates to neuroscience, to music, to chakra shaman ceremonies. We get people a little bit out of their usual headspace, and that's where some of the interesting blending and connections happen outside of your usual button-down kind of conference.

Michael Krigsman: As I was looking at the attendee list from some of the past years. I found it striking that you have, among those folks, senior executives from traditional healthcare as well as senior execs from major pharma companies. Given the state of healthcare today, how can we start to integrate the things you're describing into our healthcare system? It seems like an enormous gap and pretty hard to do.

Dr. Daniel Kraft:   Particularly in the United States, there's no one healthcare system. There are thousands of types of systems, many of which are designed differently, and some are sort of aligned as a payor player. I mean Kaiser, Geisinger, or VA, the clinicians there or the system is not paid per procedure or per admission. They're aligned with, hopefully, being proactive and preventative.

Big healthcare systems, just like big companies, often have trouble innovating, innovating at scale. One of the nice things about coming to Exponential Medicine or getting in the mix is, it opens your mind to what's here or what's coming.

Often, again, it's not about the technology but how you integrate it in. Design thinking, how you might redesign your clinic so the waiting rooms, the patient stays in one room; the medical team comes to them. How you think about the design elements of how you communicate differently to a baby boomer versus a millennial and learning from others.

When you're coming from big pharma, especially, those are big ships and slow to move. No one wants to be the disruptee. You want to be the disruptor. No one wants to be the next Kodak or Blockbuster.

We always overuse the phrase, "You want to Uber yourself before you get Kodaked." We hopefully open the eyes and sometimes scare folks a bit, like, "Wow. If we don't get ahead of the curve here or start thinking a little more proactively and innovatively, we're going to be left in the dusk by the next generation payment models or virtualized care systems, et cetera." It's often a challenge for people to get out of their silos and that's what we try and do is break open the silos and connect the dots.

Transformation and traditional healthcare

Michael Krigsman: When you're speaking with, again, senior folks, decision-makers, innovators from traditional medicine and healthcare and pharma, what's the reception that they have to the things that you're describing?

Dr. Daniel Kraft:   Sometimes, it's a bit of shock and awe, like, "Oh, my gosh. We're behind the curve." Others are trying to do things like a chief innovation officer or someone who is very forward-thinking inside of a larger organization and it's hard to bring their folks along.

Back to the Kodak example, Kodak invented digital photography. It was invented there, but they didn't want to cut into their film sales because maybe the VP of film was blocking things out.

Sometimes, it's a matter of sparking leadership inside of a traditional organization and getting them to think about how do you accelerate some of these things internally with their five- or ten-year plan because, if you're doing your ten-year plan with the mindset of 2020 and not thinking about where AI, robotics, 3D printing, nanotech, genomics, and crowdsourcing are going to be, you're not going to be making a very good plan. Plans change, but you need to be somewhat, again, not on the linear track but the exponential.

I think sometimes it spurs some new thinking. A lot of the cross-fertilization that happens, we've had the head of innovation from National Health Service come for several years. He got spooled up and built a young entrepreneur physician or clinician program in the U.K. and that started a bunch of their docs and clinicians starting to go, "Wow! Here's a problem. I might be able to solve that and then role that out at the scale of the NHS."

Part of what I love about Exponential Medicine is it's catalyzed a lot of next-generation innovations that I don't even know about all of them. Part of it, again, is about understanding technology, where it's heading, their convergence, what's possible today, and what's coming next, and how to see a pain point and solve for that not just with what's in your pocket today but what you'll be able to do with next-gen systems, and those next-generation systems are coming quickly.

Digital transformation in healthcare

Michael Krigsman: Are we talking then about healthcare, technology, or business disruption?

Dr. Daniel Kraft:   I think it's a bit of all of it, right? It's also psychology. Again, moving the cheese is sometimes hard. If you create a new app, service, or platform that a good example might be virtualized angiograms where you can now do a 30-second CT scan, send the data to the cloud, it'll reconstruct your coronary blood vessels. It's gone through the FDA, et cetera. A company called HeartFlow.

