Health at Google: Eric Topol

>>Roni Zeiger: Hello everyone. Thanks for being here. Itís a pleasure to be back at Google. My name is Roni Zeiger. I was here for about six years until just a couple weeks ago. And, uh, itís especially sweet to get to present, uh, to introduce a friend, Eric Topol, who, um, is actually a little bit of a hero to me. I wonít get to weepy donít worry. [Laughter] >>Roni Zeiger: But heís um, heís a professor of translational genomics at the Scripps institute, south of here, also director of that institute. Heís also the co-founder, um, of the West Wireless Institute down in San Diego. Heís also a cardiologist. And, if youíre starting to get a sense that this guy is, um, sort of a rocket scientist and a brain surgeon, heís almost all of those things. Um, he, uh, heís been central in developing a lot of medications, um, and other technologies that many of us in the field of medicine take for granted and use every day. And, perhaps most importantly, if someone asks for a doctor on an airplane, Eric will not only volunteer, but heíll bring his iPhone, put it on their chest and get a cardiogram. So, so this is a guy that you really want to travel with. [Laughter] >>Roni Zeiger: So, letís go on a, on a journey with him now. [Applause] >>Eric Topol: Great! Thanks, thanks a lot. Okay. Itís great to be here with you. Great to be at Google, Iíve never been here before. And, uh, well it should be fun. I know maybe because so many people are young here, theyíre not so into their health or the health world. But, those of you that are here, I hope will have an interesting, uh, informative experience. Iíll certainly enjoy it. So first, I put this quote up because I thought that would set the tone for what weíre gonna talk about during this hour. And this is a Voltaire 250 years ago, and Iím afraid itís not much different today. And, uh, the whole notion that doctors are doing things with good intentions but they donít have the information. And, thatís going to change very quickly. So, thereís a very noted, uh, very famous Austrian economist whose name was Joseph Schumpeter and he, uh , was responsible for the idea that great innovation in an economy with entrepreneurship could change an economy and that graph of old economy going to new economy shown here. And this term of creative destruction is really credited for having pushed forward, and thatís what I think applies to the opportunities in medicine and health care and thatís really an exciting thing that we can do. So, since Schumpeter is one of my heroes, I was really surprised when I was reading the Economist, my favorite weekly read, reading the Schumpeter column, this is just a week ago. And Iím looking at this column saying, ìOh, now for some good news.î I have no idea what it was gonna be about. Then I found out it was a book review. This book, uh, and it was very positive about a godsend for those that suffer from Armageddon fatigue. So hopefully you will find this to be a very upbeat experience as the viewer did there. And, of course, the Economist is interesting 'cause they donít, theyíre unsigned. So I donít even know who Schumpeter is on the Economist. But, um, what were gonna talk about is, how digitizing human beings, which is what generates this remarkable information, is going to reboot the future of medicine. And, before I get into that topic, 'cause thatís really how we can do this, I wanted to get a sense of how many of you are on Twitter here. Everybody? Not everybody, but the majority. See, most times when I talk, the people who are really worried about their health, happen to be at least 50, 60, 70, and they donít even know Twitter exists, for the most part. This is a different group, and itís fun to talk to folks who are more plugged in. I get most of my valuable information from Twitter. Iíll show you a couple of slides that I made this morning, through Twitter. So thatís, kinda for me, a, a, great reservoir, if everybody shares their, their information that they get to, with everyone else interested in a particular space, itís great. So, I wanna convince you of three things. The first one hopefully will be the easiest, because weíre here at a, a, major force thatís done this. Our world has been Schumpetered. The second is that medicine is going to go there, and itís just started now. The third is that we need consumers to drive this whole thing forward, because otherwise, uh, at least some of us will not be around to see it. And, I certainly want to see this thing take hold, and improve the whole way we render, uh, prevention and healthcare in the future. So, I wanna start off on the digital side of thisÖ and thatís your kind of comfort zone I knowÖon zero-one and just to point out, and I think youíre very well aware of this, in the last decade there was just a remarkable jump forward, the likes of which weíve never seen. And, of course, in the, uh, in context for example, there are now more cell phones on the planet than there are toilets or toothbrushes. Thatís a pretty big, uh, thing that who would ever had th--, when Marty Cooper invented the cell phone in 1973, who would ever of thought that would actually happen, and so quickly, particularly in the last decade. And then these devices have been remarkably transformative. And, the span of time from the iPod in 01í, all the way through, uh, the Blackberry then was renamed crack berry, now more recently slack berry. Then thereís iPhones, prototype phone. And, of course, I guess here I should have put a Droid phone up there, but, sorry about that. Then thereís the EBooks and, uh, the Tablets. And this is nine years. And these devices and Iím looking around thinking, ìWell how come youíre not looking at your device right now, because youíre basically surgically attached to them?î And youíre giving me the great privilege of a few minutes of attention, before you delve right into your mobile devices. So theyíve been very remarkably transformative. And, in fact, everything that we do, well beyond how we communicate, uh, how we think and behave has been very much influenced by these wireless devices. In fact, when you think about that, if life could have changed so quickly in this span of nine years, how come it couldnít do that in the medical sphere? And that really got me thinking. So, in fact, this current issue of the Economist, um, uh, is this article, this Schumpeter column, ìSlave to the smartphone.