Health care: Information tech must catch up to medical marvels
Michael Dowling, Northwell Health's CEO, believes we're entering the age of smart medicine.
- The United States health care system has much room for improvement, and big tech may be laying the foundation for those improvements.
- Technological progress in medicine is coming from two fronts: medical technology and information technology.
- As information technology develops, patients will become active participants in their health care, and value-based care may become a reality.
In his book Health Care Reboot, Michael Dowling, Northwell Health's CEO, argues that "[the United States] is constructing a solid foundation upon which the new American health care is being erected." To those steeped in news of health care's administrative bloat, under-performing primary care, and low levels of insurance coverage, such a thesis may seem bold, wishful, or downright delusional.
But Dowling does not ignore the health care system's need for improvement. Rather, he believes that contemporary trends can foster such improvement if we recognize their value. He cites advances and disruptions in areas such as consolidation, education, payment reform, and mental health to support his progressive view that "better, safer, and more accessible care" is coming.
Among those trends is big tech's move into health care, or as Dowling puts it, technology may soon move us into the age of smart medicine.
Medical tech marvels
Dowling sees big tech's stride into health care as coming from two fronts: medical technology and information technology. On the medical technology front, the technology available to doctors has accelerated at an unprecedented pace, resulting in tools and techniques that are "the stuff of Star Wars."
"Some of the most advanced technology tools ever developed in any field are in use to care for patients. Look at any modern operating room or intensive care unit, and the technology to treat patients and keep them alive is remarkable," writes Dowling.
To pick one of many examples, Northwell Health's Cohen Children's Medical Center was the first pediatric program on Long Island to institute ROSA, a "robotic operating surgical assistant." Before ROSA, children suffering epilepsy would have to undergo a full craniotomy to target and monitor areas of seizure activity. With ROSA's assistance, surgeons can get the same results through a minimally invasive procedure, reducing the risk of infection and strain on the patient.
Even technology not designed for therapy has been co-opted to play small, yet supportive, roles in quotidian treatment. A study out of the Children's Hospital Los Angeles found that virtual reality can help reduce a child's anxiety and stress during basic procedures such as a blood draw.
Information tech plays catch up
Photo: Sisacorn / Shutterstock
Dowling characterizes the information technology front as "less impressive," pointing to the well-known difficulties of onboarding electronic health records. Beyond concerns of cybersecurity and interoperability, such systems have caused widespread burnout and dissatisfaction among practitioners thanks to their time consumption and complicated workflows.
But progress is being made. Apple recently added a Health Records app to its iPhone, giving patients from 39 health systems access to their medical records.
"This existing new reality is that a fat file, that until recently was stored away unavailable to the patient, now sits in its entirety on the patient's phone," writes Dowling. "For patients with chronic conditions who make frequent use of medical services, this leap forward enables them, whether a mile from their doctor's office or a thousand miles, to track and share with their doctor essential data on blood pressure, heart rate, glucose levels, and scores of other important clinical markers."
But to succeed, this information must be gatherable, accessible, and understandable to any patient. Big tech will need to streamline such systems for maximum user-friendliness, all while keeping operations on a device with which patients and practitioners are intimately familiar.
That device will be the smartphone and tablet. 77 percent of Americans own smartphones. Among Americans over 65 years of age — the demographic most in need of such advancements — 46 percent own a smartphone, a number that is likely to climb.
Big tech's vision of integrating information technology with health care is some ways off. Much experimenting must be done, and big tech needs to better collaborate with traditional health care stakeholders. Even so, these incipient steps may lead to a framework where practitioners can gather more data more quickly and with greater ease, while patients become partners, not passive recipients, of their health care team.
Accelerating value-based care
In the United States, value-based health care exists today as a should-we, could-we debate topic. Big tech's entry into the field could push value-based care closer to practice. As noted on the health care blog Tech Prescribed, integrating improved data acquisition with AI-powered platforms could turn value-based care into a manageable venture.
"As a result, we will see the move to VBC accelerate even further as more firms turn a profit through this business model. Good news for docs — this will make you the primary customer for provider technology and really improve your user experience as a side effect," writes Colton Ortolf of Tech Prescribed.
