>> i thought because of this phenomenon that these cartoons would help just before that mentioned that united health was the last to announce last month they're going to have a cloud-based platform for doctors and patients who are insured by united health. this is the check is in the cloud. this one it was much nicer before people started storing all their personal information in the clouds. [laughter] so now we've had to put the pieces together. basically these pieces from technology that are contributing to the formation of a digital infrastructure, which is what's going to set up this new era of medicine. cell phones, personal computers, internet. these things we just talked about, digital devices, social networks good evening in one would've forecasted help cloud computing. this sets up this great inflection of medicine. we will get into what that really can mean. so, i did want to get this, this is of course the prediction of the demise of hardcopy books. many of you have a hardcopy book right on your lap. i'm curious about that. how many of you only read books through and the reader now? no one. that's an interesting crew. this is a bookstore grew. sometimes you go into the bookstore and you borrow the book for your kindle, right? i guess. i'm like you. i think having a hardcopy book is a great thing except when you're on an airplane and italy important to have it because you shutdown your kindle order either. in your times last week there was an article that people now reading a book on and i've had can't even concentrate to read the book because they're getting all the e-mails and searching the web all the time because there's no ability to have linear action. so this is the thing that really convinced me the world had changed. i did my cardiology training at johns hopkins and the library is the second largest medical library in the united states. i would just say was because on january 1 of this year it was close. this whole building which i spent inordinate amount of my time in training is no longer functioning. there's no need for medical library at johns hopkins. so that i think is another reflection. just to add to that, today it was announced after 244 years the encyclopedia britannica will no longer he produced. so that's kind of another creative destruction. so i hope i have convinced you in this first segment of the world is changing. and if you buy into that then we can go on to phase to. if anybody doesn't except that, please come this is a good time to move on. all right, now let's talk about how the world will change on top of this digital infrastructure, much bigger than the medical microcosm. it is a cocoon. when that happens, which will happen, it is beginning to happen as i will show you, that sets up digitizing man. that's where we want to be. you will see what changes in just a minute. so right now everything we do in medicine is based on populations. medical trial on large populations. the recommendations or guidelines, like, for example, women should have a mammogram every year. a lot of the women have zero risk of ever developing breast cancer. why do they have to have a mammogram every year? all the things we do we give the same drugs for the same condition same goes for all people. that's not a good way to practice medicine. is another way to practice medicine which is the other 10 letter word which is remarkable, and we have now new tools to do that. that's what's so exciting. these tools kind of started in the fitness world. fitness and health. the nike shoe, the sensor in the sole of the shoe could sense how much distance you have traversed and velocity and all sorts of physiologic metrics. does anyone have a nike plush issue and this group? i bet not. i'm just trying to get a sizing of the group year. it's important. then the other -- direct life, the jawbone up recently released last week nike fuel been. does anyone use that? one, okay. there we go. i recommend them to my patients because that gets them to get active and get to 10,000 steps that most people don't. what's great about it is throughout the day you're getting reading of how many subjugating and gets people moving because they want to be more active to fulfill not getting alums and having the right like to show or whatever it helps to remind you. the other problem we have today in the health side is sleeplessness. we are so wired to our wireless devices that we can't sleep. this is a really significant problem. i should ask, has anybody heard of this device? no one. a couple people, okay, that's good. that is the only -- the are several sleep monitoring devices you can put under the mattress or under your pillow. they don't measure brain waves. this measure bring ways. it is a headband and it goes directly to your phone and it captures every minute of sleep, which face of sleep you're in. it started out with the clock and now it goes to the phone. i was testing this. i still have it, and this is what shows up on the clock. every minute of sleep so you can see the orange bars are when you're away. and, of course, sometimes during the night you're awake and you don't even know. then there is a light sleep which is in gray. the deep sleep is dark green. that's the stuff you really want to usually in the first third