î I donít know if you think youíre a slave, I certainly feel Iím an eSlave to the smartphone or tablet. Because thereís so much information coming in and you certainly want to try to communicate with your, with your network. So, whatís going on now is that itís not; it isnít even just one screen that we are attached to; itís now become multiple screens. And, now itís a tablet, itís a PC, a computer, itís a smartphone. And now we have a new species of man, a *** Distractus. As demonstrated here, a *** Distractus has a new add on feature, cause later this year I understand thereís gonna be these Google glasses. And I havenít seen exactly what they are and this is one speculate of design of them, but if you really have augmented reality, uh, as well as being able to potentially read things, uh, from the web or your e-mail from your glasses, thatís gonna be yet another screen to, uh, to add to the *** Distractus. It starts at a very young age, uh, this whole process. So, youíre not so far removed from that. [Laughs] >>Eric Topol: And, I uh thought that was pretty young, when I looked at that, and then I didnítí realize itís actually starting at an even younger age as shown here. And so, this is a, I think, a phenomena thatís very, very interesting. And I know that so many of you are digital neighbors here, the vast majority, so you can appreciate that for those of us whoíve had to learn this whole world in the mid-stream of our lives, has been much more challenging. So thereís some questions Iím going to ask you, and theyíre obvious, but Iíll ask them anyway. Uh, but, I wanted to give you a sense of time compression. So what was zero in 2004, and then was 800 million in 2010, was? >>Eric Topol: I know you know the answer to this. >>male #1: I think it was the number of users. >>Eric Topol: Yeah. There you go. OK, I like that answer. So, that of course, represents a competitor. But, youíre well aware that thatís gonna be about a billion, unless thereís an awful lot of defriending that occurs between now and then. To go to Google plus, or I donít know what. Uh, or just abandon social networking, which I think is most unlikely. Of course, the evaluation of this company is predicated on the like button and this is a beginning of a social network dedicated company of digitizing people. Weíve been doing that for a long time, at Google, much longer. What year was Google founded? >>Eric Topol: NinetyÖninety eight? Anybody know here? ë98. Ok, so youíve been in this world of digitizing people, in some respect, for a long time. And of course, the worst thing that could happen is you wake up and you donít have any friends. Thatíd probably be good if you were trying to, uh, promote your social network. But these companies, your company, Facebook, Amazon, Apple, have done an extraordinary job of digitizing people at a very superficial level, not medical, of course. Weíll get into some exceptions of that. But, what it shows is that you can collect some data. And this, of course, can be very important for, uh, individuals likes and affinities and important for, uh, consumer engagement and purchasing and that sort of thing. But, the way to this goes is medical, and thatís where this can go over time. So I thought you might have seen this article, perhaps, in the Atlantic, uh, just a couple weeks ago. About, uh, Iím being followed, how Google and 104 other companies are tracking me on the web. Have you seen, or read that article? Yeah? No? You donít, anyways itís a very interesting article. It talks about how no matter what youíre going to get digitized, essentially. Not using those terms. And then this other feature article in the New York Times magazine, was about, uh, the idea that the retail, itís not just Google and 104 other companies that are, that are set up to do this, but in fact thereís Target and all the retail companies that are doing this. And so they know, for example, a woman is pregnant before her family even knows that sheís pregnant because of the data that can be, uh, acquired. So I thought you might enjoy this if you hadnít already seen it. This is how to protect yourself from getting digitized by Google. Um, have you all seen this already? I saw this and I broke out in hysterical laughter. Because something I said, ìoh my gosh, play the music loud so they canít hear what youíre typing, unplug computer from power source, medical gloves to obscure fingerprints and finger scans on keys.î You know, but obviously this isnít just applying to Google, this is applying to the fact that you may be getting digitized to some extent. And you donít really have a way, all these things are not gonna work, of course. So, thatís the way life is today. Then thereís this social network. This is uh, of course, zero in 2006, zero. Now two years later after the beginning of Facebook, and now well over 300 million per day. And you know what that is? Thatís the number of? >>Audience member: [inaudible] >>Eric Topol: Somebody said it. Yeah. So, that is of course part. Now the big three, perhaps in the US, um, but thereís all these other social networks around the world and are, of course, many of them are country, continent specific. You know, thereís Brazil with Orkut, then thereís QQ in China, and that sort of thing. Well this together, has created a force that no one couldíve predicted. And, you know, I think when Eric Schmidt said, we missed the friend thing, we all missed the friend thing, it wasnít just at Google. But now this friend thing with sharing pictures, and emotions, and thoughts, and videos, has had, of course, monstrous, uh, phenomenal impact. And thatís why revolutions have occurred, the Arab Spring, the Occupy Wall Street movement and so many other things are power to the people by crowd cheering, crowd activating, and crowd sourcing, really a remarkable time in our history and in our civilization because of this electronic bounty of people. So, this is an example of a rudimentary social network that has had a medical impact. And this is, uh, as far as we know, the first person on Facebook, whoís punitively, his life was saved, a young boy who was very sick and, uh, he couldnít get a diagnosis. He went to two pediatricians and then, uh, his mother posted his picture on Facebook, and one of her Facebook friends made the diagnosis of Kawasakiís disease. And thatís what led to, uh, the right treatment and of course heís doing very well. And now, there are, uh, an explosion of these online health communities. And this is a good thing, but itís also been an awakening because now so many people with a chronic condition, whether it be diabetes or, or a type of cancer or things like multiple sclerosis, they go on these patientís like me and other communities, uh, together, they find people with the same condition, and now these virtual peers become the people who they trust the most. Theyíve never met them, but they trust them much more than their doctors. Which is really a uh, in many ways, a seismic shake up of the relationship between doctors and patients. And so much so, that this to me is shocking, this is nearly 4,000 doctors who were polled, as to, ìdo you know that thereís these things, like patients like me?î And only 11% and this is recent just a few months ago. [Laughs] >>Eric Topol: Only 11% even knew they existed. But if they talked to their patients, they would find that thatís who their patients are spending their time with and getting guidance. So that shows you the chasm that exists today between the medical profession and what the needs are and the access, the capabilities, of empowered consumers who want to get this information. Now, I know youíre gonna get this one right. Right? This is the one group that could get this one right. What does this represent? >>Eric Topol: Nobody knows? Really? Okay, itís at the San Diego Zoo, does that help you? >>Eric Topol: No? Okay, Iím really surprised. This is historically very significant. This is the first YouTube ever video. Ok when was that? April 2005. Well over 6 million hits. Now, why is this important? Itís a stupid video, it just says, ìHere I am at the San Diego Zoo!