Vinod Khosla “Video visits aren’t new technology, just the same doctors making same subjective judgements”



mobihealthnews khosla video visits arent new technology

Tech Billionaire Vinod Khosla is always good for stirring it up at a Healthcare Technology event and at the Connected Health Symposium in Boston he’s commented on video consultations with Doctors making an assumption that I think is ignoring the big change that happens when you empower Patients with the ability to share information with you and reach you via the device that’s already in their pocket.

mHealth Insights

I really welcome the contributions of smart technologists like Vinod Khosla to conversations about where healthcare is going but I think it’s important that we appreciate where they originate from and that we weight them together with the opinions of those of us who have experience providing care and practising medicine.

There should be no doubt that the healthcare industry needs smart people like Vinod Khosla to shake things up. I for example fully expect to learn more at next weeks WebSummit (an event that is sponsored by fizzy drinks brands!) than at the mHealth industry meetings that I will attend around the world over the next month. The Partners Connected Health event in Boston was an event that really needed Khosla’s input as their understanding of tech was all over the place eg. remember when they were gushing on about kitchen counter automatons with blinky eyes as though they would save the world?

“The error rates in medicine, if you look at the Institute of Medicine studies, are about the same as if Google’s self driving car was allowed to drive if it only had one accident per week,” Khosla said. “I’m not talking about the best doctors, I’m talking about the median doctor or the below median doctors — the bottom 50 percent of doctors.”

We hear about this all the time from technologists but it’s really wide of the mark as it’s comparing apples and pears.

I don’t really get why technologists think self driving cars are somehow as complex as Patients. mHealth is becoming compulsory and we’re slowly getting medical devices that have embedded connectivity but a Google self driving car is fundamentally different because it really has no choice about decisions as they’re all programmed to be made for it. If they programmed a personality into a Google car I’m sure the frequency of errors would never permit it onto the highway – who would want to ride in one after it indulged on 50 litres of Ethanol?

The technology being implemented today, according to Khosla, is simplistic, but serves a very useful purpose. “There’s no technology in telemedicine, or very little, from my point of view, because there’s no new data,” Khosla said. “It’s the same doctors making same subjective judgement. Instead of you sitting in their office, they’re doing it remotely.

This is completely inaccurate. Sure there are a few insurance companies who provide the token offering of Doctor video consultations in a bid to attract younger lower risk Patients etc who then have low utilisation rates. But in our experience (providing 24×7 Video Consultations for nearly 10 years) if you want to offer video consultations that Patients pay for out of their own pocket you are going to need to provide Patients and Doctors with the ability to also share information. This is something I explained in Paris at the Doctors 2.0 event:




Fail to take on this best practice and 99% of the time you’ll have a Video Consulting service that achieves little more than a Patient could get by Googling their symptoms and involves Doctors waving at Patients (because there is no context for the consultation) before telling them to go visit their normal Doctors office or to a drug store to pick up a prescription for an antibiotic that they don’t need.

Doctors don’t need information to be able to better program their Patients behaviours they need it to know how to motivate them.

He explained that a symptom navigator tool as it exists today helps patients who have the common cold or another similar illness, rule out something like strep throat, but the next generation of this tool should be able to address more serious concerns

The next generation clinically validated version of Symptom Checkers is already deployed at leading institutions like the Mayo Clinic, here at 3GDoctor (in the UK and Ireland only) and by GPs working in the NHS (see AskMyGP). It collects the relevant medical history information and presents it to the Clinician in a standardised format before the consultation begins and it enables the Patient to be provided with a concise electronic report of the information that was shared and the advice that was given in the consultation.





“You are diagnosing a condition, you are talking to a patient, you ask a bunch of questions, very typical,” he said. “Now imagine a rare condition that is very serious… If you don’t ask two questions to exclude that rare condition — and you may not have seen it because it happens one out of 10,000 times — you are not going to remember to ask as the doctor. So the first generation of systems might actually say, ‘Here’s additional questions to exclude this other thing.’”

This is exactly what Instant Medical History (the product we have integrated into the 3G Doctor service) does. Here’s the slides from a recent talk that Dr Richard Sills gave to the recent International Congress of Aviation and Space Medicine at Oxford University (UK) that summarises the long history there is of smart tech-savvy Doctors who have been utilising computers to help them take Patient histories:


Clinical decision support tools, Khosla argues, will allow healthcare professionals to do more than they could before and take on different roles when caring for the patients. For example, the next generation of digital health tools may let a skilled nurse do what a primary care physician does and then perhaps allow a primary care physician to do what a cancer specialist or cardiologist does

This already happens and it’s not just shifting workload to another Healthcare Professional it’s empowering self care and helping Patients and their Carers to get the care they need more efficiently. In his 2009 Mayo Clinic Proceedings Paper Dr John Bachman MD, Professor of Primary Care at the Mayo Clinic, has already shown that Patients who share an Instant Medical History output with their Doctor can safely manage 40% of what would be a Family Doctor’s normal workload.

