The Future of Research and the Complexity of Care

Q&A with Melissa Hortman, Microsoft Research Technology Strategist, and Dr. Chris Hewitt, Associate Program Director, EMS & Disaster Medicine Fellowship

I’m thankful to have Melissa Hortman joining the newsletter this week. Melissa has spent more than 15 years in healthcare research and academia; she currently serves as a Research Technology Strategist at Microsoft where she is focused on healthcare research innovation and client partnerships. I’m equally thankful, that Melissa’s brother, Dr. Chris Hewitt was in town visiting her family and agreed to join the conversation.

Chris, served as a PJ Medical Director and Flight Surgeon in the United States Air Force’s Combat Search and Rescue. Chris has also held leadership positions and fellowships in Emergency Medicine and Disaster Management, and Humanitarian Aid through while also supporting the city of Austin’s COVID pandemic response, and supporting the first American College of Surgeons verified Level 1 Trauma Center outside of North America (Abu Dhabi, UEA).

Here's a quick summary of my own top takeaways from this wonderfully insightful conversation.

• There is a significant amount of work still to be done in improving the general population’s health and finally turning the “inverted triangle” of healthcare in the United States right-side up. That’s not to say we don’t need the continued investments in specialty, rare disease, and geriatric care – but, we can asynchronously contribute to better population health prior to advanced ages.
• Healthcare research will continue to be a driving force in the healthcare delivery continuum. Researchers role is likely set to increase as greater collaboration will drive more centricity with care givers as the onset of “Learning Health Systems” change our current care paradigms.
• Improving healthcare delivery will require well-aligned and capable leaders at the federal, state, and community level working well with public, private, education and hospital system leaders.

Jake: Our conversations about healthcare delivery will look much different in the next decade – that’s largely driven by research, but until the Pandemic, medical research wasn’t in the forefront. Why is it the driving force of creating the future of healthcare?

Melissa: Chris, you should answer this one. You sit in the middle of research, academics, and healthcare delivery.

Chris: I believe a generational transformation is occurring right now and we’re in the middle of practicing medicine that way we have been for decades with your local physician and the next generation of care delivery that’s accelerated by a pace of learning that’s only recently possible.

In medical school 15 years ago, I remember the educational messaging of a good percentage of what I knew and what I would learn during my education was going to be proven wrong. Medical care evolves, it’s expected that we get better, but that’s accelerating with the personalized data we’re generating from wearables, technology improvements, AI, and the reality of data access that patients have prior to care. The population of patients that aren’t going to accept physician answers that are backed up with “because we’ve always done it this way” is growing.

Melissa: I’d add that the age of specialization has been aided greatly by research. Chris is speaking about the next layer of general (non-acute) care impacts. Most recently, research is leading the way into specialty care and physician specialization. Large hospital systems brands are built on quality, cutting-edge care and a large piece of making that a reality is the technology advancements that speed up translation research and connecting discovery and innovation with patient care and practice. You can’t have the cutting edge care that isn’t safe and effective; research delivers the certainty physicians, care systems, and patients need.

Chris: There’s another side to this research provability argument that’s a popular conversation right now and that’s Ozempic. We know, because of research efforts, that it’s proven to work safely in a population set that needs it to control diabetes. Then it was found to have an impact on appetite control and weight loss and now there’s a new population using it that weren’t part of these original efforts and we’re finding out there are other symptoms in this new population. Does anyone honestly know the long-term impacts of taking a diabetic medication when in a population that doesn’t have diabetes? Do we know what’s going to happen in 10 or 20 years and the metabolic impacts of taking that medication? This feels like an example where care is out ahead of research.

Jake: Three items that are a part of our conversations with academic medical centers and hospitals systems are population health, precision medicine, and speeding up research to care timelines. How do you believe we’ll find the right balance in saving lives now without causing future harm given the advancements in cloud, data platforms, and AI?

Melissa: The right balance is rotating around the need for rapid evolution in patient care. We need to democratize data to empower research teams and of course do so in a safe manner. Disparate systems, varying EMR strategies, and siloed environments make it challenging to unify data and that platform unification is what drives insights. Embracing digital across the research and care continuums in ways that allow entire systems, communities, and individual patients to increase access, improve their experiences, and enhance the healthcare outcomes they ultimately live with require an intense focus. Getting the focus right at the system level, which is obviously quite challenging, is where we will find the right balance in my opinion.

Jake: You mention system level challenges, the care model here in the United States isn’t one that is built to readily accept rapid innovation and change. Outside of the tight regulations, there is also a reality that the majority of health system transactions are fee-for-service based. That’s different than the value-based-care models that research is rapidly making more possible every day.