But is that going to be exciting to the interventional cardiologist who gets paid to do those procedures or the hospital itself that makes a lot of money from doing diagnostics in the cath lab? That's a business model meets technology meets mindset. I think it's a blend of all those.

Frankly, the old models of healthcare were medical devices and drugs. Now, in the last decade or so, we have AI-based drug discovery. We have robotic surgery. We have digiceuticals. We have virtualized care. We have fields that have built at the interface that didn't even exist, in some cases, 10 or 20 years ago, and so it's business models meets innovation.

Then where the money hits the road, how do you pay for these things? There are a lot of great apps, devices, platforms, gene therapies that just don't ever get out of the gate because of misaligned incentives.

Michael Krigsman: From that standpoint, this is really not much different than any other business innovation problem where you're looking at disruptive technologies and trying to figure out how do we bring those into the market.

Dr. Daniel Kraft:   Except that you've now got the added layers of lives are at stake and it's not like you can just ship a new software version or print a new widget. You've got to go through regulatory.

To their credit, the FDA has now been getting out of their linear mindset. We've had Bakul Patel, Head of Digital for FDA, come to Exponential Medicine several times and, through workshops and other outside elements, go, "Well, what's coming and how do they now build a software and medical device platform for speeding up how you might think about the app controlling your insulin pump using AI machine learning?" or a precheck platform. If you're a well-established startup or company, you don't have to go through every hoop every single time and send in PDF books of your trials.

I think it's about bringing all these folks together, including the patient population. My friend Lucien Engelen calls it Patients Included or Nurses Included. You need to bring often the caregivers and the patients who are the need-knowers when you're solving a problem.

When I was a fellow at Stanford in hematology, oncology, and bone marrow transplant, I was part of the very first year of a program called Stanford Biodesign, which brings together medical folks, engineering, and law. In the first third of the year, you're just looking for problems to solve and really understanding them because many folks will build it and no one is going to come because it doesn't work with a nurse or fit into the medical records system or the payment model.

For anybody out there, many of you are nonmedical, you've got incredible skills in platforms and blockchain, gaming, design, IT, or apps that may have never been applied to healthcare. But if you find a pain point, particularly when you collaborate with clinicians, patients, and caregivers, a lot of things can move quickly. But you also have to understand and engage the regulatory process at the same time.

Michael Krigsman: It's bringing together of the technology, addressing the economic aspects, addressing the patient experience, the regulatory aspects, the business model aspects, and these are the kind of building blocks, could we say, who are driving healthcare change, essentially.

Dr. Daniel Kraft:   Right, and all those are moving parts. Now we're in the setting over COVID. We're speaking now in August of 2020. A lot of things have been catalyzed in sometimes good ways by the COVID pandemic. Virtualized care is an obvious one. I think, in April of 2020, the number of virtual visits when up by 1000% and maybe have come down a bit.

Now, because HIPAA got relaxed so you could do Zoom-based virtualized calls that weren't against the law and reimbursement models matched so you could get paid to do a virtual visit, those have exploded and the genie is out of the bottle and I don't think it's ever going to go completely back in because now we're able to see the value of not just a Zoom call for business but, in many cases, for a clinical encounter because you don't often need to lay on hands for every follow-up visit.

The ability to add connected devices is the future of virtual visits so it's not just the doctor or nurse on the screen. You can look at your Fitbit or your Apple Watch data or you're connected to a stethoscope or home ultrasound and use that as part of your care. Asynchronous chatbots, which can do early triage. Is that cough related to COVID or the flu? Bring in-home diagnostic platforms that could do labs or use your voice to diagnose conditions.

Lots of things are converging and being accelerated is a bit of the silver lining, as well as the speed and pace of taking all this data and moving it from data to information, actionable information. Then narrowing the gap from knowing that actual information the clinic, like, how do you manage a sick COVID patient in the intensive care unit?

Lessons from Wuhan, China, and from Italy, and from the ICUs in New York City are now distributed across the U.S. and the world. There is an acceleration of collaboration as well because it often is a long journey between something becoming known and being standard of care.