î Alright? But, the point is that this is just not even seven years ago and look at the data for YouTube. Okay? This is an amazing thing. 800 million unique users per month, 3 billion views per day, 3 trillion hours of video per month. I mean this is staggering, 60 hours of video are uploaded every minute. What are we doing sitting here? We should be watching a video or uploading or both. So this is an amazing amount of data in this video and graphic world that we live in. And so much so, that we are generating data at a clip which no one could ever have forecasted. That is from the beginning of civilization to 2003, there were only a billion gigabytes, which is kind of amazing because we walk around with lots of gigabytes in our pocket. And now we are generating a trillion gigabytes, a zettabyte, at least one, every year that plot of course, is markedly increasing. And thatís why it looks like weíll have well over 35 zettabytes by the end of just this decade. So that creates a big problem with data, especially when you wanna extract out of that data, the useful information that has heretofore often been only scratching the surface. And this big data term, is terribly underplaying the ginormity of this data issue. But, just like Moneyball, um, we can have this in medicine; we can learn a lot more about a particular pitcher or batter by doing a lot more work on that data. And weíd like to learn a lot more about each individual. Prevent them from becoming a patient, by doing this sort of thing. How are we going to do that in this world of just, ginormous data flooding? Well, the super computer of Watson has been, uh, and other super computers, has been suggested to be able to save a life. And, of course the reason for that is that because a super computer, Watson, can process two million pages of content in 3 seconds. Now, there are a lot of really good doctors out there, but I donít think they can get to two million pages of content in 3 seconds. And if you have a really complex patient, that you donít know whatís going on, like what happened with WellPoint, one of the largest insurers, they decided to contract Watson, because then they could feed all the, get all the information about a new individual patient to help sort out in a complex diagnosis. Thatís a good thing. Why donít all doctors, and all patients, have access to a super computer in times of need. Thatís where things will go, eventually. Then thereís the cloud, of course. The cloud story, which is amazing, itís important that this of course emerged these massive server farms because otherwise we wouldnít be able to store, or even, um, handle, manipulate some of this data. So whatís great about the cloud is now itís even making its way to places like United Health. And recently they have, uh, just last month, uh, declared theyíre gonna make their cloud data, which is their largest private insurer of health in the United States, available to all their doctors and soon to all their patients who are covered by United Health. Thatís a step in the right direction. But this cloud thing is so overcooked, that I thought these cartoons might help put it in perspective. This one is the check is in the cloud, and the other one, it was much nicer before people started storing all their personal information in the cloud. Ok, so now we have this kind of rapid fire, it started in the 70ís, it wasnít so rapid then, the cell phone I mentioned, the personal computer, the internet. And then things really started taking off. And you see this, uh, clustering. In a short period of time of wireless digital devices, sequencing social networks, cloud and super- computing, all setting up the potential for this, uh, era of a great inflection in medicine. And thatís where Iím gonna be, of course, trying to convince you, that weíre on the cusp of that right now. Of really, uh, actualizing that opportunity. So, book stores and books, thereís a really interesting story there. How many of you only read books as an E-book? >>Eric Topol: No. One? Two? I guess, three. Alright. And how many will read only hard copy books? >>Eric Topol: Ok, four. Ok, so should I assume that the rest donít read any books or read a combination of the two? Help me on that. >>Audience: Combination. [Laughs] >>Eric Topol: CombinaóOkay. Okay. Anyway, thatís alright, if you donít read any books, you have a lot of other things to do I understand. Um, so, the reason I show this, of course, that thereís a prediction that hard copy books are gonna be no longer with us. And, of course, weíve seen the likes of things like Borders Book Store chain of book stores closing. Well, today is a big day. Today is the day on the front page of The New York Times, The Encyclopedia Britannica, after 244 years, thatís the same time when Voltaire were saying that we didnít know anything about medicine. 244 years later, The Encyclopedia Britannica, is mea culpa, weíre not going to print this thing anymore, ever again. Thatís pretty striking. Thatís today. And, to me, the final thing about this book, Iím using the book thing as to, uh, emblematic of the world changing. I could go into all sorts of other things, but this is the one, I think, that really hits home for me. I did some of my training, my cardiology training, at Johnís Hopkins. And Johnís Hopkins has this library that I lived at a lot, called the Welch Medical Library. And this library was closed on January 1st, the second largest medical library in this country, no longer functional. Does that tell you a story about where we are in a changing world? In a world thatís been Schumpetered. So I hope Iíve convinced you of that fact in this opening segment. And if I havenít, then this probably would be a good time to move on because itís the best I can do, in this time span. [Laughs] >>Eric Topol: Okay. Now weíre gonna talk about medicine and how it will, inevitably, be Schumpetered. Because up until now, the digital macrocosm ginormous infrastructure, thatís been developed, which Iíve very briefly reviewed with you, that youíre very much, uh, in touch with. Then thereís this medical microcosm cocoon thatís done everything possible to not let there be any conversions, or any penetration of the digital world. The only foray into that has been this very weak lack of, uh, real legs, use of electronic health records, and, of course, accounting for the difficulties that you experience with Google health records, and that sort of thing, because itís so resistant to the digital world. Well, thatís gonna change. And this is all gonna come together. There will be a conversion itís just a matter of when. And when that happens, thereís a big, big thing, that weíve never had