Future Care: Sensors, Artificial Intelligence, and the Reinvention of Medicine

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EP LAB DIGEST. 2023;23(8):1,14-15.

For this episode of The EP Edit, EP Lab Digest’s Clinical Editor Bradley Knight, MD, talked with Jagmeet Singh, MD, about his new book, entitled Future Care: Sensors, Artificial Intelligence, and the Reinvention of Medicine.

Brad Knight: Hi, I am Brad Knight. I am the director of cardiac electrophysiology at Northwestern in Chicago and clinical editor of EP Lab Digest.

Jag Singh: I am Jag Singh, a cardiac electrophysiologist at Massachusetts General Hospital in Boston and a professor of medicine at Harvard Medical School.

Knight: I am grateful to be joined by my friend and colleague, Dr Jag Singh. He has recently written a book entitled Future Care, and I am very excited to spend some time with him to hear more about this. I can tell you it is very intriguing that an electrophysiologist has written a book like this. I find it very exciting that a colleague in my same field has really taken on a topic that is broad and has a lot of generalized applications.

But maybe we can start with the beginning of the book. I remember very well, at the beginning of the COVID-19 pandemic, learning that you were one of the first colleagues of ours, I think, who experienced COVID-19, and I think we all learned it through social media at the time. But you begin the book with that experience of being in the hospital with COVID-19. Maybe you can tell us more about that. Do you think that you would have ever written this book had you not been in that position?

Singh: Thanks, Brad. So, this is my first book. Obviously, I think both of us have written textbooks before, but writing a trade publication has been a phenomenal experience. I have thoroughly enjoyed it.

I started writing this book about a year before the COVID-19 pandemic, and my work in the realm of sensors and device innovations predated that by almost a decade-plus. So, the book was always bubbling over, and I think the COVID-19 experience probably helped catalyze the whole process, but I had done a fair amount of research work prior to the pandemic. With COVID-19, the acceleration and pace of the acceptance of digital technology accelerated significantly, so a lot of what I wrote was probably already outdated in a short period of time. But nevertheless, the book started before.

I believe my experience with COVID-19 really changed the tone with which I was writing the book. Having been a patient at the vantage point of looking at clinical care from the other side of the bed really influenced the way I changed my tone in writing, because now I could write it not just as a clinician, but also as a patient. One thing about the book is that it is an easy read, and a part of the fact that it is an easy read is because it is peppered and punctuated by several stories, both personal and patient stories, which really highlight the implementation of digital technology and what the right way of actually putting that into practice should be.

I think the important part about my experience with COVID-19 was that it allowed me to give a humanistic appeal to the book, because I think you can talk about digital innovation and you can talk about technology, but if there is no humanistic appeal, it really does not mean a whole lot.

Knight: Yes. There was humanistic appeal that you generated with these patient stories, which I found, interestingly, were beyond the topic of EP. You have a lot of stories about health care experiences that are not just within cardiology. The fact that you were in the hospital with a noncardiac problem makes this even broader in scope.

You divide this book very nicely into 4 categories. You talk about sensors, telemedicine—which had an explosive impact during the pandemic, artificial intelligence, and then the health care system itself. But you really start with the health care system we have and how broken it is. That is a very capturing read, because I think we all agree with that. Particularly, maybe it is true for electrophysiologists, maybe more so than other subspecialties, because we are very dependent on the hospital. We are dependent on the medical system, maybe more so than other physicians and other health care providers.

It is easy to talk about how broken the health care system is in the United States and the limitations. But to start this conversation, I want to ask you, would you have wanted to be in an intensive care unit (ICU) in any other country?

Singh: That is a nicely framed question. Let’s put it this way. I think there are lots of things in the US that work really well, but there are lots of things that can be done better. I think every country had a unique experience with COVID-19. Within the US, we found that there was a lot of disparity in care, and not every patient was able to get the same care that I received. I was very privileged to be in an academic center where I received the best possible care and did well. But I do not think the same has transpired across the country in all rural areas.

One of the things that was really highlighted during the pandemic was the inequity of care. The social determinants of health became a topic that we never talked about before, and now it was front and center. So, we learned a lot of lessons. I also believe that we are the most powerful nation and have the best health care system, but at the same time, we clearly do not have the same quality metrics compared to many other developed countries who spend half the money we spend on health care. So, the way we practice medicine is nonsustainable in the long term, and there are a lot of things that can change. Even though I am grateful for having received care here, I think there are lots of things that can be done better.

