Medical Data Navigator
This week I am talking to Maneesh Juneja, (@ManeeshJuneja) Digital Health Futurist who has been exploring the future and how emerging technologies can make the world a healthier and happier place. We share some common interests and passions around sensors, wearables and even intermittent fasting (IF) aka Time Restricted Feeding/Fasting (TRF)
He was early to use data to provide insights helping Tesco’s leapfrog their supermarket competition using data from their club card to drive customer loyalty. He translated this into the pharmacology world but was surprised to discover the lack of data on patients that was recorded every 6 months or sometimes even longer. His question was what happens in between those times.
His early experiments included testing the first Apple Watch that came with Fall detection, throwing the device down onto the floor to test the effectiveness. This reminded me immediately of “Will it Blend”
Maneesh discusses the challenge of too much data and the push back from the healthcare world to receiving data from a patient. These attitudes changed dramatically as the Pandemic impacted so much of our world including everyones’s brain health and activities, including the provision of medical care. Suddenly home based medical devices were useful and the data was showing up in the data in your EMR.
Listen in to hear about Maneesh’s data toolbox he has built and applies to health and wellness problems. This is not data that individual clinical staff would be processing but potential inputs to increasingly ‘smart’ computer systems that use AI and Machine Learning to analyze and provide insights. We talk about the positive experiences with these devices as well as the worried well and how healthcare, medicine and the medical data navigators hat need to be part of healthcare system future
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Maneesh Juneja. He is the digital health futurist hails from mild shores. Maneesh thanks for joining me today.
Maneesh Juneja
Glad to be here, Dr. neck.
Nick van Terheyden
Now you’re gonna have to put on a different accent otherwise you’re confused the listeners because they won’t be able to separate us. No, no, seriously. So you’re obviously based out of the UK. And you’ve you’ve had a really interesting background. Tell us a little bit about how you got to this point as a digital health futurist, and you know, some of the things that you’ve learned along the way. Yeah, so
Maneesh Juneja
essentially, I started off my bachelor’s was in business, business and computing. And then I worked in academia for a couple of years at University College London, working on data sets that have been collected as part of the Whitehall study, looking at social inequalities in health. Then I decided to take my data analytics toolbox. And I went to an agency in the UK, there was a startup over 20 years ago that had was launched the Tesco Clubcard database. So essentially, if you’re in the US or anywhere else, if you have a loyalty card for the supermarket, and you collect points, this was the first organization in the world and to use loyalty card data to generate insights on what coupons to send to their consumers. And, you know, so I was in charge of that big data set of all these transactions every day of 8 million shoppers across the UK. And that helped the use of that data helped Tesco, the end client, the supermarket, leapfrog their competitor, because they gain this insight into how what their customers are buying and what they want to buy more of, and what’s more profitable, etc. So then I spent a few more years in advertising and marketing using data from customer marketing databases to optimize decision making and communication, personalized communication to customers. And then I decided, again, to take my toolbox of data analytic skills, but to apply it within epidemiology at GSK in r&d, and this was based in the UK, but I was working with supporting drug development and drug safety, what they now call real world evidence I was generating. And essentially I was hands on working with the biggest electronic health record databases in the US and Europe. So UK was 5 million Germany 20 million patients or their diagnoses and lab tests, etc. And in the US, I had access we were using health insurance claims data as big as 120 million patients, the last 15 years of older insurance claims, which is incredibly rich data. And then I spent nine years there. And I then heard people from Silicon Valley speak at an event in the UK. And there’s this amazing future of the Internet of Things and sensors, and E health and M health and where everything’s heading. And I thought, wow, I went back to GSK The next day, and I couldn’t reconcile the two. So it sounds completely crazy, Dr. Nick, but those especially who are entrepreneurs will appreciate this, I resigned on the spot with no plan of anything, what I was going to do next very great job in GSK amazing prospects. But I resigned on the spot, everyone thought I was mad. I took a risk. I went around the world for two years, I spent a lot of time in Silicon Valley, went to a number of conferences, found out what’s happening with technology, what’s happening in the world, at the edges at these new frontiers. And then I just started blogging and tweeting and I started just sharing my I had the freedom, working myself to just share what I thought was wrong with healthcare, with human health, with prevention of disease, and what was happening technology and trying to join the dots and help people understand how to navigate this weird uncertain rollercoaster future. Then people started paying me to speak and then becoming a short term doing consulting. And then I ended up just, you know, calling myself a digital health futurist. And then nine years later, here I am, where I’m talking to you during this podcast, and I have worked with so many different people around the world, and I’m able to just look at things, especially from the context of health beyond healthcare. So what are car companies doing that could influence their health? What are people who design office chairs doing that could influence their health? And how should the healthcare system interact with all these new players?
