A New Age of Connected Health - Dr. Daniel Kraft, Founder of Exponential Medicine

SHIV GAGLANI: Today I'm really happy to be joined by Dr. Daniel Kraft, who probably wears more hats than any of our previous guests on Raise the Line. For starters, he's the chair of medicine at Singularity University and founder and chairperson of Exponential Medicine, a cross disciplinary program, which explores how rapidly advancing technologies can shape the future of healthcare. Of particular significance in this year of the pandemic, he is chair of the XPRIZE Pandemic Alliance task force, which is seeking solutions to address COVID-19 and improve our ability to predict, prevent, and respond to future pandemics. Dr. Kraft is a Harvard and Stanford trained specialist in hematology oncology, and adult bone marrow transplantation, and an advisor to several leading biomedical and digital health startups. He also serves as a flight surgeon, practicing aerospace medicine in the California and Massachusetts Air National Guard with F15 and F16 fighter squadrons.

And we go way back. I first heard his TEDMED talk, I think about almost a decade ago, and actually attended Singularity University as well. So, Dr. Kraft, it's great to have you on the show today.

DANIEL KRAFT: Great to see you and great to see all the progress you've been doing in catalyzing the future of Med Ed and everything else.

SHIV GAGLANI: Right. So, I obviously know a lot about your background and I think for our audience, which is primarily current and future health care professionals, I think they would love to hear in your own word words what got you interested in medicine and then specifically hematology oncology?

DANIEL KRAFT: Well, I was lucky to grow up in the DC area and I always sort of liked science in general. I spent a summer high school internship at the NIH and had to do a science fair project. Eventually my science fair project ended up winning all the science fairs because I came up with a way to cure allergies with a monoclonal antibody and that eventually got adopted into a drug called Xolair by Genentech, though I didn't know anything about IP or biotech back then. But it was a fun entree into the idea that you could come up with sort of a science element and how that could potentially impact human health.

And then I really sort of solidified getting into medicine when I went to Brown. We had a student run Brown emergency medicine service. So I got to be a crew chief and run around with Code 3 sirens. Mostly twisted ankles and drunk students, honestly, but it was a good experience there. I liked the combination of both the research side and the clinical side and that led me on to medical school at Stanford and beyond.

I guess I've always sort of been hard to put into one bucket. Even when I was in undergrad, I was learning to fly and doing immunology research. Then as a Stanford medical student, spun off to do planning missions to Mars with Aero/Astro department, as well as getting into stem cell biology and it always looked like convergence of different fields and that sort of helped catalyze where I went next, instead of staying bucketed and starting medical school with the idea that I'm going to be X, Y, or Z.

SHIV GAGLANI: Absolutely. I think that's where creativity comes from. It's rarely in a vacuum. It's from combining elements from different fields. And so one of the things that I think you became first most famous for was inventing a way to get bone marrow. Can you talk about maybe your first breakthrough moment that puts you on the map in terms of being a leader in healthcare technology?

DANIEL KRAFT: I think the high-level concept to have, particularly for medical students or folks who are fresh out of medical training, is that you have a bit of a beginner's mind. You can see problems in new ways. Like why are you still using fax machines? When I was a bone marrow transplant fellow back at Stanford after a meds residency at Harvard, I was in the operating room doing bone marrow harvest with a needle and trocar that hadn't changed in 30, 40 years. I was kind of a sideline Fellow on the new Stanford Bio Design program, which was all focused on finding pain points and unmet needs and solving them. So my pain point literally was my hand was sore and the donor's rear end was painful in harvesting bone marrow and I thought, well, there must be a better way to do that and kind of came up with this idea of what we now call the marrow miner. It's a bit of a roto-rooter to go in one or two punctures as opposed to a hundred, and harvest bone marrow stem cells for bone marrow transplant or regenerative medicine or potentially banking. There are a whole new set of applications and tools.

And so I always like to coach, particularly folks early in their medical careers, that you have this perfect lens to see things with a fresh eye, so keep a little notebook and journal. You can't solve all of them. But there's such opportunity to accelerate, whether it's building a learning platform, or 3D printing a med device, or building an app that might solve a problem for you or your patients. It's an opportune time to do that. So that's how I sort of got into the medical device side of things. Then that also bridged into digital health and other fields.