Knight: Maybe we will get to how we can make these changes, but you are right. I think the disparities in health care are why you are comfortable being in an ICU in the US. That would be my preference if I were quite sick. But it is very clear that there are haves and have-nots in this country, particularly in the health care system. I almost wonder if that makes things worse, that the people who are able to take advantage of the health care system in the US seem to not be motivated to change it for others. A good example is the trend of concierge medicine. I see a lot of primary care doctors going into concierge medicine. The people who have the resources to hire these physicians perpetuates this disparity and further demotivates those with the ability to make changes in our health care system to actually make those changes.

The topics that you cover start with sensors, and as an electrophysiologist, you have a lot of experience with that. Can you spend a little time on the topic of sensors, either in our field or more broadly?

Singh: Happy to do that. First, I would like to take a step back on what you just touched upon, which I think is a big issue, and that is the whole concept of disparities getting worse. I think the propensity within the health care system in the US has always been to backfill the gaps after they have already occurred. With the digital strategies or technologies that we have now, we have an opportunity to, in a forward-thinking manner, prevent those gaps from occurring and actually backfill the gaps that are already there in a completely new way. So, we are in a situation that we can really enhance equity through this digital transformation, and I think we need to look at it from that lens.

On the topic of sensors, when I first started writing this book, it was entitled Sensored. I did not call it Future Care at that point in time, because the focus of the book was largely on sensors since that is what I understood best at that point. But that section of the book focuses on digitization of the human body. It talks about not just implantable sensors that you and I are familiar with because we implant them all the time, but with wearable sensors and where they intersect—where implantables and wearables, in conjunction with each other, can translate into better care and outcomes.

As you know, we treat patients with heart failure (HF). We treat patients with atrial fibrillation (AF). We treat patients who have a high propensity for sudden cardiac death, let alone the entire other spectrum of patients with diabetes and hypertension, all of those being disease-modifying conditions that influence our practice of care with HF and the other conditions I just labeled. But there are sensor-based strategies now that allow us to not only get into the realm of secondary or primary prevention, but even a step beyond into primordial prevention, to also prevent the risk factors from coming up. So, the section on sensors largely deals with this, but along the way it talks about not just cardiovascular diseases, but also about cancer, chronic obstructive pulmonary disease, diabetes, and the other conditions that afflict this population in a big proportion.

Knight: I think at least there is an awareness that these issues are important. Even our guidelines and classifications of diseases are starting to touch on primordial prevention, whether it is AF, HF, obesity, or the other causes that seem to be driving these increasing comorbidities.

On the topic of sensors, you raise the issue of privacy in the book, and it made me think. People do not want their data from Twitter and Instagram shared, so how are the average Americans going to feel about sharing their steps and personal health information?

Singh: I think that is the job for the regulatory bodies to figure out a strategy of ensuring that privacy is maintained. But in all honesty, there are already incentives being given to patients to share that information by their insurance companies, for example, and their premiums are then accordingly adjusted based on how they are engaged in these lifestyle measures, because that in turn helps wellness, prevents disease, and saves the insurance companies money. So, there are already strategies for that. It is just that the guard rails need to be put into place to ensure that they are happening in the best possible fashion.

We practice this principle in electrophysiology of exception-based care where we remotely monitor patients with devices and see them only when they have a problem, or when they have a problem, they come to your attention. I think that is going to happen across the entire breadth of medicine, that there will be continuous care strategies because the way we practice medicine now is oftentimes transactional. You see them at 3-, 6-, or 12-month periods, but patients do not fall ill in a transactional fashion. They fall ill anytime during that continuous spectrum. That is where continuous care is going to become the central way in which we actually follow and treat our patients, which will then translate into savings and make health care more sustainable. n

Knight: As a personal anecdote, things seem to be getting back to the way they were just based on the traffic in Chicago now. We had the luxury of easy commutes for about 3 years, and now it is worse than it was before the pandemic. It makes me worry a little about going back to where we were and not taking advantage of the progress we made during the pandemic, specifically in telemedicine. Personally, I do telemedicine appointments. I think they are discouraged, because the compensation or reimbursement is not as good. I still do it by phone, even though there is probably a video link, and patients seem happy with that. Reimbursement for telemedicine was encouraged or promoted, and the obstacles were removed very quickly. I am afraid that this will not continue. In our field of electrophysiology, I would say a majority of the patients I see in clinic are patients that I could see remotely.

Singh: That is a good point. Like you, I have experienced the pendulum swinging backwards, and find myself saying, “What is going on? I thought we were moving in a forward direction.”

Knight: Right.

Singh: One of the things the book really emphasizes is that the future of care will be virtual, at least in part, that it will be sensor-aided, which will be powered by predictive analytics and AI, but will need sustainable workflows that can then translate into improved clinical outcomes. So, there are many parts of the future care equation that need to fall into place to make each of these components effective. I think virtual care is the most essential component for decompressing our practices and allowing patients to be seen where they are in a timely fashion in the way they want to be seen and for whatever they want to be seen for.