of the night. so i'm using this device, my wife is a night out. she comes in a room and she looks at the clock and she says i know you're awake and i want to talk. [laughter] so you do get one of these things, watch out. you really can't play possum any longer what's interesting is when i use this device or the sensor, i really was, i never thought that this story that a just told you was going to be a callout in "the wall street journal" of the book. that was kind of embarrassing. this is the thing they made a big deal of. that was kind of a surprise. which was a wonderful review and is very gratified. this is a compilation. just think of this, this is your sleep manage competition and against your peer group it there are 10,000 people my age and all with the same metrics. just think of it being your blood pressure, glucose, your heart rate, any metric you want. that's what this is. this sets up with your social network which is free. so i can compare whether i'm a good sleeper and quantitatively every turn aspect of it, and that's interesting. what's interesting, athletes have now figured out that this is a way to really ramp up their performance. much more so than even drugs. illicit drugs or things like -- triathletes are using it. the three nba teams are using every night and they have shown correlations with a composite score and how well the team does in terms of their winning percentage and the athlete. what's also interesting is, this has now led to getting multi-dated together for pro athletes. this is a summary of that. you will note that the king of sleep is lebron james who averages 12 hours a night of sleep. no wonder they haven't won any playoffs. but i also want you to note on this graph the person with the least sleep of all pro athletes is tiger woods. and i'm not going to comment any further on that. [laughter] so there are these devices that exist today that you can measure your blood pressure. i often recommend this to patients, because he used the i would always recommend the one device which is usually 50 or $60 at costco. but now i use these devices because they are fun. i get a lot more reading from patients who have high blood pressure. so much of a great way that you can hit start, get the blood pressure and archives it insensitive to your doctor or your facebook friends or whoever you want. your google+ france, your circle, whatever you want. in the same thing with glucose. there's devices which was up here in northern california, same thing with glucose. if you're a diabetic you can measure glucose every five minutes through a sensor, and it doesn't go to your phone right now, but it will. in fact, i have a device to show you. i am wearing this center. it looks just like the one there, and you can put it on your arm or your abdomen, whatever. when i turn my phone on, i have two phones, i turned to stone on, it's 7:36 and i just hit, okay, and i just like this in my glucose right at this moment is 96, okay? if i want to see what it's been like over the last hour or three hours, you know, whatever i want to do here, i can call that up. here it is. it's acting a little silly here. well, it doesn't give the drink but its giving me every minute glucose. i don't know what -- okay. here. so here is over the last three hours, and i can do the same thing over 12 hours, 24 hours, whatever. why is this important? you know you're connected to your phone and then you're looking at this really nice piece of cake or cookie, whatever it is. this changes everything. do i want to eat that snack that's going to screw up my glucose and put my pantries into a taxing experience? this is an interesting thing to have on your and looking at your glucose all the time, particularly if you're prediabetic and don't want to get into diabetes. okay, now the next one i want to show you is alive court electrocardiogram which i use on all my patients now instead of normally getting a cardiogram. this is a case that goes on the iphone. you see on the back and as these two sensors. it makes a circuit with your hard with your fingers on the center. i just pop this case on my iphone, i turn it on. because i am in the health system i have to have a password and have to put this on. i will just put my fingers on this, and you will see in just a second my cardiogram. see that? this is not heart rate. this is your cardiogram, a big difference. i can tell what rhythm it is and i can tell all kinds of things about this. there's a credit card version, so if you're dizzy or lightheaded or you're feeding a pounding in your chest, instead of going to the emergency room you can use the credit card version apple out of your wallet or your purse and send it to your doctor or your friends or whoever you want to send. i didn't realize how this would become invaluable in unpredictable circumstances, but back some months ago i was on a flight, cross-country flight nonstop, when the call for doctor on a plane. just after they got up in the air. the passenger in the last wrote on the plane was having chest pains. of course without a way to do a cardiogram we would know, i would know whether it was indigestion or heart attack or whatever. but because of having this device i could tell exactly that there was a very significant heart