before, and thatís the ability to digitize man, digitize human beings. Not to find out what theyíve purchased now, or what they will purchase. But rather, what makes them tick. And thatís really an exciting thing. That takes us away from where we are in medicine today, which is at the population level. Everything we do is population based. So, for example, when we say all women after age 40 should have a mammogram every year, thatís treating all people the same. When in fact, many woman, a significant portion, have zero risk of ever developing breast cancer. Another example, we give a medicine for a particular condition, letís say diabetes, we use Metformin. Thereís 400 million diabetics on the planet, they get the same drug, the same dose, even though 25% of them are unable to respond to that drug. But thatís how medicine is practiced today. We do large clinical trials of thousands of patients, we find a few per hundred benefit, and then everyone gets the drug. Thatís wrong, totally dead wrong. And now, for the first time, we have the tools to understand things at the individual level. And thatís extraordinary. And thatís what weíre gonna get into. So, uh, Thomas Goetz, the editor of Wired magazine, wrote this really brilliant feature article in that magazine about the feedback loop, and the whole point here is, itís a feedback loop of data where thereís genomic data or physiologic metric data, Iíll show you a couple of examples. And that changes things. Thatís like a real reset of how we understand any given individual. >>Eric Topol: So, this started in the healthcare world. Uh, fitness world I should say. Whereby, uh, Nike shoes, I donít know how many of you have these Nike plus shoes that have sensors in the sole of the foot and they can track the distance and the velocity and other metrics of exercise. And then these wireless accelerometers, have any of you tried things like the FIT Big BodyMedia? You have? Okay, great. So those are, I recommend them to my patients because they encourage you to be more active. And, uh, um, I think that, thatís a great thing. Theyíre relatively inexpensive. The most recent one, was just um, uh, announced a little over a week ago, the Nike FuelBand. And so they encourage people to be more active, thatís good. And then thereís the use of sensors for detecting your quality of sleep, because we live in this wired world of wireless devices. [Laughs] >>Eric Topol: And we donít get enough sleep. In fact, the overall sleep of the population has been declining in a very, uh, worrisome pattern. So thereís a device that Iíve used, there are many devices that monitor sleep this is the only one that monitors brain waves. And this is a new device, have any of you ever used it here? >>Eric Topol: So we got the same 3 people that have used all these sensors, okay. [Laughter] >>Eric Topol: Thatís alright. Someday your, your experience will wear off on the others here. Anyway, this is a great, uh, home electroencephalogram. Who would have ever thought you could have your brain waves at home, for $99, going directly to your phone, pretty neat. And, uh, thereís also a clock version, which is what they came out with originally, and it shows right on the clock every minute of sleep. This is a night of my sleep. You see the orange bars are the awake time, the grey bars are light sleep which isnít worth much, the light green bars are the dream rapid eye movement sleep which is a good thing. And then the best of all is deep restorative sleep, the dark green .So Iím using this and, uh, Iím trying to get to be a better sleeper and very shortly after I started using this, my wife who is a night owl, comes in the room and she looks at the clock and she says, ìEric, I know youíre awake, and I wanna talk.î [Laughter] >>Eric Topol: Ok. And thatís good that people at this age can appreciate that, because thatís, of course, one of those kinds of things that, uh, you would particularly appreciate getting older. [Laughs] >>Eric Topol: Anyway, whatís interesting is, uh, you also know, of course when anybodyís, their brain is awake. And besides, this was discovered by three, Brown university college students. They didnít wanna do this. What they wanted to do was not to have to be woken up out of a deep sleep. So they invented this sensor, just so they wouldnít have to wake up, they wanted only to be woken up when they were in a light sleep. And thatís what led to this interesting device. Well, of course, when the Wall Street Journal reviewed this book, the Creative Destruction book, but what was really interesting they picked this as the call out for the article which was kind of I didnít think that was the most significant statement in the book. But it was kind of interesting that they did that. Now, what was also, uh, interesting is that itís representative of where medicine is going, because now you have data for your sleep, compared to ten thousand people of your age group, your peer group, because as you likely know, as we get older, our sleep deteriorates, and so you want to have a group that you compare with. And just think about glucose, thatís blood pressure or any metric thatís relevant in medicine so you can compare. And now whatís really interesting is that this has become a big fad in, among athletes. And so knowing your DQ score of your sleep, now thereís triathletes that are using this, thereís three NBA teams that are currently using Zeo every night to maximize their athletic performance. And so this is now a very safe way, as opposed to other historic ways, that athletes would try to improve their performance. Well whatís also interesting is that now among pro athletes thereís a compilation of all the data of pro athletes. And this is a, uh, bar graph that, uh, summarizes it. The King of sleep among all the pro athletes is LeBron James averaging 12 hours of sleep a night. And whatís interesting is, no wonder theyíve never won the playoffs. [Laughter] >>Eric Topol: And then, the other interesting facet of this is the person with the very least sleep is Tiger Woods. And Iím not gonna comment further on that. [Laughter] >>Eric Topol: Now, there are, um, very, uh, kind of early staged devices now that you can get your blood pressure that are fun. It doesnít quite gamify things, but it does make it a lot more fun. So now my patients, instead of recommending the traditional blood pressure cuff, called an Omron device, that go to Cosco, I now send them to iHealth or Withings to order it online, again, $99. These things are fun, you just press the button, gets the blood pressure, it charts it, it sends it to your doctor or your Facebook friends or your Google plus circles, whatever. And then you have it all stored. And then you, uh, have it all stored. And the same thing for glucose, thatís a good thing. Thatís not where we want it to be, we want it to be seamless, but thatís at least a step in the right direction. Well, this is also the case for diabetes. For, uh, Type1, also called insulin- dependent juvenile diabetes, we can measure glucose every 5 minutes. But currently, thereís separate receiver, itís bulky. If youíre a diabetic, you donít want to have this big device to be pulling out all the time because then people would say, ìWhatís the matter with you?