The reason for writing this book is to influence change from the outside in, because inside-out change is always challenging. Many of our colleagues, sometimes us included, are so vested in the status quo that you feel comfortable with practicing the trade the way you have always practiced it. As a consequence of that, some of these changes are going to take a while, but I think they will certainly change. There is no way that we are going to go back to every clinic visit in the future being in person, because the only way for it to be sustainable is by having these components come together.

The downside, and I talk about this a little bit, is the role of the virtualist versus the traditionalist, and that there is a happy medium out there that needs to be reemphasized. I think we are moving in that direction, and it may be slow, but I am hoping that this conversation, along with others, can institute some of those changes outside-in.

Knight: Yes. You mentioned influencing others. I think your goal was to empower people, and knowledge is power. You are sharing this information not just with your peers but with health care administrators, patients, industry, and other people who are in a position to make these changes by showing them what the future of care could or should be.

Singh: Exactly. The book is essentially for a wide readership, certainly for the clinician, but even for the sophisticated nonmedical reader, and largely for that population of readers. I am hoping that administrators begin paying attention to the impact that this strategy of care can have in the future.

Knight: You talk about big companies such as Google and Facebook that have risen in the last few years, and it seems to be that tackling the health care system by these companies is a big challenge. It is much more complicated than other industries. One roadblock or driver for a lack of change is the way we reimburse and compensate. There is a lot of talk about reimbursing for quality. I think the more you consider that, it is hard to do. How do you think that the physician reimbursement model could be changed in a realistic way to drive some of the changes that you are suggesting?

Singh: I agree with you that the current fee-for-service model is nonsustainable because what it perpetuates is largely volume over value, and what that focuses on is sickness over wellness. So, the health system is only healthy as long as patients are sick. We need to flip the argument and create the quality metrics that we talk about that are so difficult to put in place. But there are many other strategies, such as shared-saving strategies, to have some sort of capitated strategy for different disease conditions. If you can save, then you share the savings to create incentives on both sides to give the best possible care or the highest value with the least amount of money. You end up getting what you incentivize. So, if you incentivize RVUs as we understand it, you get competition, but if you incentivize synergy and incentivize strategies for team building, you get better outcomes, and we know that. So, I think there are ways to do this.

The onus is on institutions such as academic institutions. Academic institutions that have their own health plans actually have an opportunity for exploring and experimenting shared-saving strategies to save money and change the practice of care to some of these digital approaches that provide continuous care. So, I think where there is a will, there is a way, and as long as there is visionary leadership, it is certainly possible because, otherwise, health care the way it is not sustainable if we are going to continue the current culture of chasing margins for everything we do.

Knight: Yes. It is not just margins. It is the budgetary process, the annual budget process you talked a lot about, and having visionary leadership is important. I will give you an example. Instituting an intravenous (IV) sotalol program in our hospital required a lot more work than you might think it should, because you need to have a particular person who is going to be able to administer the IV sotalol. Now, it saves that patient admitting to the hospital for 2 to 3 days. You would think that someone would recognize that, take those resources and move them over here, but even simple movements of resources for big-picture benefit can be very difficult in a rigid system.

Singh: Absolutely. I could not agree with you more. I think that is where you need not only visionary leadership, but folks who actually understand what it looks like on the ground floor so they can open up the hood, look inside, and see what is going on rather than just dictating things. Leadership needs to be boots on the ground at the same time.

Knight: Well, this is an amazing book as your first book. What are your plans for your next book?

Singh: I have a contract for a second book that I am working on. It is going to be in an area that I am most comfortable with, and it is probably around harnessing electrical energy for human health. It is still in its early conceptual stages, and the research end of things is still in its early stages, but I am looking at that. We will see how it all plays out.

Knight: I do not know what you were considering when you came up with the figure for the front of your book. It is a handshake between 2 people. It is a digitized view of that. That was something that we did not do during the pandemic, so I thought that was an interesting choice. What were your thoughts on that?

Singh: So, the important part of Future Care is the word “care.” There is a lovely saying by Dr Francis Peabody that says the secret of the care of the patient is in caring for the patient, and I am hoping that that handshake brings forth the fact that the human bond is essential for how much digitization of health care may occur, and that is why the 2 hands are partially digitized, but there is a nice clasp, symbolizing that the human bond should always be and will always be preserved if we are able to and want to look after our patients.

Knight: Jag, Future Care is an outstanding creation. I look forward to the future and what you have coming. Anything else you want to share with us?

Singh: No, I just want to thank you for the opportunity, and I look forward to chatting with you again.

Knight: We have had the benefit of spending time together on some medical advisory boards. It is great for me to see your insight and your commentary. So, thank you for doing this, and best of luck in your new writing career.

Singh: Thanks so much, Brad. Appreciate it.