Nick van Terheyden
You know, it’s really interesting. I don’t know that you diminish it necessarily, but it’s sort of glossed over, that you were doing this a long time ago, relative to where we are. So when you state your sort of stake in the ground of a digital health futures you really want You saw all of this and the potential of it and sort of jumped in and, you know, huge props to you for leaving your job there. And then I mean, that’s not an easy thing. But that’s a, an essence of your convictions, I would say. So I’m just I mean, in all of that. So let’s talk a little bit about some of that data analysis and the things that you’ve seen and learned, I know, one of the areas that you’ve really focused and blaze something of a trail is in terms of the sensors. I mean, you and I both know, blood pressure, oh, we’ll measure that once a year. That’ll be good enough. Yeah, clearly, it’s not. But there’s so much more to it. Tell us a little bit about your thoughts around that.
Maneesh Juneja
So thanks, Doctor, Nick. So as part of my journey, especially when I started working on my own and looking at the future, and especially as these especially wearables, and other types of sensors were kicking off several years ago, I was buying all of them with my own funds, and I was testing them in the real world. So when the Apple Watch first came out, and they had the fall detection, where it would alert and it detected if you fallen over, and it’s gonna call the emergency services. So I remember testing, and I shared this on social media when it first came out, and I threw the Apple Watch from a distance of about seven feet onto the carpet of the driver’s seat of my car, right. And I threw it onto the carpet with force, and it was obviously off my wrist. So I wasn’t wearing at the time. And it basically I tried it a few times until I got it to actually think that I had fallen over. And then it said, like calling emergency services or you know, do you want to click that you didn’t fall? And so that’s the kind of level of work that I do is like, well, challenging all these claims in the hype and just understanding where’s the signal in the noise? But going back to the question about, especially about wearables, and sensitive and where we’re heading, and what’s important, so, yes, my frustration at GSK. And r&d practical frustration was if I’m analyzing electronic health records for patients to look at the natural history of disease, let’s take multiple sclerosis. They’ve come in to see the specialist twice a year the neurologist, so have two visits recorded in between to the second visit, I can see according to the codes, their symptoms have worsened, right? Whatever the neurologist has recorded, What I don’t know is a medical researcher is trying to understand the natural history of multiple sclerosis is what happened in those six months between those doctor visits. Dr. Neck right. That’s what was frustrating what we couldn’t answer so many questions within drug development and drug safety, what’s happening in those six months in terms of epidemiology of the disease? So then now, when I’m working, I’m trying to understand how do we fill in those gaps? When it comes to real world data and real world evidence? How do we actually plug in those gaps in a wearables enough? Or do we need things like smart toilets? Do we need sensors in their bed in our car? Do we need to be tracking people 24 seven to detect when they’re at risk of certain diseases. But the crucial question, each time I present these future worlds to clinicians, especially in my travels, they say Minish, even if you could collect so much data on my patients 24 hours a day and stream into an EHR, and it’s secure and interoperable is who’s going to act upon those signals. So if we can detect tomorrow, if you as a practicing physician, wherever you are, could get signals from all these sensors that could tell you hey, look, these are the 100 patients in your practice that you need to reach out to today, because they’re at risk of a heart attack or a stroke or something else in the next three months. These are the people at risk and AI and the sensors we’ve identified who in your practice has the actual resources to reach out to each of those 100 patients who are at risk. So that’s the missing half of the puzzle that we don’t discuss. We just get, oh wow, here’s this new wearable, here’s this new sensor. It can collect this data and detect this disease early. But the healthcare system, especially the clinician, and the patient was so what, how does this actually work in reality?