Michael Krigsman: The other day, I was party to a conversation between two physicians discussing a patient and one physician said to the other, "Oh, yes. I have to get this information." A question was asked. "I have to get this information," and he was looking through the chart and couldn't really find it. The other physician said, "Oh, yeah. I also prefer the paper records." The first physician said, "Yeah, you know, well, that's what I'm used to using."

Dr. Daniel Kraft:   That's a great example. I'm sort of that digital, bridging the digital divide. I got my first mobile phone when I was a medical resident. When I grew up, we didn't have Twitter or Facebook, or email when I was an undergraduate. Now you have folks graduating medical school who completely grew up on all these platforms.

Yes, there are some benefits to just looking through a paper chart. I started in paper charts. Then you go to digital and that has pluses and minuses.

A great example, Dr. Bob Wachter, who chairs medicine at UCSF, gives a great example of when I trained. You go to radiology rounds. You go to the radiologist with the whole team and you look at the actual physical x-rays. You put them on the light board, you look at them, and you have a discussion.

Now, in the digital age, you can look at your x-rays on your mobile phone or a computer and you miss that sort of interaction piece. There's something that changes in this element of interaction and sometimes solving problems.

Then there's the issue of, you can digitize a medical record. Unfortunately, that's what the problem is with our EMRs, things like Epic, Cerner, Allscripts. They've become basically digital versions of a long list of what used to be written by hand and they don't really add to your cognition. They can get in the way. Too many clicks. There's burnout from trying to just enter data.

I'm hopeful, whatever solution, a lot of these exponential solutions need to be integrated into the workflow of the doctor, the nurse, the pharmacist because there's so much friction, whether it's fax machines or CD-ROMs, just to be able to synthesize.

My favorite example that most people kind of get is, 15 years ago, we all used to drive with paper maps and now you couldn't imagine driving without Google Maps or Waze where we're crowdsourcing our data. Our private speed and location build the driving map that's hyperlocal. Imagine our electronic medical record systems and our personal record systems are building a bit of our own personal Google Map or Waze to take us on our healthcare journey, whether it's for our patients or for ourselves, that is gleaning knowledge from other patients like me or patients like mine on the genomic level, on the sociome level, on the digital exhaust level. There are a lot of challenges to make the technology integrate with actual clinical care that goes all the way down to your medical record and eventually using AI, machine learning, et cetera to really upskill the doctor, the nurse, or the community health worker to use that at the point of care in much more impactful ways.

One of the points of exponential medicine in general is, how do we democratize healthcare and improve health equity? There's a lot of disparity and that can be definitely improved using something as common as a smartphone.

Exponential medicine and culture

Michael Krigsman: We have a question from Twitter. Exponential medicine isn't just about technology and science, but it's about ways of working.

Dr. Daniel Kraft:   Sometimes people tell us at the conference, which we have at the Hotel del Coronado in San Diego, when we're in real life, on the beach, it's sort of like Burning Man meets a medical conference. Sometimes it's, how do you work together out of the usual silos of title and rank all the way to how do you interact at a conference at a silent disco or doing an unconference where people are sharing things in new ways?

I think we do need new ways of working together. Part of that can be facilitated by the connection digital, virtual layer. In the cancer world, we can now think about doing virtual tumor boards where might bring the oncologist, the radiologist, the pathologist together, and then also look at the data from their digitized slide and using AI machine learning. Have a thousand experts around the table virtually in terms of learned information.

New ways of doing asynchronous care. We just did a series with UCSF called "Hospital to Home." I like to call it hospital to homespital. All these new ways of doing remote patient monitoring, so whether it's an Internet of Things type medical device or sensor in your underwear band that can track your respiratory rate and your steps and shows you if you're getting into trouble from a pneumonia or COVID. How do you connect the dots on that for managing folks outside of the clinical realm? Something else that's been obviously catalyzed by COVID and that means we need new definitions of who does what where and when.

Transformation and medical education

Michael Krigsman: We have another question from Arsalan Khan. "Doctors can benefit greatly from learning technology during their education not only as an end-user but perhaps even as developers. Why hasn't the education system emphasized this enough?" He is raising the broader question of medical education, which seems like a really important part of this.