The Northwell Health entity Pharma Ventures was created both in response to collaborating with big pharma and as a means to promote value-based care. Pharma Ventures was designed "to link drug prices to drug performance" and "to serve as a super-site for clinical trials." The goal is to drive down costs while simultaneously improving patient experience. Such an initiative is only possible due to Northwell's integrated systems and system-wide electronic health records.
Entering the smart age of medicine
For Dowling, health care in the United States is laying an important foundation for the medicine of tomorrow. We're moving away from the view that health care is something the patient receives at a medical facility. Soon, health care will see the patient take an active role alongside a team of health care providers.
"The new American medicine is proactive and has physicians working in teams with nurses and other caregivers to reach out to patients and guide them along a pathway to health and wellbeing," writes Dowling.
By creating new machines, proliferating information, and making that information easier to obtain, big tech's dive into health care will be a fundamental element in this upcoming paradigm shift.
The author of 'How We Read' Now explains.
During the pandemic, many college professors abandoned assignments from printed textbooks and turned instead to digital texts or multimedia coursework.
As a professor of linguistics, I have been studying how electronic communication compares to traditional print when it comes to learning. Is comprehension the same whether a person reads a text onscreen or on paper? And are listening and viewing content as effective as reading the written word when covering the same material?
The answers to both questions are often “no," as I discuss in my book “How We Read Now," released in March 2021. The reasons relate to a variety of factors, including diminished concentration, an entertainment mindset and a tendency to multitask while consuming digital content.
Print versus digital reading
The benefits of print particularly shine through when experimenters move from posing simple tasks – like identifying the main idea in a reading passage – to ones that require mental abstraction – such as drawing inferences from a text. Print reading also improves the likelihood of recalling details – like “What was the color of the actor's hair?" – and remembering where in a story events occurred – “Did the accident happen before or after the political coup?"
Studies show that both grade school students and college students assume they'll get higher scores on a comprehension test if they have done the reading digitally. And yet, they actually score higher when they have read the material in print before being tested.
Educators need to be aware that the method used for standardized testing can affect results. Studies of Norwegian tenth graders and U.S. third through eighth graders report higher scores when standardized tests were administered using paper. In the U.S. study, the negative effects of digital testing were strongest among students with low reading achievement scores, English language learners and special education students.
My own research and that of colleagues approached the question differently. Rather than having students read and take a test, we asked how they perceived their overall learning when they used print or digital reading materials. Both high school and college students overwhelmingly judged reading on paper as better for concentration, learning and remembering than reading digitally.
The discrepancies between print and digital results are partly related to paper's physical properties. With paper, there is a literal laying on of hands, along with the visual geography of distinct pages. People often link their memory of what they've read to how far into the book it was or where it was on the page.
But equally important is mental perspective, and what reading researchers call a “shallowing hypothesis." According to this theory, people approach digital texts with a mindset suited to casual social media, and devote less mental effort than when they are reading print.
Podcasts and online video
Given increased use of flipped classrooms – where students listen to or view lecture content before coming to class – along with more publicly available podcasts and online video content, many school assignments that previously entailed reading have been replaced with listening or viewing. These substitutions have accelerated during the pandemic and move to virtual learning.
Surveying U.S. and Norwegian university faculty in 2019, University of Stavanger Professor Anne Mangen and I found that 32% of U.S. faculty were now replacing texts with video materials, and 15% reported doing so with audio. The numbers were somewhat lower in Norway. But in both countries, 40% of respondents who had changed their course requirements over the past five to 10 years reported assigning less reading today.
A primary reason for the shift to audio and video is students refusing to do assigned reading. While the problem is hardly new, a 2015 study of more than 18,000 college seniors found only 21% usually completed all their assigned course reading.
Maximizing mental focus
Researchers found similar results with university students reading an article versus listening to a podcast of the text. A related study confirms that students do more mind-wandering when listening to audio than when reading.
Results with younger students are similar, but with a twist. A study in Cyprus concluded that the relationship between listening and reading skills flips as children become more fluent readers. While second graders had better comprehension with listening, eighth graders showed better comprehension when reading.