Nick van Terheyden
Yeah, you you, you voice one of the push backs that I hear frequent, I don’t care how many steps you walked. And I’ve always responded, you know, with a sort of stack frame, it’s never a data problem. It’s always a search problem. And I think the new thing Well, I call it new, I know AI isn’t new. My brother is you know, very quick to tell me he studied that when he was in, in college. So yeah, it’s been around for a long time called different things, you know, progression. I’m wondering a if, you know, part of the change or the the potential opportunity from this is our ability to process this in more intelligent ways? Or is there more to it than that? Is it because we’ve got more data, we’ve now got some better insights, because we can associate things in different ways. So
Maneesh Juneja
that’s a great question not to Nick. So I think, again, when I speak to clinicians, they their immediate reaction is, well, I don’t want to be looking through all my patients Fitbit data in the stream, right? So that’s, that’s what they’re thinking of maybe, and I kind of like push back and say, Well, in this brave new world, I don’t anticipate that individual clinicians will be sitting there looking at 1000s of 1000s of rows in an Excel spreadsheet, right? A that’s pretty boring, but that’s not why they’ve been trained while they’ve gone to medical school. So it’s to help them work, their highest level of clinical competency at the highest level of their license, what they’ve been trained for those complex cases to really use the human brain or their trading their wisdom. So I think there’s probably and this goes back to medical education, there’s probably a gap here in terms of, we probably need it, whether it’s, say the GP surgery here in England, in in the NHS, whether its primary care set up and direct care or hospital systems in the US some form of new function or job role within medicine itself, where you have somebody who has a level of medical training and clinical background, they may not be a full MD, but they also have studied our with them, they may be built algorithms and built AI models themselves and collected data and built maybe a few sensors. And they’re almost providing a hybrid role. And maybe in this new world. There’s this new function that allows with this marriage of the medicine medical side and the technology side that allows those people to interface in the system, bridge the gap, but most importantly, automate this flow of data into the healthcare system so that the the individual clinician or the team there are they just get automatically alerted to what the things that they need to do next, without having to think oh, my God, like, what I have to go to school back to med school or grad school to learn how to pass through data? No, I just want to know what to do next, as a clinician, and how’s all of this? through all this hybrid function? How is this not only going to integrate into my clinical workflow, but on top of that, how this is going to make my workflow easier, so that I can spend more time with patients. But how’s it going to make the patient workflow easier? Because the patients have their own workflow, right?
Nick van Terheyden
Yeah, I I’ve heard this from another physician friend of mine who talks about the sort of, you know, the, the additional medical skill set that’s tied to data processing. Those two are not always linked in physicians, you know, they don’t necessarily want to and I think it’s an essential element to this. And you know, the opportunity is for building that resource. For those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Manish Joon ager. He is a digital health futurist. He was telling us about his sort of past and history, how he was one of the early testers of the Apple Watch. In fact, the vision I had was him throwing it into a blender like some people used to do with their iPhones. I thought, maybe that’s how he became famous. No, no, I’m teasing him, of course, but he was actually testing these devices and demonstrating the value and trying to close the loop, which I think is essential. But here’s the other pushback. And, you know, I hear this frequently is Okay, great, but it’s not clinically valid. It’s not what you know, clinical grade and get into that, certainly, in the US with the FDA clearance process is an expensive time consuming. Can we still get value from you know, you talked about Apple Watch version one, I think it’s I forget what it is. Now they just have another one. So I’m
Maneesh Juneja
COVID is the latest one? Yeah.