Dr. Daniel Kraft:   Medical education has not changed dramatically maybe a hundred or so years. Things were set up in the early 1900s to hopefully make medical education much more regulated, which makes some sense. But we're still picking medical students based on their ability to do well at organic chemistry and physics and not maybe on their ability to have engagement, empathy, decision-making, and maybe even manage apps and services because you need your memorization muscles less now than synthesis, potentially, going forward.

Part of this is who do we select for, let's say, medical school and how do you train them, not just for 2020, but they're going to be working into 2040, 2050? What skills do you need? How do you use some of these new platforms like virtual reality and augmented reality to vastly accelerate your ability to have a virtual patient in front of you?

There are several apps where you can pull up a virtual heart and play with it, learn its anatomy, walk through it, and add a heart attack, add a valve problem, or add a drug to treat it or a medical device. You can dramatically learn in new forums and even do that collaboratively. The opportunity reinvent continued medical education all the way back to how do we educate clinicians and, again, the ability, I think, to democratize and upskill folks.

If you're a nurse in a rural village in Rwanda, you can use one of the little tools, the Eko Stethoscope. It's a general stethoscope with an EKG. You can listen to heart sounds and potentially diagnose a heart murmur as good as a highly trained cardiologist. Blend in, again, the virtual coach that can come on your iPad and help you through sewing up a tough laceration or be inside the robotic surgeon surgery with you.

There are lots of ways we can do real-time, crowd-sourced, not just if you talk about a Waze or Google Maps for patients, but for clinicians as well to be always sort of virtually coached and seeing the map to a path forward clinically.

About patient experience and transformation

Michael Krigsman: Do clinicians even have the time and anything beyond a very broad, abstract interest in patient experience? Even to go further, if it's true that the body is essentially a set of mechanistic equations and chemical reactions, then why do you have this focus on design thinking, patient-centeredness, and everything else? Why don't you just train people and force them to learn better? That'll lead us to better healthcare and life will become simpler. We don't have to worry about all of this other stuff you're talking about.

Dr. Daniel Kraft:   We can always try and learn better and even how you can flip classroom education to gamifying education. There are now video games where you can learn, as a nonmedical person, do a full operation and do a heart transplant.

I think now there is just so much data. You have your digitone from your wearable devices like an Apple Watch or a Fitbit. Remember, Fitbit has only been out for 11 years. It's pretty new to the point we can measure almost every element of physiology and behavior from our wearables or insideables or our invisibles. Wi-fi can measure our data now.

That creates exponential data sets, including our genomics, our microbiome, our sociome, and the challenge in terms of learning is we can't learn it all. You can't read every paper. The amount of medical information is going up fast, so we need to leverage—it's over buzzwordy—AI, machine learning, and big data because AI is not going to be replace a doctor but the doctor using AI will replace those who don't – or the healthcare system. Pick your favorite specialty or any field. It's when you blend those together to give us the best insights.

A simple example would be: Okay, Michael. Let's say you have high cholesterol. Normally, I would just pick the standard dose of Lipitor. Hopefully, I could look at your microbiome because that might impact how you absorb Lipitor. I could look at your genomics from something as simple as 23 and Me to look at your pharmacogenomics to know that Lipitor is not the best drug for you because you're at high risk of muscle myopathy or inflammation. We need to skip to Simvastatin.

How do we then combine that with your blood pressure medicines that are personalized to you? What if we could 3D print those in a single medication so that, every morning, you take your combined blood pressure med, your statin, and the right amount of aspirin for you and even print that every morning, which is something I'm doing with a new startup called IntelliMedicine? We need to start to pull this together in ways that isn't just learning but is continually learning and, hopefully, surfacing the best information at the point of care to the patient and the system around them.

Healthcare policy and transformation

Michael Krigsman: Dr. Rasu Shrestha makes this comment. He says, "Policy has always been a big catalyst for tectonic shifts in healthcare in the United States. With the elections around the corner, do you see opportunities to exponentially move forward with the right policy catalysts?"

Dr. Daniel Kraft:   Yeah, you can't get a lot of this out of the gate. We can just look at our current predicament in COVID. A lot of our challenges in testing, et cetera, were based on bad regulatory or policy decisions that slowed up testing or other elements.