Research on learning from video versus text echoes what we see with audio. For example, researchers in Spain found that fourth through sixth graders who read texts showed far more mental integration of the material than those watching videos. The authors suspect that students “read" the videos more superficially because they associate video with entertainment, not learning.
The collective research shows that digital media have common features and user practices that can constrain learning. These include diminished concentration, an entertainment mindset, a propensity to multitask, lack of a fixed physical reference point, reduced use of annotation and less frequent reviewing of what has been read, heard or viewed.
Digital texts, audio and video all have educational roles, especially when providing resources not available in print. However, for maximizing learning where mental focus and reflection are called for, educators – and parents – shouldn't assume all media are the same, even when they contain identical words.
Ancient corridors below the French capital have served as its ossuary, playground, brewery, and perhaps soon, air conditioning.
- People have been digging up limestone and gypsum from below Paris since Roman times.
- They left behind a vast network of corridors and galleries, since reused for many purposes — most famously, the Catacombs.
- Soon, the ancient labyrinth may find a new lease of life, providing a sustainable form of air conditioning.
Ancient mining areas below Paris for limestone (red) and gypsum (green).Credit: Émile Gérards (1859–1920) / Public domain
"If you're brave enough to try, you might be able to catch a train from UnLondon to Parisn't, or No York, or Helsunki, or Lost Angeles, or Sans Francisco, or Hong Gone, or Romeless."
China Miéville's fantasy novel Un Lun Dun is set in an eerie mirror version of London. In it, he hints that other cities have similar doubles. On the list that he offhandedly rattles off, Paris stands out. Because the City of Light really does have a twisted sister. Below Paris Overground is Paris Underground, the City of Darkness.
Most people will have heard of the Catacombs of Paris: subterranean charnel houses for the bones of around six million dead Parisians. They are one of the French capital's most famous tourist attractions – and undoubtedly its grisliest.
But they constitute only a small fragment of what the locals themselves call les carrières de Paris ("the mines of Paris"), a collection of tunnels and galleries up to 300 km (185 miles) long, most of which are off-limits to the public, yet eagerly explored by so-called cataphiles.
The Grand Réseau Sud ("Great Southern Network") takes up around 200 km beneath the 5th, 6th, 14th, and 15th arrondissements (administrative districts), all south of the river Seine. Smaller networks run beneath the 12th, 13th, and 16th arrondissements. How did they get there?
Paris stone and plaster of Paris
It all starts with geology. Sediments left behind by ancient seas created large deposits of limestone in the south of the city, mostly south of the Seine; and gypsum in the north, particularly in the hills of Montmartre and Ménilmontant. Highly sought after as building materials, both have been mined since Roman times.
The limestone is also known as Lutetian limestone (Lutetia is the Latin name for ancient Paris) or simply "Paris stone." It has been used for many famous Paris landmarks, including the Louvre and the grand buildings erected during Georges-Eugène Haussmann's large-scale remodelling of the city in the mid-19th century. The stone's warm, yellowish color provides visual unity and a bright elegance to the city.
The fine-powdered gypsum of northern Paris, used for making quick-setting plaster, was so famed for its quality that "plaster of Paris" is still used as a term of distinction. However, as gypsum is very soluble in water, the underground cavities left by its extraction were extremely vulnerable to collapse.
Like living on top of a rotting tooth: subsidence starts far below the surface, but it can destroy your house.Credit : Delavanne Avocats
In previous centuries, a road would occasionally open up to swallow a chariot, or even a whole house would disappear down a sinkhole. In 1778, a catastrophic subsidence in Ménilmontant killed seven. That's why the Montmartre gypsum quarries were dynamited rather than just left as they were. The remaining gypsum caves were to be filled up with concrete.
The official body governing Paris down below is the Inspection Générale des Carrières (IGC), founded in the late 1770s by King Louis XVI. The IGC was tasked with mapping and, where needed, propping up the current and ancient (and sometimes forgotten) mining corridors and galleries hiding beneath Paris.
A delightful hiding place
Also around that time, the dead of Paris were getting in the way of the living. At the end of the 18th century, their final destination consisted of about 200 small cemeteries, scattered throughout the city — all bursting at the seams, so to speak. There was no room to bury the newly dead, and the previously departed were fouling up both the water and air around their respective churchyards.