Chris: The right thing for every physician and caregiver is to maximize the potential health outcome while also minimizing long-term dependencies on treatments and care. How the system reconciles it’s revenue models with enhanced care models driven by research and technology in the next 20 years? That’s a tough question but we’ll have more right answers and certainty in terms of clinical care than we’ve ever had. I did an EMS fellowship and there’s oddly a lot of economics in emergency care. One way that we evaluated the care we provided was something called quality of life years. We needed to measure outcomes for EMS, it’s not just we picked up two people and we dropped them off at the hospital – we need to positively impact their care in a short period of time – sometimes critically.

Sometimes you needed to prevent a bad outcome so that they could lead a functional life, and that leads EMS professionals to certainly see the value in preventative care. Honestly, the highest value care we can provide is preventative care. You can take Pediatrics, we have this well-known “inverse-triangle” and everyone talks about it in healthcare. We severely undervalue early healthcare interventions and drastically over value late in life health care. Our health system was built to spend financial resources and effort at the end, unfortunately. The reality is that a disease process for many afflicted patients could have been prevented starting very early on, one area we see this recently is on lowered vaccine rates. Right now, kids are starting to show up with diseases that are preventable, even polio. All of this impacts the quality of life years that a person has.

It’s an odd way to measure but think about what could actually change economically if we had a productive population of people in their later years – healthy, high functioning, active older adults would drive additional economic value, not less. If we could spend our time in less doctor’s appointments, hospital visits, in a state of illness or lack of mobility by focusing on preventative care early and throughout our lives there’s a serious positive economic impact to be unlocked.

The military is actually a good example of this. They recognize that we are not better off with our experienced service members being broken down. Our military needs those highly trained and experienced team members out on the job, doing great work and being the sharpest knives in the military’s belt. That can’t happen if they are unhealthy. So, I believe we have flipped that triangle in some ways within the military but we are also dealing with a population of 2 million and 350 million.

Melissa: There is a driving connection between the need for health system changes that at some level are about the proper data strategies and utilization and current patient trends. I think that connection lives in the current patient desire to see more healthcare data that’s personalized and does help them be healthy throughout their lives, not just seek care for problems that exist in their later years. While it’s hard to combat the everybody is invincible in their 20’s mindset, we are seeing huge populations of people with wearable healthcare technology like Apple Watches, Whoops, Fitbits, and many more. Many more patients have exposure to their BMI, variable heart rates, their sleep and a lot more health trends. At the system level, it may not fix the challenge that doing preventative labs on a 26 year old pays little to no revenue, but the circumstances are changing as at least a percentage of the population is recognizing that need for personalized care throughout life. It’s still much easier to build revenue models around specialty care and treatment than preventative care, but the tides are turning.

Jake: What else might it take to get more of us seeing the doctor more regularly throughout lives, not just when we need them? I saw a Boston NPR survey done prior to the pandemic and the average time between visits for those under the age of 35 was nearly 27 months.

Melissa: As Chris said, that’s troubling. It’s basically setting yourself up to make the later years of your life less valuable with much less quality. Is economic benefit going to be enough? Can we say to people that coming to your normal visits, doing routine testing, and generally being up on your health is going to have a great economic benefit…yes, we certainly could and it’s true. But is it enough to get them to schedule an appointment? It may take another generation of people taking control of their health via wearables, creating vast amounts of personalized data, and enough stories of catastrophic healthcare outcomes prevented.

Chris: It’s an interesting concept to think about currently – if a patient has their personalized health data, can I see a chatbot AI doctor every quarter? Maybe get some questions answered, verify the dosage of my children’s medicine, and ask about a new mole?

Melissa: I think we could see this personalized health effort go even deeper into our daily lives. What about a personalized recommendation for dinner based on the families allergies and our health goals? Could that recommendation change based on our exercise level that day and even account for my kid’s taste preferences? It doesn’t seem impossible to me – when you get to that level of convenience, I don’t think that’s something you want to be left out of. Maybe that’s what brings people in to taking care of themselves and flipping that “inverted triangle” of care we have now.

Jake: I certainly wouldn’t mind my watch or phone taking a look at my calendar and my medical records and asking me if I was okay with it scheduling my general check-up appointment on a workable day and time. I would be fine letting it share my wearable data as well (at least as I think about it right now).

Chris: One challenging piece is who owns these improvements? Healthcare systems are one thing, but as you think about regions or country wide the need for direction is certainly going to require smart, effective leadership at the county, state, and federal levels. I worked with the City of Austin’s IT department during COVID; it was their entire focus and they did leverage technology for registering, tracking, and supporting community health efforts like vaccines and contact tracing. The pandemic was certainty a strong motivator, how do we keep expanding on those joint efforts to break through in varying communities is a question that needs to be asked.

Jake: Well that does it for our time – I appreciate you both taking the time to do this and of course sharing your thoughts with our readers.