Exponentially changing things might be always difficult in healthcare, but I'm hopeful. I'll show my biases that we have a new administration come January that's much more forward-thinking, can align what we need to do next in policy to reward not just healthcare, but sick care. We're paying for prevention, for public health, thinking about new models.

I like the idea I came up with a colleague of mine of a global public health corps where you could volunteer, just like an EMT or fireman, to be your local public health servant and use all these technologies to do contact tracing and address social disparities. A lot of that does come from the policy level and how we pay for things at the NIH level, the NSF level, and beyond.

We need smart, exponential mindsets to shift policies so that these exponential technologies can come together and really shift things because we have so much room to go. We spend more per capita in the United States for an individual that have 20th in terms of lifespan, so we have a long way to go to align our technologies and our capabilities, and that requires leadership and smart policy.

Michael Krigsman: We have another question from Twitter. You can see I prioritize the questions from Twitter over my own. Very often, the questions from Twitter are better than the ones that I have because they are from practitioners in the field such as Shawna Butler, RN. Shawna says, "How is exponential medicine catalyzing cross-disciplinary teams and making health innovation a team sport that has a variety of new and unexpected players?" She also is asking, "How are we innovating for the "bottom billion" that don't have access to high-tech healthcare?" Two questions, the cross-disciplinary teams and innovating to help the remainder of the world that doesn't have access to all of this high-tech.

Dr. Daniel Kraft:   It's not just about the traditional doctor or health administrator. We need to, as Shawna has proposed, accelerate nurses being involved, physical therapists, the team element so that we're all upskilling the nurse practitioner to do what a primary care doctor did and was assured to primary care docs, to being part of innovation.

There are several examples. It started as MakerNurse where nurses see challenges in the clinic and they solved them with macgyvered systems and now can scale them through 3D printing and democratized platforms, which also leads to democratizing healthcare. There are good examples now. A community health worker with a $50 or $25 smart tablet can collect data, can do diagnostics, might have a pocket ultrasound or other device that are coming to market, and can give them the ability to interact with the community and do smart diagnosis and triage. Then when they need care, may not need to send them 100 miles walking to the city or central village. They can mediate some of that with an AI assist or with telemedicine type visits.

Tremendous ability to democratize healthcare and I think that's one of the great potentials of the fact that we all now have smart apps that can integrate our data, show us when we're off track, and make us, each as individuals, empowered to be on top of our health, not waiting for the problem to happen. That can be globalized and can play a key role in preventing the next pandemic as well. That means it's patients included, nurses included, doctors included. All of us can be helping create the future of healthcare.

XPRIZE Pandemic Alliance Task Force

Michael Krigsman: What about things like COVID testing? The word that came to mind starts with cluster and ends with something that we probably shouldn't say, although why not? I will say it. You know it's been such a clusterfuck. What can be done about that? I bring that up because it's just such a practical problem that affects every person who is listening.

Dr. Daniel Kraft:   Absolutely. The key thing to getting ahead of a pandemic or stopping one is to have smart identification, isolation, and quarantine. Contact tracing is the key term, but that's driven by testing. Some of our regulations have slowed down. Better tests, the ones we have now that often take several days to come back, are over $100.

I've been chairing the XPRIZE Pandemic Alliance Task Force and have worked with Jeff Huber, who is the founder of GRAIL, and started OpenCovidScreen. With XPRIZE, we've now launched an XPRIZE for rapid or fast, frequent, cheap, and easy, FFCE. Fast, frequent, cheap, and easy, that's the hashtag #FFCE. To be apprised to make tests under $5 in an hour or less that can be done multiple times a week at a school or workplace to get us back to normal life and to identify cases when you're asymptomatic. That's an example of leveraging an innovation prize to get things to move and scale faster.

There are some pretty exciting, fast, frequent, cheap, and easy tests that are coming to market now as well. That blends with our regulatory needs. To get out of our cluster, we need to have the ability to do fast, frequent, cheap, and easy testing. You can go to xprize.org/testing to learn more about the prize.