SHIV GAGLANI: So, again, you gave this amazing TEDMED talk, I think a decade ago, and you've given more recently. You have a great perspective on all things future of health, and we'd love to hear how you think this COVID-19 pandemic has changed the adoption curve. Obviously, we know a lot about telemedicine. We've had people like Joe Kvedar on the podcast, who runs the American Telemedicine Association. But what are some of the things that you think are accelerated as a result of COVID, that maybe you thought would have taken a much longer? And then other things that may be taking a step back because of COVID?

DANIEL KRAFT: Sure. I mean, we can think in the positive terms, that COVID is a bit of a catalyst. Just as Sputnik sparked the space age, COVID in a sense can spark a true health age in that hopefully some of the innovations, collaborations, and innovations that come out of this horrible pandemic will lead to much better health and health equity and technology and solutions across the healthcare continuum. So I think the positives out of it are that clearly we've unleashed creativity and collaboration. I've been in so many other meetings internationally and otherwise just sitting in my home office on Zoom that have created, hopefully, impact and will catalyze new solutions that help prevent future pandemics, as well as address this one.

I think obviously, virtualized care. We've moved increasingly from hospital to home or hospital to “home-spital” with the advent of remote patient monitoring. Even the idea that a patient can simply have a pulse oximeter at home and use that in terms of triage and monitoring and therapy has sort of been accelerated. So there's that quote that, "In eight months, we've had eight years of acceleration of digital health." And because of the key pain points, some of the somewhat analog regulations like HIPAA, which was restricting ways we could talk on telemedicine, and payment models have accelerated the telehealth side of the equation. I think the genie is sort of out of the bottle. We're never going to go completely back to pure analog. It's going to be more of this blended model. Now patients and clinicians have been sort of forced into a bit of that virtualized element, that's going to continue on.

The other plus sides, of course, are that now we have sort of a new interstitial of international learning and collaboration. The mortality rate on admitted ICU patients was what… 60%, 80% early in the pandemic? It's gotten significantly better. We've accelerated clinical trials, whether it's for dexamethazone or immunotherapies. Clearly the example, as we're seeing with the vaccines rolling out, it’s pretty amazing that we could sequence it, basically create the RNA vector, and get into clinical trials by March. So those will lead to other vaccines and therapeutics in an accelerated form in the future as well.

So those are just a few of the elements that have been accelerated. Part of it, again, is a bit of a mindset. And hopefully, we recognized and now amplified some of the huge challenges and disparities, whether it's socioeconomic, all the way to challenges in supply for PPE or workflow. We'll hopefully catalyze new solutions from the entrepreneurs out there. And any of you who are quote unquote non-entrepreneurs, I would encourage you as the med student, resident, fellow, or post-grad for sure, to always be looking to give those opportunities and partner with the folks who can help build those solutions. You don't need to start a company to see a challenge and accelerate innovation.

SHIV GAGLANI: Absolutely. I mean, I like that in eight months, we've had eight years of progress in digital health, and obviously a lot of great initial public offerings of some of these companies that are maturing now. Eight years ago, I think I was at Singularity University. You were running the course on the future of health. I actually did a smartphone physical on Sami Inkinen who was just starting to create Virta Health and just a couple of weeks ago, they announced a Series D and they're now a digital health unicorn. So it's really cool to see that progress being made, and no doubt that it's happened in the middle of COVID.

I'm curious, given that you run Singularity and Exponential Medicine -- that's another hat you wear -- these in-person innovation, catalysts conferences. How has that changed because of COVID? Obviously, a lot of conferences have been delayed or done virtually. Can you talk a bit about some of the training you do and how you've maintained the spirit of innovation even virtually?

DANIEL KRAFT: Well, first a step back. So you were lucky to come to ... I think, yeah, almost 10 years ago, the first Exponential Medicine programs, which we started with a pretty small group at our headquarters. The idea there was that most of us get more and more specialized. We get more and more siloed. I'll go to oncology meetings like ASH and the cardiologists go to ACC and the GI folks go to their meetings, and there's digital health and pharma they're often pretty separate, and often there's not a lot of cross-fertilization. So the whole idea about Exponential Medicine in a nutshell is to bring patients, physicians, pharma, payers, all together to kind of see what's cutting edge, and with that exponential mindset.

