Sharif Vakili's Profile

Ravi has a great post on Teledoc I encourage you check out! A system like teledoc’s implemented seamlessly in our health care system would be very cool.

I totally agree, liability in developed nations is definitely a big issue. It’s led to telemedicine being used more as a physician to physician consultation service where physicians can speak the same language to each other, minimize miscommunication, and trust that they’d give each other reliable information without important omissions. Patient- physician telemedicine interactions are more risky and consequently have a higher burden of proof in showing safety, efficacy and reliability. For each telehealth application, there have been a handful of studies looking at the error-rates of each of these systems.

This is a very cool model capitalizing on an ever-increasing sharing economy! A couple of players have come up in the space of peer-to-peer carsharing in addition to getaround, like turo, flightcar, drivemycar and justshareit. I think a huge challenge to overcome in creating a sustainable model in this space will be creating trust between the carholder, the car renter, the insurance company and the broker. Car sharing has the benefit of a low barrier to entry for the carholder and cost savings for the renter, but unlike a traditional rental company, if something were to happen to a private carholder’s vehicle, their headaches are significantly more costly in terms of the time they need to devote to resolving the issue, the loss in productivity in their own life unless they have backup cars, and the lack of scale to streamline administrative work they may have to go through. If getaround can overcome those challenges while providing an attractive set of terms for all parties, I think the model can provide significant value.

http://www.marketplace.org/2014/08/19/your-money/you-can-rent-your-car-out-airport-cash

This article is very interesting! Thanks for teaching us about athenahealth’s payer delivery model. I hope more models like these are part of the future of healthcare. Athenahealth provides a strong balance of checks, incentives and collaboration between payers and providers, which is necessary in a healthy healthcare system.

Athenahealth is a quintessential example of the products of the ACA and its incentive system: EHR systems, experimentation with innovative payer/provider models, cloud billing systems, value based healthcare, and new services to help bridge the gap between payers and providers. If the ACA falls, it will be hard to see the role for companies like these and their paths toward innovating the health system. A lot of healthcare business leaders are afraid the work being done here and with the Center of Medicare Services Innovation center will be lost. Athenahealth discusses its ACA-enabled projects here: http://www.athenahealth.com/knowledge-hub/practice-management/healthcare-payment-reform.

I should clarify that, thinking twice, an RCT would probably not be a feasible trial method to use for telehealth program assessment, but that’s a minor point. A similar study like a prospective control trial would be applicable here. But same concept.

I love this article! It’s a very clear, concise and structured overview of how we can think about telemedicine in our health system.

I completely agree that teledoc should run randomized control trials and cost studies in each of its services to assess its impacts. Unfortunately, healthcare is a very risk averse business that lends itself to very slow progress in the face of complex challenges. The only way to mitigate that is to expose uncertainties as vigorously as possible.

In teledermatology, for example, the American Academy of Dermatology and other prominent academic journals has published a number of trials looking at multiple telemedicine approaches for each of a large number of dermatologic diseases. For example, there have been trials looking at using DSLR camera images of microscope slides for remote cytology analysis (1), using contact immersion dermoscopy images for remotely assessing pigmented skin cancer lesions (2), and using DSLR camera images for remotely assessing non-pigmented skin cancer lesions (3). There have also been many studies looking at the costs of each of these programs (4).

I hope teledoc publishes similar studies of their own, because if their model is superior to what’s out there and they can reveal that through sound studies, that would be enormously beneficial to the field with growth and adoption of their models.

1.) Durdu, M. and Harman, M. (2016), Diagnostic value of telecytology in tertiary teledermatological consultation: a retrospective analysis of 75 cases. Int J Dermatol, 55: e392–e398. doi:10.1111/ijd.13219

2.) Erin M. Warshaw, Frank A. Lederle, Joseph P. Grill, Amy A. Gravely, Ann K. Bangerter, Lawrence A. Fortier, Kimberly A. Bohjanen, Karen Chen, Peter K. Lee, Harold S. Rabinovitz, Robert H. Johr, Valda N. Kaye, Sacharitha Bowers, Rachel Wenner, Sharone K. Askari, Deborah A. Kedrowski, David B. Nelson, Accuracy of teledermatology for pigmented neoplasms, Journal of the American Academy of Dermatology, Volume 61, Issue 5, November 2009, Pages 753-765, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2009.04.032.