Something radical had to happen. And it did. From 1785 until 1814, the smaller cemeteries were emptied of their bones, which were transported with full funerary pomp to their final resting place in the ancient limestone quarries at Tombe-Issoire. Three large and modern cemeteries were opened to receive the remains of subsequent generations of Parisians: Montparnasse, Père-Lachaise, and Passy.
The six million dead Parisians in the Catacombs, from all corners of the capital and across many centuries, together form the world's largest necropolis — their now anonymized skulls and bones methodically stacked, occasionally into whimsical patterns. The Catacombs are fashioned into a memorial to the brevity of life. The message above the entrance reads: Arrête! C'est ici l'empire de la Mort. ("Halt! This is the empire of Death.")
That has not stopped the Catacombs, accessible via a side door to a classicist building on the Avenue du Colonel Henri Rol-Tanguy, making just about every Top 20 list of things to see in Paris.
An underground economy
However, while the Catacombs certainly are the most famous part of the centuries-old network beneath Paris, and in non-pandemic times draw thousands of tourists each day, they constitute just 1.7 km (1 mile) of the 300-km (185-mile) tunneling total.
Subterranean Paris wasn't just used for mining and storing dead people. In the 17th century, Carthusian monks converted the ancient quarries under their monastery into distilleries for the green or yellow liqueur that still carries their name, chartreuse.
Because the mines generally keep a constant cool temperature of around 15° C (60° F), they were also ideal for brewing beer, as happened on a large scale from the end of the 17th century until well into the 20th century. Several caves were dug especially for establishing breweries, and not just because of the ambient temperature: going underground allowed brewers to remain close to their customers without having to pay a premium for real estate up top.
Overview of the Paris Catacombs.Credit: Inspection Générale des Carrières, 1857 / Public domain.
At the end of the 19th century, the underground breweries of the 14th arrondissement alone produced more than a million hectoliters (22 million gallons) per year. One of the most famous of Paris' underground breweries, Dumesnil, stayed in operation until the late 1960s.
In that decade, the network of corridors and galleries south of the Seine, long since abandoned by miners, became the unofficial playground for the young people of Paris. They explored the fantastical world beneath their feet, in some cases via entry points located in their very schools. Fascinated, these cataphiles ("catacomb lovers") read up on old books, explored the subterranean labyrinth, and drew up schematics that were passed around among fellow initiates as reverently as treasure maps.
As Robert Macfarlane writes in Underland, Paris-beneath-their-feet became "a place where people might slip into different identities, assume new ways of being and relating, become fluid and wild in ways that are constrained on the surface."
Some larger caves turned into notorious party zones: a 7-meter-tall gallery below the Val-de-Grâce hospital is widely known as "Salle Z." Over the last few decades, various other locations in subterranean Paris have hosted jazz and rock concerts and rave parties — like no other city, Paris really has an "underground music scene."
Hokusai's Great Wave as the backdrop to the "beach" under Paris.Credit: Reddit
Cataphiles vs. cataphobes
With popularity came increased reports of nuisance and crime — the tunnels provided easy access to telephone cables, which were stolen for the resale value of their copper.
The general public's "discovery" of the underground network led the city of Paris to officially interdict all access by non-authorized persons. That decree dates back to 1955, but the "underground police" have an understanding with seasoned cataphiles. Their main targets are so-called tourists, who by their lack of knowledge expose themselves to risk of injuries or worse, and degrade their surroundings, often leaving loads of litter in their wake.
The understanding does not extend to the IGC. Unlike in the 19th century, when weak cavities were shored up by purpose-built pillars, the policy now is to inject concrete to fill up endangered spaces — thus progressively blocking off parts of the network. That procedure has also been used to separate the Catacombs to prevent "infiltration" of the site by cataphiles.
Many subterranean streets have their own names, signs and all. This is the Rue des Bourguignons (Street of the Burgundians) below the Champs des Capucins (Capuchin Field), neither of which exists on the surface.Credit: Jean-François Gornet via Wikimedia and licensed under
The cataphiles, however, are fighting back. In a game of cat and mouse with the authorities, they are reopening blocked passages and creating chatières ("cat flaps") through which they can squeeze into chambers no longer accessible via other underground corridors.