î You gotta tell them, ìWell, I have diabetes Iím looking at my glucose.î What I have is a prototype that Iím wearing a sensor just like pictured on this, on this slide. Uh, you can wear it on your abdomen, or your arm or wherever. And I can just turn on my phone and, uh, I can see it when I turn it on 137 and I can just say my glucose at this very moment in time is 10. And thatís good since we just ate lunch at your cafeteria with the unlimited buffet. Iím glad itís not a lot higher than that. But whatís also nice is I can just, um, get the data for the trend for, you know, hereís the three hour trend for glucose, six hours, twelve hours, 24, whatever I want. And I can send it, if Iím concerned, to whoever I wanted to send it to. Thatís the beginning of an exciting time for example, lifestyle improvement, if youíre looking at something, should you eat it or not, and youíre looking at your phone and itís gonna tell you what your glucose is gonna do when you eat this big cookie. Well, you might not eat the cookie because you donít want to stress out your pancreas. Particularly if you know that youíre pre-diabetic, or youíre genomicaly vulnerable to get diabetes. Now, Roni mentioned this in the intro is that this is a device, that, uh, I can get, uh, I gotta pull up my iPhone. But this is the device where I can get a cardiogram, right on the device. And so, itís, you see these two sensors on the back; you make a circuit with your heart like that. And so, um, you know, this pops into the case. I can then just turn this thing on and get a cardiogram, just gotta um, um, put in, uh, my password and the app. Get that ready and then Iíll just show you, that hereís my, put my fingers on the back and then weíll pop up my cardiogram. Now, itís really a cool device, because, you say, ìMy gosh, why wasnít this invented tens of years ago?î And whatís also pretty cool is that I have this credit card version, where you can put it in your wallet or you can put it in your purse has the same two sensors. And then you can hear the chest leads, I donít know if youíve ever had a cardiogram but you can get the different leads, like this. And thatís what you heard about being on a plane, it actually happened, where someone in the last row was having chest pain, they called for a doctor on the plane; there were three other doctors who were surgeons that donít really know how to evaluate chest pain. And I donít know if Iíd know how to evaluate it fully unless I had a cardiogram. And, uh, this is, you know, at 30,000 feet. You donít have a cardiogram to do. [Laughs] >>Eric Topol: But, now I have it and I can say this person was having a bona fide large heart attack. And that led to an emergency landing of the plane. And also, when we landed, and the, the passenger was whisked off to get the artery, the heart attack artery opened up. Then the pilots and the flight attendants all wanted to have their cardiogram done. [Laughter] >>Eric Topol: Which was really interesting. Okay. So, those are just a couple of devices to show you, to give you a sense of how this field is moving fast. And, you know, theyíre actually getting old now, there are a lot of other devices I couldnít bring with me today to give you a sense. This one is really interesting, the Holter monitor. You probably donít know what that Is, but this was invented in 1949 with a frozen design. And you have to wear all these wires to find out your heart rhythm over the course of 24 hours. You have to go in and get it connected, then you have to go to a clinic, then you have to go back to get it disconnected. You canít shower, you canít exercise. Now you have band aid, you send it in the mail, you send it back. Itís a Netflix model of heart rhythm monitoring. Okay and itís great. But, you know, itís only happened in recent months that this was available. And then, just to, uh, give you a little bit of more sense about what you can monitor on a phone this is all the vital signs. Not just blood pressure, but also your oxygen in your blood, concentration, your blood pressure, heart rhythm, temperature. And, you know, this is an amazing ability to basically have all vital signs on your phone continuously. So your phone in the future will look like this. This is technically feasible today. And it will get your constant read out of all your vital signs. As if you were in an intensive care unit. Now you may not want to look at that data or have that, but it certainly will be interesting to see how that plays out and how it can help prevent people from having to be in the hospital. In fact, I think there wonít be hospitals in the future, except for intensive care units. Why would there be a hospital when you can do all this stuff at a patientís home? And itís much less expensive, much more comfortable. So why, eventually, are we gonna need hospitals except for very limited reasons. Now, just some other apps to mention that are useful. If youíre, um, for someone who has a skin lesion that youíre worried about, you donít have to go to the dermatologist anymore. You just get a picture done, text within minutes saying not to worry, or you should indeed get this looked into. And then, this one is amazing, if youíre an optometrist, you better watch out because now thereís a $2 add on to the phone, it was invented at MIT, that gets refraction of your eyes and then sends that data to your, uh, to get your glasses made, for $2, pretty remarkable. And then you can pass it around for all your friends, and your social network. And itís not, of course, being used that much in the US but its sure getting likes around the world. And this, just speaking of eyes, thereís ways to monitor the pressure in the eye, to prevent glaucoma. This is available in Europe, constant monitoring going to your phone. And then thereís these things like a Wheeze-o-meter that analyzes your breathing to prevent an asthma attack. And then this morning, I, I encountered that there is another, uh, interesting facet to asthma. This was reported that thereís this smart inhaler, most people, when they use an inhaler they use it wrong. And now thereís a video game to make you use it right. And thatís really part of this gamification of medical devices. Itís all part of this new era of medicine. Thereís also the ability to digitize breath, to say whether or not someone might have lung cancer, at a pretty high specificity and accuracy. So, youíre competitor, Apple, has certainly been seen, like Google, as a big innovator. And so, in fact, at the time of Steve Jobsí death, it was thought well may the logo should be changed, and of course, like you, this company has had a big worldwide impact. And I thought you particularly might enjoy this one if you havenít seen it. This is the cover of The New Yorker. [Laughter] >>Eric Topol: And then another company cartoon. >>Eric Topol: Well, in this biography, which I donít know if any of you have read here. Some of you may have read, I think itís a very good book. But Iím particularly, because it traces a digital revolution over the course of really three decades. Took a while for it to be where it is today, but itís now, of course, going in exponential fashion. And then what was striking to me is this quote, because it was occurring near the end of the book. And it said, from Steve Jobs, ìI think the biggest innovations of the 21st century will be the intersection of biology and technology.