Nick van Terheyden
But is it clinical grade at this point? And if not, is it still valuable? How do we deal with that?
Maneesh Juneja
Yeah, so it’s still a wellness fitness product, but albeit in the Apple Watches case, you have now the FDA cleared algorithm, which allows you to take the 32nd ECG and it tells you whether you have an abnormal rhythm or a normal rhythm, but you could you still have to consult a physician based upon the result if you feel that you need to. But interestingly, I’m just going to quickly mention there was so there are stories you read on the internet of of the Apple Watch, saved my life gave the detection of it and abnormal heart rhythm, and I went to the ER and then they said yes, you definitely have a problem. We need to do something right now. But then equally, there was a study published recently with a case of a 70 year old lady in the US, and she had been diagnosed with atrial fibrillation. And they they talked about her health anxiety linked to the fact that as a patient going home once he’d had been diagnosed with a F, I can’t remember it was an apple watch or another smartwatch. But they talked about it as smartwatch related health anxiety over the course of a year after her initial AF diagnosis, she did 916 ecgs at home over the course of a year, right. So this is again, why people are concerned because like you’ve got obviously she was a patient with a diagnosis. But there’s this category of what people call the worried well, so with design, these new technologies are coming out, they’re often expensive, and they require a level of digital literacy and the people who are using them, often people who are not necessarily at higher risk of disease. And and that’s why they’re labeled the worried well, and so the so companies are producing products for these people. But getting back to the question of, you know, can we get any value from sensors that effectively not necessarily gone through the regulatory process and not Nestle clinical grade? Well, I’ll share my story of long COVID. So I’ve now fully recovered from long COVID It’s been over five months, thankfully. But I spent over a year being unwell. And when my symptoms first began in April 2020. So early on in the pandemic, the NHS here in the UK, pretty much became an emergency service, you could barely get a phone call with your GP, you couldn’t even get face to face. So over the phone, when I had my symptoms, and my GP was trying to rule out whether I had a serious illness or I needed to go to hospital. And over the phone, there’s only so much you could understand from my voice. And I was like, Hey look, I’ve got like 2000 pounds of sensors at home, some fitness sensors, some medical devices, do you want that data and normally clinicians will GPS he’ll just say I don’t want to touch your patient generated data and our suppliers because the pandemic forces to say, Minish whatever data you’ve got, I’ll take it as your GPS. So I gave her data from the sensor underneath my bed, I gave her data from my outer ring, I gave her my ECG information from my Apple Watch. And it was amazing because she took it all on board, and it helped to rule out okay, you don’t need to go to hospital. Based upon this information from all your senses at home, on top of that, five minutes after each phone call ended in those early days in my symptoms, when she was checking in over the phone, I’d go into my NHS app on my phone, and I’ll be able to see the data from my senses at home I shared with her over the phone verbally entered into my electronic medical record. Amazing. So my respiratory rate data from my ring that is not a medical device is now in my medical record.
Nick van Terheyden
So I think the the learning point, from my perspective is that there is you know, there’s clearly some understandable resistance, but it was providing value it delivered value in that, let’s call it a special circumstance. But if it was able to do it there and ought to be able to do it in other places, by the way. Glad to hear that you’ve come through I mean, you’ve been generous with your sort of sharing of that. I think that’s one of the other benefits of this data. And people learn from that. And perhaps that provided some insights to others, if not just you know, into your own medical decision making. So there’s clearly value from this whole scope and potential but it you brought it up a little bit and you know, there’s there’s a discrepancy that worried Well, you know, these are not cheap devices, they’re expensive, and they’re not getting to the folks that potentially would benefit the most from them, or are they not? I mean, I struggle with this sometimes if you gave gave folks that really needed those insights, one of these devices, would it get used? Or would it just be you know, great, I’d rather have decent food as an example.