The Future is already here

I think the first generation of systems in the next decade will be about assistance,” Khosla said. “If you are a heart patient and something happens at home, you have a little AliveCor device that tells you, ‘Hey, this is actually atrial fibrillation happening, not just heart burn.’ And you won’t have to decide in a blind way whether you should rush to emergency or not. Those kinds of systems will happen. Over time, Khosla said the systems will start answering more advanced questions, like ‘Do I need to rush to [the emergency room] or is there something else wrong?’. But to get there, digital health offerings need a lot of data

I think Vinod Khosla’s confusion arises because he’s failing to see the connection between mHealth tech and remote Doctors who can see the data being captured by the Patient. I don’t understand why this confusion exists for an Alivecor investor eg. there are plenty of Patients here in Ireland who have been prescribed Alivecors who get to send ECG data direct to their Cardiologists. These Clinicians have already started answering the more advanced questions Vinod Khosla is talking about computer systems answering.

“My hope is in 10 or 20 years we go from the practice of medicine, which doctors practice today to the science of medicine,” he said. “[A patient] might… read an ECG the same way that a doctor would today and then telemedicine would present that remotely for a doctor to look at or to diagnose it. But if you can find new kinds of data that says you’re about to have a heart attack in six hours, and predict it, you have invented new science and that’s much more exciting.”

I think Vinod Khosla has missed the memo from Alivecor about the reassuring “No abnormalities have been detected in your ECG” message that today gives Patients with the Alivecor app the ability to look at a single lead ECG in a way that’s almost equivalent to a Doctor reading it.

I think the 6 hour prediction thing is interesting and there have been mHealth tech companies like Cardionet that really talked this stuff up but the jury is still out. What will happen when a rival rocks up with an app offering you a 12 hour or a 12 month prediction on having a heart attack? Isn’t it obvious that customers will start feeling a little bit like a bee in a colony?

I think the proponents of Big Data need to ask themselves the following question before trying to predict the future: If a big data calculation told you to walk to work today in high vis clothing and a cycle helmet would you do it without questionning it or are there some risks you’re prepared to take to live your life?

khosla-digital-health-medical-centre-powered-by-ibms-watson-winner-of-jeopardy & HealthWatch

A hard sell maybe but perhaps by the time it’s available Google will know how to convince us we need it?

*** *** UPDATE SAT 31 October 2015 *** ***

On Twitter this morning I asked the question ‘if big data told you to go out tonight in high vis clothing would you?’ as I find it humorous that the very entrepreneurs who turn right when they are told to turn left seem to think having big data make decisions for us is the answer to the healthcare industries problems.

It started an interesting chat that eventually ended with me being shot down with the accusation that I’m such a bore that this discussion with me amounted to “death by Twitter”.

I wonder how many people realise how boring life might be when every uncertainty in your life is determined by looking at a graphic that has been produced by calculations of big data sets that are so voluminous that it would take you weeks to just analyse the data that is presented to you to decide upon in a fraction of a second?

If big data told you to go out tonight in high vis clothing would you


Related Post: It’s DOCUMENTATION not BIG DATA that’s set to transform the performance of the NHS

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3 Responses to Vinod Khosla “Video visits aren’t new technology, just the same doctors making same subjective judgements”

  1. David Trainor says:

    David, that is a complete misrepresentation of my comments. I did not call you a “bore”. Like many of your ill-informed statements it twists reasonable debate from other people to fit your own narrow-minded views. I jokingly called our discussion “death by Twitter” because you don’t discuss – you try to browbeat and project your views onto others by thinly veiled sarcasm and dismissal, You are not boring, but you are close-minded and arrogant enough to make many reasonable people avoid talking with you. The ultimate irony is that the mHealth Insight Twitter account summary says “let’s find ways to improve healthcare”. Clearly it should add the corollary “as long as those ways align exactly with my views and no others”.

    Enjoy being a professional keyboard warrior!

  2. David Trainor says:

    Comments don’t seem to be working?

  3. Hi David,

    Yes you’re correct my Twitter account summary does says “let’s find ways to improve healthcare”. I see calling out hype as being a way of improving healthcare and presenting the evidence I have (eg. as above where I’ve quoted a Mayo Clinic Proceedings paper by Prof John Bachman MD and the slides from Dr Richard Sills’s talk at the recent International Congress of Aviation and Space Medicine) as being a key part of how I do this.

    Roy Symth (@willsmythemd on Twitter) does a great job of pointing out how hype hurts Patients and slows important innovations from improving healthcare and helping Patients:

    Healthcare hype is quackery once removed. Selling “vaporware” in some sectors may be tolerated, and even expected. However, it just doesn’t play well in medicine. Unlike Huck Finn’s frontier contemporaries, most healthcare providers charged with making the decisions to deploy these solutions do not lack sophistication, and are not easily entertained. Promoting new healthcare tools beyond their capabilities is harmful, even if it enriches a few. The faults will always be found out in clinical application, where the margins for error are low, and will push needed innovation further into the future

    PS. while I welcome the contributions of others to help improve healthcare (and call out hype) from your comments I see that while I’m not a bore I am in your opinion a ‘narrow/close minded keyboard warrior’ so if you don’t mind I’d like to take you up on your offer to ignore me in future, thanks.

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