3.) Erin M. Warshaw, Frank A. Lederle, Joseph P. Grill, Amy A. Gravely, Ann K. Bangerter, Lawrence A. Fortier, Kimberly A. Bohjanen, Karen Chen, Peter K. Lee, Harold S. Rabinovitz, Robert H. Johr, Valda N. Kaye, Sacharitha Bowers, Rachel Wenner, Sharone K. Askari, Deborah A. Kedrowski, David B. Nelson, Accuracy of teledermatology for nonpigmented neoplasms, Journal of the American Academy of Dermatology, Volume 60, Issue 4, April 2009, Pages 579-588, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2008.11.892

4.) April W. Armstrong, Julie Wu, Carrie L. Kovarik, Marc E. Goldyne, Dennis H. Oh, Karen C. McKoy, Alison M. Shippy, Hon S. Pak, State of teledermatology programs in the United States, Journal of the American Academy of Dermatology, Volume 67, Issue 5, November 2012, Pages 939-944, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2012.02.019.

Thanks for this perspective, that’s really interesting! I can’t imagine the true day-to-day challenges that arise in that work and how complicated it is to entertain solutions to them. You already highlight a handful of immediate, enormous obstacles right there like working with local governments, tackling perceptions of overhead, developing an electricity grid, and just transportation through unforgiving terrain. It’s awesome you worked on this in Swaziland. Finding personnel for these projects is a challenge itself. The BMJ estimated a $2.17 billion in lost investment from emigration of doctors from sub-Saharan Africa (http://www.bmj.com/content/343/bmj.d7031). The MSF might be able to make a small dent in that.

Thanks for the comment Sander! The question of why telemedicine is not more widespread is very interesting because you’re right, though it’s adoption has been increasing, it’s been rather slow. The context matters a lot. MSF is an interesting case study for telemedicine because it highlights two challenges to its growth: 1.) the need for centralization and coordination within a health system and 2.) the need for technological infrastructure for telehealth programs.

For MSF, the second challenges has been a greater issue for implementing telehealth. MSF has to prioritize providing basic healthcare needs to the areas it serves before it can tackle a telehealth program, and those basic needs are enormous obstacles in themselves.

For developed nations, the first challenge has been a greater issue. Telehealth in the US health system, for example, has been hindered by lack of infrastructure for reimbursement, liability and accountability protections and privacy. Conversely, unlike these more complex, developed health systems, MSF’s structure and ability to use its resources as it wishes lowers its barriers to entry for telehealth. MSF does not need to be a nation’s health system. Its model is structured on figuring out at which projects it can have the greatest, most needing impact and tackle the pockets of the world without healthcare.

If you’d like to see more ways of how MSF has been tackling telemedicine projects, feel free to check some programs here: http://www.doctorswithoutborders.org/article/msf-telemedicine-brings-care-patients-remote-areas

Thanks Sam! Those are some great points. Yeah, I think you bring up how challenging it is to think about the ethics of divestment and what its end goals are. I would, however, challenge the notion that ExxonMobil’s R&D initiatives will truly be gauged toward sustainable energy since that’d be undercutting their own business. They’d invest inasmuch as sustainable energy or environmental initiatives are in line with their bottom line, and the vast majority of the time they are diametrically in conflict (like the valdez oil spill, their promotion of climate change denial despite knowing better, etc) – https://en.wikipedia.org/wiki/ExxonMobil_climate_change_controversy.

I actually can’t argue with this logic. I think you fundamentally changed my position Michael. I really have to scratch my head on this.

I’m with Michael Michael on how funny it is the way people act toward climate change when their money is on the line. In this case, All State, as you’ve pointed out, is straight up suspending homeowner’s insurance in coastal areas.