î Thatís where you sit today in a digital frontier, and this is the big uncharted opportunity, and I certainly couldnít agree more that this is the real story going forward. So now we just touch on the one aspect that is really biology. We were talking about physiology, but letís get into a little bit of biology and that is genome sequencing. >>Eric Topol: Up until now, in the recent years, weíve been relying on these next generation sequencers that cost æ of a million dollars. And then a whole lot more expense for the re agents that are proprietary to run the sequence. The six billion letters that comprise a human genome that has to be sequenced 40 times, at least, to be accurate. Well, in January, this device, the ion and proton, was released and it said that it could sequence the human genome in two hours, prior to this and still today it takes us about ten days. Dropping down from ten days to two hours? Thatís pretty good. Well then this device last month was released. This is a USB size device. This is now to get a sequence of a human genome in 15 minutes, for less than $1000. In fact, itís quoted as $900. This is, uh, exceeded Mooreís law at a level that is unprecedented, uh, you know, in our history. And so whatís exciting about this is how you can apply it. And youíve been hearing about the human genome since 2000, if youíve been at least looking into this impact on the future of our world. But, you know, this is a sequence you can get right to your laptop. Then you can take a boy like this, whose life was saved by sequencing. Nicholas Volker. At this point he was nearly going to die. He had 100 operations. I donít know any human being thatís had 100 operations, no less a 5-year-old. And he was very sick in the hospital intensive care, in a hyperbaric chamber. His pediatrician said, ìLetís sequence him and see what is potentially this disease weíve never seen in a human being before.î And that led to a finding the mutation that was the root cause, and that let to successful treatment. And now Nicholas Volker is healthy as could be, cured 6-year-old. And thatís a great story because it tells you the power of sequencing. Telling you, digitizing a human being who is so sick that no one knows what it is, and be able to turn that around into having, hopefully, with this young boy, a normal life. This is a family from San Diego, the Beery family. Uh, and so, these twins, Alexis and Noah, were very sick. They had a movement disorder, they couldnít really function. In fact, Alexis was in the emergency room, she couldnít even breath many times, she had a respiratory arrest. And so they got sequenced. They determined the cause. They determined the right therapy. And now Noah is a soccer star and his sister is a track star, just by sequencing. This is a protocol that we have at Scripps, called IDIOM. IDIOM, it stands for idiopathic diseases of man. Thatís a terrible term, idiopathic. Itís a fancy medical term for we donít know, idiopathic. Why donít we just say, ìWe donít know?î [Laughter] >>Eric Topol: Anyway, this is a 15-year-old girl, who is wheelchair bound, whoís brilliant. Blogs and is cheerful. But, she has an unknown condition, and weíre sequencing her along with other individuals right now, trying to digitize their biology so we can get the root cause and hopefully it will prove to be actionable. So we wanna get rid of this term idiopathic, itís a bad term anyway, but itís also one that we can get rid of because we can sequence people and understand what is really going on. Then thereís of course the cancer war that was declared decades ago. But now, itís the real deal. We can actually do something in cancer. This is an example of a tumor called malignant melanoma metastatic. Skin cancer all over the body and this is a PET scan that shows the extent of the burden of cancer, and then two weeks later, after an oral pill directed to the mutation, that was causing this cancer, a BRAF gene which is present in about 2/3 of people with this type of cancer, there was no evidence of any cancer. And this occurs in 85% of people, who have this type of mutation, in this particular cancer. So itís a great step forward and it shows you the power of knowing what is the root cause of a cancer. And then having a therapy directed towards it. Hereís another example of a different drug that just got approved. But this is another basal cell carcinoma or brain cancer. Medulla blastoma, two weeks later specific against this hedgehog gene pathway and then you have no evidence of cancer in over 85% of people just to prove. The problem we have in cancer today, is to do this, we like to have, uh, the tissue to be able to sequence. In fact, get a whole genome sequence. But today, the tumor specimen from a biopsy or a surgery is deposited into formaldehyde and itís ruined. So weíd like that on track to just being FF, which is flash frozen. So that needs some work. But this cancer improvement, in getting people to get the right therapy, is on the way. And then beyond the whole area of cancer there is many conditions like cystic fibrosis, weíve known the gene for many years, but finally have a breakthrough. This is a drug called Kalydeco which is just approved, itís directed against a specific mutation that causes cystic fibrosis and only is accounting for, letís say, 3 or 4% of cystic fibrosis. But itís very potent and works exceptionally well. And then this young girl, who couldnít breathe hardly at all, she now is, as you see, uh, very mobile and living a normal life. And this drug, as I mentioned, not only did it just get approved, but it had eureka effect. In terms of normalizing things like so called sweat chloride and beyond that, even more importantly, that you could see the impact, the breathing, the placebo sugar pill versus the drug. And here you just see a weight gain of kids, just dramatic, uh, eureka type effect, which is great to see in a small number of people. This is a pretty gory slide, but what is showing is the drug reaction that can be lethal. The reactions called the Stevens- Johnson syndrome and it can be particularly induced by a drug Tegretol, which is used commonly. But now we know the gene that predicts this and we can prevent someone from dying or having to be so sick from this. Because one genotype, one basic analysis can solve that problem. And then just last week, I had a op-ed in the New York Times about statins. I donít know if youíre familiar with statins, itís the most commonly used prescription drug. But unfortunately, itís overdosing the country and the side effect of diabetes