Another word we've heard a lot about this year, exponentials, in terms of the spread of disease, applies to many technologies like our smartphones. When I was a medical student, we didn't have smartphones. I didn't get even a mobile phone until I was a resident at Mass General. I mean, crazy. How did we operate? These sort of trends accelerate. It's often hard to appreciate those. And then when you can connect where AI, big data, 3D printing, wearables, internet of medical things, AR, VR, flipped classrooms, all come together, that's where the magic can happen to accelerate prevention, diagnostics, therapy, and public health. So that's a bit of that lens around Exponential Medicine, which you've experienced. That smartphone physical that you led-off was an example of all of those things coming together in your pocket, that can really digitize and up-level anybody to do a smart physical exam that can integrate in-person or in a telehealth context, as we've seen accelerate this year as well.

So, of course we couldn't do our annual live program with 800 people from 45 countries like we did the last few years. So we're doing a virtual program in late February of 2021 and we're shifting things up a bit. I think maybe people have a bit of Zoom and meeting fatigue, but we'll try and keep some of that magic of how do you interact? How do you spark new ideas and collaborations from folks outside of your normal bucket? One example is beyond the technology piece, you might have this amazing smartphone physical application but unless it's paid for and regulated, it's a bit of a so what? Or if that data that flows to the clinician, they don't want to look at it or it's overwhelming -- no one wants every EKG and hiccup and blood pressure number -- so we want to go from exponential data to useful, actionable information, and then narrow that gap between that new information to something you can use at the point of care in the clinic, in the ICU, or a patient themselves.

As you know it can take 17 years from publication to being standard of care. We want to narrow that gap, something that you guys at Osmosis are doing as well. So I think we have the opportunity in this blended virtual, and hopefully, in-person age, is to kind of create the interstitial. You have an in-person meeting, but then you can have the digital touchpoints and virtual salons that can keep that energy and catalyzation of accelerating the future of medicine and move from incremental medicine, which many of us experience, to exponential medicine. Because in reality, some things haven't changed that much. When I go back to visit the ward at Mass General where I trained, it pretty much feels the same. I'm still using fax machines.

SHIV GAGLANI: Absolutely. The impetus of us starting Osmosis was, on day one of my med school journey at Hopkins, they were talking about how Hopkins set the standard for medical education a century ago -- 1912's Flexner Report -- and that was still being talked about as a big achievement, where we felt like it was pretty antiquated and we could do better.

So speaking of going exponential, another person I really liked interacting with at Exponential Medicine when I first attended was Peter Diamandis, another physician who I know you're friends with and the XPRIZE is definitely something that you guys have worked on together. Can you tell us a bit about this XPRIZE Pandemic Alliance Task Force? I know you were on a panel with our chief medical officer, Rishi Desai, a couple of weeks ago for the Council of Medical Specialty Societies.  Tell us about XPRIZE's interest in re-skilling and up-skilling very quickly given all the massive unemployment that's happened over the past few months.

DANIEL KRAFT: Yes. The idea of the XPRIZE, if folks aren't familiar with it, it was sort of stimulated originally by the fact that Charles Lindbergh crossed the Atlantic not just for kicks, but to win a prize. That when you put a prize out there for something audacious but achievable, some pretty amazing collaborations and solutions can come forth. So the first XPRIZE -- I think 14, 15 years ago -- was to get a non-NASA rocket into space twice in two weeks and that led to Richard Branson and others funding scale composites, which turned into, hopefully soon, you can go to space at least briefly. We've launched several other XPRIZEs since then. I came up with the Medical Tricorder XPRIZE about 10 years ago, which stimulated a bunch of teams and energy to integrate a lot of these digital diagnostics into almost like a Star Trek-inspired medical tricorder. Several amazing teams and solutions came out, many of which are now in the clinic or moving through the FDA process.