Catacomb climate control
Alone against the unstoppable tide of concrete, the amateurs of Underground Paris would be helpless. But the fight against climate change may turn the subterranean labyrinths from a liability into an asset — and the City of Paris into an ally.
The UN's 2015 Climate Plan — concluded in Paris, by the way — requires the world to reduce greenhouse gas emissions by 75 percent by 2050. And Paris itself wants to be Europe's greenest city by 2030. More sustainable climate control of our living spaces would be a great help toward both targets. A lot of energy is spent heating houses in winter and cooling them in summer.
This is where the constant temperature of the Parisian tunnels comes in. It's not just good for brewing beer; it's a source of geothermal energy, says Fieldwork, an architectural firm based in Paris. It can be used to temper temperatures, helping to cool houses in summer and warming them in winter.
One catch for the cataphiles: it also works when the underground cavities are filled up with concrete. So perhaps one day, Paris Underground, fully filled up with concrete, will completely fall off the map, reducing the city's formerly real doppelgänger into an air conditioning unit.
Cool in summer, warm in winter: Paris Underground could become Paris A/C.Credit: Fieldwork
Strange Maps #1083
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Meconium contains a wealth of information.
- A new study finds that the contents of an infants' first stool, known as meconium, can predict if they'll develop allergies with a high degree of accuracy.
- A metabolically diverse meconium, which indicates the initial food source for the gut microbiota, is associated with fewer allergies.
- The research hints at possible early interventions to prevent or treat allergies just after birth.
The prevalence of allergies arising in childhood has increased over the last 50 years, with 30 percent of the human population now having some kind of atopic disease such as eczema, food allergies, or asthma. The cause of this increase is still subject to debate, though it has been associated with a number of factors, including changes to the gut microbiomes of infants.
A new study by Canadian researchers published in Cell Reports Medicine may shed further light on how these allergies develop in children by examining the contents of their first diaper.
The things you do for science
The research team examined the first stool of 100 infants from the CHILD Cohort Study. The first stool of an infant is a thick, green, horrid-looking substance called meconium. It consists of various things that the infant ingests during the second half of gestation. Additionally, it provides not only a snapshot of what the infant was exposed to during that time, but it also reveals what the food sources will be for the initial gut bacteria that colonize the baby's digestive tract.
The content of the meconium was examined and found to contain such varied elements as amino acids, lipids, carbohydrates, and myriad other substances.
A graph of the comparative, summed abundance of different elements in a metabolic pathway after scaling to median abundance of each metabolite. The blue figures are those children without atopy, the yellow ones show the data for those with an atopic condition. Petersen et al.
The authors fed this information into an algorithm that used this data, along with the identities of the bacteria present as well as the baby's overall health, to predict which infants would go on to develop allergies within one year. The algorithm got it right 76 percent of the time.
A way to prevent childhood allergies?
Infants whose meconium had a less diverse metabolic niche the initial microbes to settle in the gut were at the highest risk of developing allergies a year later. Many of these elements were associated with the presence or absence of different bacterial groups in the digestive system of the child, which play an increasingly appreciated role in our overall health and development. The findings were summarized by senior co-author Dr. Brett Finlay:
"Our analysis revealed that newborns who developed allergic sensitization by one year of age had significantly less 'rich' meconium at birth, compared to those who didn't develop allergic sensitization."
The findings could be used to help understand how allergies form and even how to prevent them. Co-author Dr. Stuart Turvey commented on this possibility:
"We know that children with allergies are at the highest risk of also developing asthma. Now we have an opportunity to identify at-risk infants who could benefit from early interventions before they even begin to show signs and symptoms of allergies or asthma later in life."
A model for early childhood allergies
Petersen et al.
As shown above, the authors constructed a model of how they believe metabolites and bacterial diversity help prevent allergies. Increased diversity of metabolic products in the meconium encourage the development of "healthy" families of bacteria, like Peptostreptococcaceae, which in turn promote the development of a healthy and diverse gut microbiome. Ultimately, such diversity decreases the likelihood that a child will develop allergies.
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