has been underplayed. And this graph just shows that 1 in 255 people, in respect of any statin thatís been looked at, get diabetes from these drugs, in the 91,000 patients in all these different trials. But whatís most particularly concerning are the potent because these are the statins that have the particular liability. And these are like Crestor, Lipitor, high doses of Simvastatin and those are the ones to be on the look- out. But yet, we donít know the genes, the variation of the genes that are accounting for this problem. Now one other area, just to touch on, about digitizing people, and thatís imaging. Now, the stethoscope was invented in 1816, this is that cartoon of Rene Laennec and that stethoscope doesnít look like that anymore, thank goodness. It looks like this. But we donít need a stethoscope, for example, to listen to the heart because we have a portable, high resolution ultra sound device that fits right in the pocket better than a stethoscope. And this device, and in just a minute, you can capture exactly what the heart looks like. And this is, uh, you know, an amazing tool because we can basically digitize the personís heart in a minute or two, and no longer are we listening to ìlub dubî which isnít really that informative when you can see everything. This is a normal heart, and hereís an example of a very sick heart, where you see much less ability of the heart muscle to contract, all the chambers of the heart are very dilated, thereís a lot less blood flow moving. Just to give you a sense, these are images that are acquired in a minute and they can be not just of the heart, the abdomen, they can be of the fetus, for a pregnant woman. All sorts of things that we can do, we couldnít do just a year or two ago. The thing that perhaps you might find the most interesting, perhaps scary, is the ability to read your mind. And the idea that we can read, see the movies in your brain. You say, ìWell, that canít possibly be.î And about imagining, this is not just mind boggling, this is mind blowing. This is now the ability to construct brain activation maps from functional magnetic residents imagining of the brain. And we can digitize brains, and best exemplified by this UC Berkley study published last fall, where they took people, young people like you, put them in a magnetic residence imagining, showed them a U2 video, and then they without any knowledge of the video they tried to construct what the individual was seeing in their brain. This is what it looked like. You say, ìWell, that doesnít really like Steve Martin.î Or, ìIt doesnít look like that.î But you know what, thatís pretty good not knowing anything about the video. And this is, you know, vintage 2011. Whatís that gonna look like in 2013 or 2015? And they just recently published the same sort of thing with auditory signals they can reconstruct the music or whatever the sound was through the same type of technique. So, I just wanna, last couple minutes, put this together. This is the, uh, crack to try to get in your mind. This is why people die; they have a crack in their artery. Whether itís a crack in their artery of their heart or to their brain that causes a stroke. And a crack is something we havenít been able to diagnose. This is, has been elusive. We havenít been able to digitize the people who are gonna have a crack. Uh, Tim Russert was in the NBC studio and he collapsed, had a massive heart attack. But two weeks before that he had a normal treadmill test, common scenario. Now why did that happen and why is it so common? Because we do these treadmill tests all the time, but they only tell us if thereís a tight narrowing thatís blocking the blood supply. Most cracks occur where there isnít a tight narrowing, and we havenít had any way to diagnose that. Well now, we have done a study where, in the San Diego area, weíve had all of the heart attack people, we got blood samples in the early minutes to find the cells that were sloughing off from their artery. We found them, identified them, sequenced them and have all kinds of genomics that weíve done and weíve shown that that is a unique signature that we can detect. And, in fact, weíre publishing on that in just a couple weeks in a leading journal. So, this is important because then we can combine this and develop within embedded sensor. We have all these embedded sensors in our car, well, I think our bodies are more important than our car. And you probably take all that stuff for granted because youíve never been sick. But, those of us that have been sick would like to have an embedded sensor to prevent significant illness. And this is a chip that was just published on at Stanford, not far away of course. A microchip that you can put in the blood to detect whatever you want, we have also been working on a nanochip the size of a gran--, grain of sand just like this. You take the grain of sand nano sensor and you put it in the blood, like in the wrist, and then you have this molecular signature of a heart attack, and guess what you have? You have the new app for heart attack. Or, alternatively, an app for detecting the first cancer cell in the blood, since most cancers have a vascular supply. And, of course, for diabetes it takes five years to become a diabetic that is, uh, immune-mediated diabetes you could detect in that five year stretch to prevent diabetes, or prevent things like a transplant rejection. Here is a cell phone, becoming center stage for the future of health because of this embedded sensor capability. So, the last thing that I just want to mention is consumers needing to drive this. Thatís actually why I put this book together. Because this is a real opportunity that would be left in a stasis mode unless we get moving. And, uh, to me itís just remarkable. This is in January in the Wall Street Journal and it was a survey report of physicians using e-mail. E-mailís been around a long time, even before Google. [Laughs] >>Eric Topol: And Iíve been using e-mail with patients since ninety, I donít know, ë93,í94. I donít what, you know. This is amazing, we had had 62% of physicians refuse to use e-mail with their patients, today, itís 2012. This is an amazing article from JAMA, the leading journal in medicine. It says, ìShould patients have access to their laboratory tests?î Well, sorry to say itís their laboratory tests, how can they ask this question? How about this one? This is, ìShould patients have access to their office notes, from the doctor?