So, when you set a goal out there, you can often achieve things faster and catalyze whole industries, just like the Ansari XPRIZE for space, I think, helped catalyze SpaceX and others. In the setting of the COVID pandemic, similarly, we don't want a thousand versions of 3D printed ventilators, which was the hot thing early on, or new forms of PPE. You want to help find the best flowers that are blooming and accelerate those. So a key challenge still with the pandemic is that testing often takes days. It's expensive and you get the swab to the back of your brain. So I was contacted by Jeff Huber, who's well known as the founder of Grail and a former VP at Google, and launched a rapid COVID testing XPRIZE in collaboration with his organization, Open COVID Screen. So how do we get what we really need: fast (like under an hour), cheap (under $5), easy (something you can do yourself), and rapid and accurate COVID tests? We put the call out. 707 teams from 70 countries applied. We've now narrowed that down to 200. They’ve already done their sort of test kits down to the judging element. We're going to move down to 20 and actually the final five, and those are going to hopefully accelerate around the world.

And yes, we have vaccines, but we'll still need testing. Hopefully that will lead to new forms of viral testing for the flu or the cold or other elements that you'll have integrated with your smartphone. So that's an example of an XPRIZE that was launched. There was also an X Challenge around better masks, and that was for younger folks, I think college age and younger. The five finalists were recently announced.  There were some pretty amazing innovations that are often cheap, but very effective at making masks better, more comfortable, more effective, etc.

So the idea of leveraging the crowd in a prize model is particularly effective. And on top of that, I've been chairing the XPRIZE Pandemic Alliance Task Force made up of a hundred organizations from academics, to NGOs, to small companies and big ones like IBM and Microsoft. The idea, again, is to help catalyze solutions and get that cross-fertilization happening like we did at Exponential Medicine. For example, recently I ran a jam session. We had Rick Bright who used to head BARDA. He was the famous whistleblower that the Trump administration fired for calling them out on their inaction, and is now on the Biden COVID task force. And we also had Mark Smolinksi, he runs endingpandemics.org, and had a fascinating conversation about how do we take the lessons from today and apply them now, but then also use those to prevent the next pandemics? Whether it's with the individual and a wearable to detect their symptoms and crowdsource that, all the way to new forms of internet of medical things for public health. So it's all about bringing smart folks together to solve things in new ways.

SHIV GAGLANI: I love that example. Actually, I've read a lot about Lindbergh, but I didn't realize it was based on a prize that led him to take that audacious trip. One thing we immediately connected on is our love for flying. You've obviously progressed way past me and do acrobatics and all sorts of other things, but I think that's one of the first things we spoke about a decade ago. I got my instrument rating, too, I think around the time I met you.

DANIEL KRAFT: Well we're both aviators. For the folks who aren't, there's some wonderful lessons from aviation that apply to healthcare. I got my pilot's license at Brown where it cost $20 an hour for the plane. It was amazing. I recently started flying a Diamond Star 40 with a glass cockpit. So I, like you, train around dials. Now we have these glass cockpits, which is a good example of how do you present data in new ways that give you the situational awareness as a pilot? Which should also apply to healthcare, because we're kind of flying blind.

We practice not healthcare, but sick care based on that intermittent data that we get usually in the four walls of the clinic, and then eventually you might see it when you're face-to-face with a patient. That gives us a reactive sick care model. We're moving to this continuous, proactive, hopefully, health care era where you're going to have a dashboard on you, your patient, your population, your neighborhood that can be used in sort of similar ways. That needs design thinking. How do you design your cockpit? It can't be to the average pilot. It needs to be customizable based on what kind of plane you're flying, where you are. We see other examples -- checklists, the checklist manifesto, changed the operating room. Simulation, which certainly applies to medical education, that's catalyzed a lot. There was a fighter pilot in Israel who's also a pediatrician who built, I think, the very first medical simulation training which has catalyzed models around the world. And now there’s augmented and virtual reality, which is used for everything from micro flight simulators to going into your Oculus Quest, which is now transforming how you learn to do surgery, to even do collaborative patient interactions around a code.

So, lots of lessons, including crew resource management. How do you talk to your co-pilot? How do you talk to your crew? That can apply to rounding on the ward or an intensivist team in an ICU or OR. So, aviation's fun.

SHIV GAGLANI: Totally. There are so many examples that you just provided. One thing I know we're trying to figure out at Osmosis, and you guys have it at the XPRIZE, is how do we re-skill and up-skill people very quickly? I think at the height of the pandemic, 40 million people had lost their jobs. Now it's down, I think, to 10 to 15 million. Some of these jobs are not coming back, especially in physical retail and some in transportation. Over the next five to 10 years, because of automation, we'll have even more of that loss and even some of the things that highly skilled clinicians do will be replaced.

