Decentralized Healthcare — Part II: Breaking It All Down

To be able to imagine the dramatic change in a system that has existed for thousands of years, stepping away to see the bigger picture is necessary. One important but the overlooked word, “healthcare”, needs to be clearly defined first. Based on Wikipedia (i.e. crowdsourced definition), healthcare is the “maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairment in human beings.” As mentioned in “Decentralized Healthcare Part I”, the current healthcare delivery system is rather centralized. Therefore, an effective decentralized healthcare delivery system needs to serve all the existing roles, if not better, than the current centralized system.

In addition, it is necessary to discuss the concept of “decentralization” within the proper context. As suggested by in one article on bitcoin/computing [ref], there are several rather independent kinds of decentralization. In healthcare, perhaps we can break it down to the following three:


1. Physical Decentralization — A healthcare delivery system that is less dependent on physical location or number of the human healthcare provider. Achievements of the prevention, diagnosis, and treatment of disease would require less and less physical conglomerate of technologies and human providers. As Vinod Khosla suggested in his paper, “’20 Percent Doctor Included’ & Dr. Algorithm: Speculations and Musings of a Technology Optimist “, Dr. Algorithm will likely take over “80%” of what doctors do today. The role of future doctors will dramatically change with the rising of technology and the ceiling of the healthcare budget. The role of hospitals and healthcare organizations will also have to change, and more likely towards physical decentralization. There are many existing innovations targeting physical decentralization of healthcare already:


     a.Prevention: Our progressively improved ability to easily (and cheaply) obtain and store data either from IoT and wearables or remote diagnostic labs and devices allow us to collect not only a lot more data but often continuous data from patients. This reduces the need for the patient to physically visit their doctors, clinics, hospitals for checkups and follow-ups.


    b.Diagnosis: Remote monitoring, remote diagnosis, telemedicine/teledentistry are more and more common and accepted. Patients are more open to cheaper, more accessible, but perhaps less intimate interaction with the new care delivery interface, ranging from robots to an iPhone with a human on the other end of the screen. What often started out as the target of skeptics is then accepted as a form of reimbursable procedure accepted by most major insurance companies. In the world of diagnostic imaging, handheld 3D scanner and ultrasound are fully commercialized. Other more portable imaging devices including MRI and CT, will surely appear as the decentralized care system matures. Many are already in the research and development phase. Perhaps with machine learning and better data management, the newer and smaller devices will provide even more accurate assessment than its larger and more expensive predecessor.


     c. Treatment: As a starter, ongoing innovations in remote prescription and automated prescription dispensing are rolling out. In dentistry, with the advancement in 3D scanning, 3D printing, and further optimized digital workflow, the clear aligner business is getting further physically decentralized with the appearance of products like Smile Direct Club, where there is a significant reduction of in-office time/cost for the patients. Decentralized manufacturing offered by 3D printing and milling allows for on-demand manufacturing of personalized medical devices, reducing the necessity of inventory or a central supplier. The 3D printed medical devices can range from arm braces to surgical implants. Additionally, “treatment” does not always mean surgery and dispensary of medications. Mental health, for example, can deliver effective therapy to patients via telemedicine, AR/VR, already.



2. Logical Decentralization — In the past, healthcare centralization became necessary because of the accumulation of medical knowledge and advancement in technologies. On top of a century-old healthcare education hierarchy, these resulted in growing knowledge asymmetry between patients and healthcare providers, and skill asymmetry among different groups of healthcare providers. However, with emerging healthcare technologies, such asymmetry will be reduced.


      a. Upskilling of a lower skilled worker to perform more complex work/procedure. For some care providers, this is possible because “skill amplification” or “upskilling”. The demand for more and better healthcare was not met with a growing aging population, and the healthcare cost is reaching an astronomical new high, such skill-augmentation or “upskilling” will be a reasonable solution to the crisis. In fact, the trend is already there: physician assistants and nurse practitioners are becoming a more dominant workforce in the primary and acute care setting. A significant portion of radiological interpretation is already currently not done by radiologists (often because of not enough radiologists available at a certain location or not available at certain hours). More dentists are now able to perform more complex dental surgeries with the help of 3D-printed surgical guides or robots without having to go through expensive and often exclusive training. The examples are and will be everywhere.


      b. Informed patients with more data to choose. With less knowledge asymmetry, the patient can play a bigger role in making a decision on his/her own care, thus decreasing the authority of a healthcare organization or provider. This can be done by providing patients with more tools and channels to digest their healthcare data. Various consumer-based healthcare and wellness startups are now playing the role of the healthcare educator, from genomics, biometrics, to various diagnostic tests. Perhaps one day, Dr. Google can generate search results that are actually based on the individual patient’s existing healthcare data, therefore directing one’s next step in care more accurately. Informed patients will translate to more responsible patients, who will also decrease medical errors either at the level of a healthcare provider or at the level of the healthcare system.



3. Political Decentralization — Physical and logical decentralization of healthcare is already taking place. However, the degree of decentralization will eventually depend on the degree of political decentralization. Currently, it is hard to imagine decentralizing the role played by many government entities (like FDA), large professional organizations (such as AMA) that setup practice guidelines, or the civil law relevant to healthcare delivery. These authorities play critical roles to protect patients’ safety and safeguard consumer rights. That said, layers of bureaucracy and lobby groups often form around these authorities. These byproducts of political centralization are often obstructionists to change, since maintaining status-quo is their primary responsibility. Will a nurse one day perform an appendectomy with robotic assistance? Will computer replace 80% doctors? Technically possible, but politically not. Or not yet.