î How could you ask that question? Just because it might say in the note, that the patient, that, uh, had something about SOB and it means shortness of breath, you know, eventually the person should figure that out, of course, maybe need a little bit of guidance. Thereís this fellow, who is in the Bay area, Hugo Campos, who has a defibrillator, he just wants to get his data of his heart rhythm from the company and they wonít let him have it. And, heís on a tear, appropriately, he should get his data. And then the worst of all is the American Medical Association. They are lobbying the government to prevent people from getting there DNA data. They only want doctors to be the ones to privy to that data to mediate giving that to patients. Which, of course, thatís not, thatís I think, violating the rights of the individuals. So thatís the right to the emergence of citizen scientists. And thatís, I think, a great thing. And this just came out. I just saw this this morning. This is a group at McGill in Canada, and they have gamified, uh, the use of sequencing. Itís very difficult to align sequences, and they made it into a game, a video game, and they have found that people with no scientific background could actually figure out how to align sequences and make it into a fun puzzle, and thatís amazing. Just to me, that you could take these sequences and make it into a game to assemble genomes. And that kind of gives you a sense of where the world could go. So, I leave you with this last, uh, thought, which is that, itís your charts, office notes, your laboratory tests, your scan results, your bio sensor data, your DNA, your tissue, your social network, thatís the way medicine should be. And since all this data is gonna be now going into high gear, your ability to access it, this is, uh, the time for the, the individual to rise. And thatís whatís gonna be necessary to really execute the future of medicine. So, I just, the whole thing putting it together, we have this old Voltaire medicine today. And we can change that by really bringing together the new tools that Iíve reviewed in digital medicine with the digital infrastructure. And that could lead to super conversions, the biggest in our history, and then of course, to this new participatory precise medicine of the future. So I hope I can leave here with this concept that was the whole goal, that the future is indeed bright. Thanks a lot for your attention. [Applause] >>male presenter: So what should ordinary people, um, like non, non, uh, medical people do? Is it now up to us to somehow figure out that we need to not sign the consent forms before having our brain surgery until they change it to say, ìWe will not put your tumor in formaldehyde.î >>Eric Topol: Yeah. I think that, well if you, if you today demand to your doctor that I want some of my specimen, I want my motherís specimen to be put in freezer, they have to do that, so, but only if you know about it. So, thatís really part of the problem is it isnít even on the consent form, itís just a matter of knowledge. And that is what we have a big problem, is people just not aware of the opportunity that exists today. >>male #1: Are there, um, any sensors to do with things coming into the body or what youíre coming in contact with. So, I would think, something that monitored air quality, that monitored, monitored what was in the food you ate, that monitored what chemicals that came in contact with your skin, and that way you could see correlations between what people came in contact with and the actual symptoms they had or the diseases they had. >>Eric Topol: Yes, great point. Um, so for asthma, a sensor of the future that some people are working on, is one that will pick up air quality as well as these other things that you, put, um, youíd be able to prevent an asthma attack, which, of course, can be lethal particularly in children. So thatís one example. But youíre absolutely right, because, you know what we take in our food stuff effects our micro biome. And so, for example, over lunch we were talking about, ìIs it all about a story of calories in calories out? Absolutely not because thereís a micro biome, you know we have this, um, millions of different, uh, bacterial flora organisms in our gut, which are changed by our diet. And also by taking antibiotics for example, and that has an reaction of, in some people, uh, pushing them towards obesity or changing their metabolism, or making them at risk for diabetes or other named diseases. So youíre absolutely right, we need to get that data, itís not just what you excrete or what makes you tick. Itís also your exposome, your environment. And that includes food, you know, um, air and your water, all those sorts of things. So itís a great point. Thank you. Yeah. >>male #2: Uh, in the uh, early 2000ís, I asked a family friend whoís also a doctor, about the fad that came out at that time about doing whole body MRI scans. And, uh, and he basically said, ìDonít do it.î Heís like, ìThe problem is that youíll find all sorts of things that are wrong with you, that probably would do more harm than good to treat.î [Laughter] >>Eric Topol: Yeah. >>male #2: And I think we see the same thing with like mammography, the recent debate thatís been going on with that. So, I guess this isnít really a good argument for not collecting the data, but it is, I think, a need for how do you analyze it? Or do you have any insights into where the thresholds are for when you actually should take action? >>Eric Topol: Right, see youíre bringing up some central concepts here. The ability to, uh, engender the incidentalome, where you basically back into findings just because you shouldnít have done the test in the first place, thatís one thing. So more judicious use of the right tests for the right person, uh, you know, a lot of people just sign up for the total body CAT scan and their just asking for trouble. And, like you also brought up with the mammography, thereís a much higher rate of false biopsies, positive biopsies and getting women and their families, you know, horrified than there is of preventing cancer. So the odds of getting a true abnormal biopsy is much lower than getting a false positive. So these are, we need much more precise tools. Who should get the studies or procedures? And how to interpret them. And part of it is this whole Bayesian thing that the test or procedure is only good if itís being done on the right person. Hopefully in the future weíre gonna pick the right people and not have all these incidental findings which wind up causing all kinds of trouble. >>male #2: So do you think, though, that it is a matter of not having precise enough tools, or could it be that even if you have all the information you still are in a situation where youíre not sure if itís a problem or not? >>Eric Topol: Well, thatís a great point. Uh, I think it, a lot of it is the imprecision of people having things done that just doesnít have any, itís just, uh, this mass medicine problem that we have today. But there still is an issue, so for example, when you have a whole genome sequence, youíre doing it for, letís say weíre trying to unravel that 15-year-old girlís story and we find these other things in there that we didnít anticipate, what do we do with that? See, whenever you have a lot of data, the chance of you coming into things, uh, in unintended way is gonna be there. So this is an issue that has to be grappled with. Youíre bringing up a very important, um, concern. Yeah. >>female #1: Well on that note, thanks so much for coming. You left us with a lot to think about. [laughs] >>Eric Topol: Sure, Yeah. >>female #1: Thanks. >>Eric Topol: Thank you, thanks a lot. [Applause]