We've had over 450 teams already enter the preliminary registration and we're going to hopefully then find, test the tests, and scale the winners very quickly. That might play a role for this pandemic but, hopefully, if we need it in the next ones, to have those sorts of tests, molecular or otherwise, spit in a tube, have the result fast and easy. That's critical as part of our cluster. Part of it, again, is going to be smart public policy, funding, and mindset.

Michael Krigsman: There has been so much attention and resources paid to the problem of testing by so many different companies and governments without a lot of, as far as I can see as a layman, a lot of apparent success given how screwed up everything is right now. Why will your approach with the XPRIZE produce results that are better and faster than just what's going on in out there in the marketplace today?

Dr. Daniel Kraft:   Well, prizes can often help speed things up. One of the early prizes was to cross the Atlantic, which Lindbergh won. That incentivized steam. That opened up transatlantic travel.

The first XPRIZE, the Ansari XPRIZE, was the first rocket to space that was privately done. That's catalyzed SpaceX and many other endeavors.

Part of what it does is sets some rules out there for fast, frequent, cheap, and easy testing. It gets people to compete and then often collaborate. Then we help support the teams from the regulatory perspective, from the scale perspective, from the funding perspective so that the best tests that meet the criteria can accelerate into market and get the attention and funding they deserve.

If we move up the ability to get 50 million tests in the United States every day up by a month, that will definitely save lives, shorten the pandemic, and have economic impact. Sometimes, it's about aligning. It's $5 million of prizes. It's not a lot in the big picture, but it gets a lot of people really thinking and motivated. Again, often teams combine.

I helped come up with the medical Tricorder XPRIZE a few years ago that was won. A lot of teams converged and now we have, coming to market soon, the equivalent of a medical tricorder to do home-based diagnostics and triage. It's often about setting audacious but achievable goals and helping speed them up when the market could use a little bit of a nudge.

Michael Krigsman: We have another question from Arsalan Khan who asks, "We talked about connected healthcare but the change has been so difficult since connected means across borders and tech is not the same across different countries. How do we develop some type of baseline healthcare technology that's available more broadly?"

Dr. Daniel Kraft:   We have challenges even state-to-state let alone hospital-to-hospital. Telehealth is required usually to be licensed in every state you're practicing in. That's hopefully going to get shifted in the United States, let alone different countries.

I think we need a baseline. I like to call it moving from quantified self where you can collect your heart rate data in your sleep, which is all great to know and can change your personal habits. Quantified self to quantified health where connected data can start to flow to your clinician in meaningful ways that aren't overwhelming and integrate with their workflow.

I've just been building out a new platform called Digital.Health. That's the website. It's still very early. A place for, eventually, clinicians to find and prescribe connected health technologies, whether it's a connected blood pressure or an app to quit smoking or a mindfulness app or a diabetes prevention program. But I think we can democratize some of these around the planet and learn.

We don't need to keep building lots of widgets. It's a matter of building the ones that work and having a data flow, closing the loop because most clinicians—we talked about this a bit—don't want to see your heart rate data or every little hiccup or sleep information. They want to see the actionable information in a way that integrates in.

"Oh, I've got a thousand patients in my panel. There are the three that the blood pressure or blood sugar are out of whack. We need to call them proactively." That needs a lot of smart not just technology but policy and folks like Russ, Sue, and others building that into their healthcare systems for the nurses, the doctors, and patients together.

Michael Krigsman: The other day, I had a test denied by my health insurance provider and I pay these guys. I won't say how much, but it's literally over a few tens of thousands of dollars a year. I mean it's insane. I said to them that I will pursue this to the ends of the earth until the day I die, because I felt I needed this test. I did and it took me a long time and they finally agreed. How is it that this is happening and what can we do about that? I realize you're not a healthcare economist, but what do we do?

Dr. Daniel Kraft:   Oh, it's so crazy. Even in my own personal and family health, the smallest things, it's just so hard to even understand your medical bill let alone your insurance plan, gold versus blue, and what's reimbursed and not. We need health education as well as financial education.