I remember at Singularity University or Exponential Medicine, a presenter famously said that 50% -- or was it 80% -- of what doctors do will be unnecessary in the next decade or so? He got a lot of flack for that because people interpreted it as saying 80% of doctors won't be needed when he was actually saying, 80% of what they do -- the medical billing, all these other kind of rote tasks -- can be automated. But can you talk a bit more about your vision for the future, the next decade of training and education, both in healthcare as well as just more broadly?

DANIEL KRAFT:  By the way, you'll sort of see things a bit early at Exponential Medicine. If you go to exponentialmedicine.com/videos, there's great talks from known and unknown folks that kind of help catalyze folks' thinking. But a bit of that is sort of the point. Not that AI is going to replace the doctor, but the doctor using AI will replace the doctor who won't, or healthcare system or nurse or pharmacy. And part of that means we need to, as you're doing, rethink medical education. Who do you even choose for medical schools? If someone is good at organic chemistry or memorizing, is that the skillset you need today when everything's available on your smartphone?

And in terms of up-skilling, a good example in my pocket here, is you've probably seen these AI-powered stethoscopes, like from Eko, which can listen to heart murmur and do an EKG and diagnose the heart murmur far better than I can and probably most cardiologists. Or I recently got the Butterfly, which blended with AI, can make almost anybody a sonographer. And that's the early stages of this. So I think we can up-skill the community health worker, the nurse, the med student, the pharmacist, the dentist, to use technologies like these to up-skill diagnostics and of course the synthesis of that information. Because there's no way our brains can keep up with every journal. The old model of just looking at vital signs and labs and maybe looking at a paper or two is not going to cut it. We can up-skill everybody. I like to call it not AI, but IA, intelligence augmentation, which is going to cut across everything.

That means now, in the pandemic age, we need new contact tracers. What if we had -- just like we have the Peace Corps -- a global, or at least United States, public health corps, volunteer corps, like ambulance and firemen can be volunteers, and you're trained and you're up-skilled? You've got your smart pad, you've got some diagnostic devices, you're the neighborhood public health element and you can help screen, test, isolate, and be that lens, not just for preventing the next pandemic or epidemic, but helping address social disparities as well. So lots of opportunity there.

I think It's going to change med education and what each of us can do. I mean, I trained in internal medicine and pediatrics, and was never really good at dermatology. But now, there’s lots of apps you can put on your phone and at least enable you to do a better evaluation of that lesion. Is it a melanoma or a mole? I think we can leverage that, in this changing world, for health. Not everyone needs an MD. Even a high school graduate can play a role in local and their own personal health as well.

SHIV GAGLANI: I couldn't agree more. The public health corps you mentioned, internally at Osmosis, we call it the care corps. Trying to get as many people to be educated about their health. At no time has it been more important than COVID in terms of even getting people to do basic things. Like getting them to wear a mask because viruses are transmitted through respiratory droplets has been a big challenge. One of the things I'm most proud of at Osmosis is partnerships with the CDC Foundation and YouTube, which is launching YouTube Health, to do that public health education because the boundary condition is everyone is their own physician. That's something you and I have spoken about a lot. We also had Eric Topol on the podcast and as you know, he wrote that book The Patient Will See You Now. So the consumerization of healthcare is very interesting as long as it has stop gaps to back it up so people aren't doing quackery kind of medicine.

I know we're coming up on time. So I had two other questions for you. The first is, again, you've had a really inspirational and innovative career in healthcare technology. What advice would you give to current medical, nursing, and other health professional students about meeting the challenges of COVID-19 and beyond?

DANIEL KRAFT: Well, I think again, it's a time of transition and hopefully acceleration to the next generation of truly connected health, digital health, mobile health. This new era where we're really using all these technologies the smart way. So there's that famous quote that the future's already here, it's just not evenly distributed. Many of you are wearing devices and might have a connected blood pressure cuff or AI-assisted app. But are they being leveraged in the clinic today? You guys can be the catalyst for that. If you have your own medical condition or have a patient with one -- it may not be reimbursed yet or even FDA cleared -- but you can try that relaxation app or the smoking cessation platform or the connected blood pressure cuff and use that with your care and start to learn what works.