I think an additional solution to the problem you’ve raised may be an active partnership with the federal government. This issue has been coming up in a several coastal jurisdictions in the United States over the past year, and it seems in response the government has gradually been trying to mandate insurance companies to provide insurance to riskier markets or incentivize them to do so because right now, the way the system has been in these newly high-risk markets has been that either the insurance company doesn’t have money to back their claims so they ask the FEMA to bail them out or the homeowner never had a claim to begin with so they ask FEMA to bail them out. The federal government doesn’t want to be left with the bill and neither does the insurance company nor homeowner. Some collaboration between the private marketplace and government assistance will probably be most optimal because there will be increasing social costs to natural disasters caused by climate change if we don’t have quick, effective ways to quickly rebuild afterwards. Policies with federal partnerships might also be able to incentivize people to rebuild homes outside of flood zones, though that may get tricky as the entire east coast turns into a flood zone.

http://www.marketplace.org/2016/01/12/world/lawmakers-consider-flood-insurance-rules-0

http://www.marketplace.org/2016/08/17/world/why-more-louisiana-homeowners-lack-flood-insurance

http://www.marketplace.org/2016/08/18/sustainability/flood-insurance

I loved this post Maria. I really hope the model of changing consumer behavior toward more sustainable fish works. I can imagine there being applications and business opportunities for these types of initiatives in other climate change-affected industries. A prominent example of how that started to come about was the pushback to the water-intensive almond industry during the California drought. Almond products were getting a lot of negative PR for some time, particularly when people were directly affected with water rations during the drought and the Almond industry served as an easy source of blame. I’m not sure how similar phenomena may be able to be capitalized to push more sustainable fish products, but I wonder if there’s something to be said about a strategy of branding certain fish as environmentally sustainable in addition to changing fish names to reduce stigma.

I really appreciate the opposing views shared above. They provide a great counterbalance to my submission, but I think on many of the points made, we do not disagree. I had originally discussed several of the points above, but I had to cut them out due to word limits.

As brought up a couple times, a very significant challenge in confronting divestment is the question of what exactly divestment means. This is not a question taken lightly by involved parties and there are several academic papers that have offered perspectives on this challenge, including raising the points EBS makes. A great methodology I have referenced is the Toronto Principle. But nevertheless, I do not think it’s fair to completely oppose divestment on the grounds that the question of how divestment should be executed is challenging. I would argue that those challenges warrant a discussion on what is pragmatic in divestment, but not whether divestment should be done.

The morals at hand are tricky and complicated. But I propose the following thought experiment to anyone thinking about the morals of this issue. Imagine we were in early 19th century America and Harvard was investing in industries profiting off the slave trade. Let’s say Harvard invested in everything from cotton plantations labored by slaves to clothing manufacturers depending on slave-picked cotton to holding slave equity to everything in between. Similar challenges arise in that situation: which investments are actually unethical, if any? How feasible or even possible is it to collect data on sub-portfolios and subsidiaries to see if Harvard’s money is investing in the company that’s using exclusively non-slave labor or conversely has a strategy of growing and selling slaves like cattle? If Harvard and similar institutions openly invested in the slave industry throughout the 19th century, would that have made any difference in the geopolitical climate surrounding slavery, when it was ultimately abolished, and how its roots seeped into American culture for many years to follow?

I would challenge anyone to think about fossil-fuels divestment from a similar perspective because the actual fundamental impact of the two industries on human lives is very similar. The degrees of separation between the moral issues neuters the emotional outrage we may otherwise instinctively weigh-in. It’s the classic trolley problem of ethics: if a trolley is about to kill five people on a track, we are more likely to pull a lever that kills one person and saves the five people than we are to push a person in front of the trolley to save the five people. Whatever viewpoint held, I simply caution others to correct for those inclinations. The true costs of climate change is otherwise very easy to rationalize away since a few degrees in temperature here or there can otherwise seem innocuous and the noise of the world’s turmoil can hide its direct impacts.