I think part of what we need to almost think about is—it's overused—the uberization of healthcare, which is starting to happen. It used to be a hassle to get a taxi and then flag them down and have a paper receipt. Now it's connecting the dots between things that these companies didn't invent: mobile, GPS, online payments.

Some of the winners that are coming to market are redesigning that experience for you as an insurance member, so it makes it more streamlined that you're not stuck on the phone or looking at fax reports and battling. I don't know. Your particular challenge of getting something approved is very, very common and it's so hard to get through all those phone numbers and emails to get an answer. I think we need to uberize that platform. That means smarter chatbots better designed to match you and your personality and education rather than one size fits all, but a huge conundrum.

I think the more we can streamline the rails and get rid of the friction in healthcare, the better we can spend time on the actual care part. A lot of that is not from future technologies but what we have now. Just putting them together in ways that are smart, engaging, and value-driving, and not crazy-making.

Michael Krigsman: Getting rid of the friction and that would require then aligning financial incentives in a way that is completely out of whack today.

Dr. Daniel Kraft:   Well, there's this payments chart of the number of doctors, let's say, doubling over the last couple decades but the number of administrators going up like this. You get rid of that friction; you're taking away someone's paycheck because that's how a lot of the money is made.

Companies like Amazon, they're famously getting into healthcare. Still with their challenges, are able to sometimes get rid of the middlemen. That's threatening to a lot of providers.

We're seeing the CVSs and Walmarts and others build healthcare hubs at their local pharmacies. That's disruptive because you can get care done at lower prices. People are going to go where it's easy and where it feels connected and it feels that it's entered the Fourth Industrial Age. You know, how we get our banking done and get our movies feels pretty natural. Healthcare, again, is still stuck on waiting on hold.

I even had my own tele-visit follow-up for a primary care visit but I still had to get four phone calls from my local healthcare team to set up the voice call. Those little layers will get improved. It's starting to happen and it's all about, again, not being stuck in our old mindsets, thinking at least accelerating things, not just always exponentially, and solving for the actual pain points, not just first shiny new object, app, device, or wearable.

Michael Krigsman: I love that, solving for the actual pain point. Combine that with patient experience all across the board throughout the patient lifecycle and, boy, that would sure revolutionize our healthcare system. We're just out of time. Any final thoughts, Daniel, that we haven't spoken about? There's been so much. I wish we did have a few more hours. Any final thoughts?

Dr. Daniel Kraft:   Maybe back to your pain point. All experienced pain points, whether it's challenges getting a test approved or tracking your mother's health or medication adherence, to better forms of detecting cancer. Many folks listening out there have built incredible technologies and platforms and see their own personal or other problems, whether it's in their own life or friends, family, or business members. I think we can all start to work collaboratively.

Platforms like Exponential Medicine are open to everybody, so it's a team sport. Again, we have a lot of power in our hands to reshape things if we align the incentives, the technology, the people, the design, the workflow to kind of talk healthcare and advance it to where it can be and where it should be.

Michael Krigsman: Daniel, if people want to look you up, what's the best URL or the best place to find you and learn about your work?

Dr. Daniel Kraft:   I try and put everything at danielkraftmd.net. You can follow me on Twitter, @daniel_kraft. If you go to exponentialmedicine.com, sign up for the newsletter, or exponentialmedicine.com/videos for lots of great content from a prior year. We're hoping to have a virtual ExMed, Exponential Medicine, later this fall, so keep your eye out for that. We've always live-streamed those and made those open to everybody because we don't want to have different tiers of access. We want to have a big tent for healthcare catalyzation and improvement.

Michael Krigsman: All right. I would like to thank Daniel Kraft. Daniel, thank you so much for being here today.

Dr. Daniel Kraft:   Thank you.

Michael Krigsman: Okay. Everybody watching, thank you for watching and particularly to those folks who asked questions. Before you go, I must ask a favor. Subscribe to our YouTube channel and hit the subscribe button at the top of our website so you can get our most excellent newsletter. Thanks a lot, everybody. We have awesome shows coming up. The fall season is amazing. Check out CXOTalk.com and we'll see you again soon. Have a great day, everybody. Bye-bye.