Maneesh Juneja
Absolutely. And just thinking back again to you know, when we think about wearables, and people say like, Oh yeah, you know, the smartwatches are great, but what if you don’t like wearing a watch too bad and you’re 85 years old, you’re living with dementia, you don’t trust this, maybe even you know, you’re not even old, but you’re younger, but you’ve got schizophrenia, and you don’t trust these authorities that are tracking you, for example. So this is why I think it’s important to always you know, we have a lot of we have a lot of people outside of the healthcare system who’ve never worked in healthcare, saying look I’m frustrated, I want to fix this amps founded a startup have built a sensor to track this. And often they are creating solutions, that amazing technological solutions, but they’re looking for problems to solve. And not only that, and it’s reminding them that you’ve got to look for problems that are clinically meaningful. So there are 1000s of 1000s of problems in healthcare today, that needs solving. But if you’re to speak to people, at the front lines, dealing with patients dealing with their struggles, dealing with their struggles, trying to treat those patients and see those patients and diagnose them, they tell me many, I want people to think about problems that are clinically meaningful to So speak to us in the healthcare system before you go inventing all these devices. And collecting data, ask us what we need to help our patients that can help us as well.
Nick van Terheyden
So um, we’re, we’ve, we’ve been through a challenging period of time, it’s changed everything, you know, people talk about getting back to normal, whatever, we’re gonna get back to something. But the impact has been significant on lots of people, including yourself, I’m and people are struggling with that. But this is part of, I think, a future that you paint and has always painted very positively this sort of health beyond healthcare, which you you turn it tell us a little bit about what’s left, and what the opportunity is, with innovation, you know, given your insights through COVID, your insights with, you know, mental health challenges or brain health, as I prefer to call it, you know, where does all this coalesce? I, you know, paint the picture.
Maneesh Juneja
I think, Dr. Nick, it’s about a future where we need more cross sector collaboration. So we need health in all policies, we need to understand as you said, like the people need a wearable that they just need access to fresh fruits and vegetables. But more importantly, it’s about people coming together, people understanding what is actually going to make us healthier, as a as a individual country as a world. And this focus on really thinking about, do we need more hospitals, more doctors, more visits to doctors offices? Or is climate change going to make us think actually, we’re going to need to have more virtual care, more remote patient monitoring, because climate change in the crisis is one of those things that is going to overrule many of the concerns or the fears that people have in healthcare, because there are big issues at stake here. I planetary health is going to impact human health.
Nick van Terheyden
Okay, I mean, I agree with you, I think, you know, major problems. Where does tech come into this? What are the opportunities for technology to help us?
Maneesh Juneja
So I think it’s where we have, we have to start off with elements of code design, co production. So again, it’s about having the right people in the room asking the right questions, it isn’t just about throwing a bit of tech over there and calling it innovation. And that’s enough. And it really needs to be ultimately, it really needs to be focused on ensuring all of this technology doesn’t widen healthcare, health inequalities, so that the rich just get access to these new innovations. And the people who don’t actually have the money or the digital literacy are left behind. And you end up with these widening inequalities, which is the last thing we want to happen. So basically, can we use ultimately my challenge is can we use these technologies to actually decrease health inequalities rather than widen them?
Nick van Terheyden
Fantastic. Well, unfortunately, as usual, we’ve run out of time, it just remains for me to thank you. I’m I could tell you, we could speak for many more hours on these topics. In fact, I’d be happy to crew and carry for you and just pick up your devices that you cast off left and right, by the sounds of it. I’m so excited by some of the things that you’ve got going. It’s an exciting time. great conversation. You know, I feel empowered about the opportunity. I think narrowing that divide is the important element that’s often missing in that technology. And that’s my learning point. mohnish Thanks for joining me today.
Maneesh Juneja
Thank you for having me, Dr. Nick.