In the setting of the pandemic, we also have an “infodemic.” So we need to think about how do we personalize communication? Sometimes you might use digital communication with your patients depending on age, culture, and language. Baby boomers are very different than a millennial in how they want to interact with health. How do you educate folks who have grown up as digital natives? Or there's those like me and you, who are a bit on the cusp.

To address that a little bit, there's so much out there, particularly in digital health. I've recently launched a new platform, it's quite early, called digital.health -- that's the domain -- where we're trying to help have a bit of an educational path. What's out there? What's the regulatory paths? What are new startups? Eventually we want to have a bit of a digital health formulary so you can find some of these existing tools, and ones that might be coming, and start to prescribe them to your patients.

So, my advice for folks would be to keep your minds open, stay cross-connected with other folks. If you're in a medical school that's got engineering and business and law, cross-connect. Keep an eye on what's happening in AI and 3D printing and nanotech and synthetic biology. All these elements are accelerating. Quantum computing may change healthcare dramatically. So if you kind of take that mindset like Wayne Gretzky, “skate to where the puck is going to be”, don't just think about medical school and medicine as static in 2020, which used to be the future. Think about where we'll be in 2022, 2025. Bill Gates says that famous quote, "We tend to overestimate what will happen in a year and underestimate what will happen in a decade." I think the next decade will make the last 10 years look slow.

SHIV GAGLANI: Absolutely. You just said two of my favorite quotes. People overestimate the impact of technology in the short term and that's something I know as a futurist, with all these technologies coming out. We've been talking about remote patient monitoring for a decade and now to see a forcing function like COVID is very interesting and kind of brings it to light. Is there anything else you want to be able to convey to our audience about you, your background, Exponential Medicine, digital.health, etc.?

DANIEL KRAFT: Well, I think that the overall theme is, as you go through your medical path and journey, we're always learning, stay curious, try things out early when you can, because then you'll get a bit of insight of what's coming. A lot of the things that are out now aren't really that new, they're just now unleashed. And sometimes it means that all of us need to also play a role in helping the regulatory bodies. I saw some news today that finally HIPAA might be relaxed a bit. That was a horrible, in many ways well-meaning, regulation built almost pre-digital and now it needs to relax to catalyze data flow and better outcomes because we've all seen patients die with their privacy intact who might've preferred to have been living.

So you have to play both sides of the equation. You might have a great idea, but understand the four Ps. How does it play to the patient, the payer, the pharmacist, the ... what other Ps are there? Oh, the bigger picture. And just like politics, healthcare is often local. We like to think in the San Francisco Bay Area, everyone drives a Tesla and has Google Glass and an Apple Watch. That doesn't play out necessarily in Peoria or in other parts of the world. So I think a big opportunity is how do we democratize healthcare and platforms like Exponential Medicine? One of my favorite quotes was shared by Tony Young, the head of NHS Innovation. It's basically an old quote that, "The biggest challenges aren't the new ideas, but escaping from the old ones that we all have.” Whether it's how you organize a medical school curriculum or how you do in person or virtualized care. So kind of think a bit outside the box while learning how to drive within it. And we can all be engines then to not just predicting the future of medicine, but creating it together.

SHIV GAGLANI: That's excellent advice to end on. And so, Dan, thanks again for taking the time to be with us today and more importantly for the work that you do to catalyze all this change. Again, personal note, your TED Talk that I watched almost a decade ago was definitely inspirational to me as a medical student at Johns Hopkins and it's just been really great to see all the things that you've done in your career and for the future of health.

DANIEL KRAFT: Thanks. I have to go back and look at that TED Talk from 2011. But a lot of those things have now sort of come to fruition and the trick is to, again, not have that failure of imagination. I mean, think two more clicks of Moore's law, what's going to fit on your smartwatch and what could you do with that for a patient? It might be blood pressure, blood sugar. What is AI machine learning going to enable you to do in a clinic in real time? What kind of digital avatar should be interacting with our patients and up-leveling each of us? How might that even inform what field you might want to go into? Because some of them are going to be more augmented. Some of them still need more of the human touch. Again, it's a really exciting time for any of us in healthcare to be thinking about and catalyzing its future.

SHIV GAGLANI: Absolutely. And with that, I'm Shiv Gaglani. I'd like to thank our audience for checking out today's show and remember everyone to do your part to flatten the curve and raise the line since we're all in this together. Take care.