attack which led to an emergency landing, and the passenger who then became a patient was whisked off to a hospital, open the artery. but will was really interesting is the pilot and the attendance all wanted to have a cardiogram done right after that. [laughter] there's this thing called a halter monitor. the halter monitor was invented by norman halter in 1949. it's been frozen and design since then. anybody ever hold or seem is but this is a bulky device. there is a hookup fee and you have to work for 24 hours and you can exercise, you can't take a shower. you've all these wires on your. then you to come back and get disconnected. now there's a new way to do this, it's a little band-aid you can wear for a week or two weeks. another company that started here up in northern california. that you just mail to the patient and they mail it back. no wires. it captures a whole lot more data. the other thing is what about this year when it's now feasible where you can just turn your phone on at get a readout of all your vital signs. so your phone will look just like this screen and you of all your vital signs going in real time heart rate rhythm blood pressure, respiratory rate, temperature, oxygen saturation. all it can be done basically three wrist band. so what is that going to do to our world when you're checking your e-mail and web and i you're checking all your vital signs. so if there ever was a potential for cyber congregate, this is a. but it can be very helpful and a select people of course. so it has to be used discriminately and it can be very powerful. things like this. if you're a dermatologist you will find this very threading. all these people would come in for a biopsy, they can just now take a picture and have it analyzed and get a text within minutes and it saying there's nothing to worry about, and it's often accurate. if you're an optometrist look out. this is an add-on which cost $2. it does retraction after i actually and it does the text to get your eyeglasses me. it has changed the world, not in the u.s. but in many places now where people can read and function that they couldn't before. then, of course, there's ways to monitor i pressure for glaucoma. in europe not yet approved any less right to the phone. there's things that can analyze your breath. so predicting an asthma attack, or even using the breath to digitize to find out if you're the earliest signs of lung cancer, which we couldn't do before because we are digitizing all the things. all these things can be digitized. so now this part of the world is known for its great innovation, and apple has been center stage. the whole logo of apple after steve jobs' death was except that it should be potentially change, but the impact of course has been worldwide. and i think it's very interesting because this cartoon kind of captures it from "the new yorker" cover to moses meets steve, he's going to upgrade your tablet. [laughter] so what's interesting here is i suspect many of you read this book, right? and if you haven't i highly recommend it. because it traces the whole digital age from the '70s all the way through 2011. it's a pretty impressive book. but what i like most about this book was a quote from the next last chapter. steve jobs was trying to survive to see his son at his high school graduation to his was a quote to walter isaacson. i think the biggest innovation of the 21st century will be the intersection of biology and technology. that's what we are talking about tonight. so now let's talk more about the real biology, not just ideology of all these different metrics. let's talk about sequencing. that's still digital. for characters. but all of us basically, each of us i should say are just billions of zero ones actg, from a medical standpoint. yes, we have a soul and personality, and we're human and all that stuff but from a medical personality you only need six characters. the way we sequenced people in the past was using these next-generation devices that cost seven, $800,000, next-generation of sequencing the not only would incredibly expensive but we had to buy these proprietary agents and these were formidable. we are in this era. this year in january we thought this is really big. life technologies announced this, not yet feasible will be later this year can sequence a whole human genome 40 times, sequence it in two hours at a cost of $1000. that's a great event. well then in february just about not even a month ago, was this device. this is a device using sequencing that is the size of a usb port. this can be without a sample prep, 15 minutes human genome can be done. this can be put into a laptop. of course we haven't seen the data but that's what was announced. it was announced a pretty regular people people. that could be a very important impact in the field when we start getting sequencing this fast hopefully very accurate, and without having the prep time to get the samples ready. why is this important? are you for me with a necklace volcker? a boy in milwaukee who was very ill. he was in the hospital almost incessantly for years. he had about 100 surgical operations. this poor boy. and he was desperately ill. event and hyperbaric chamber. constant infection and eventually before he was going, they're going to listen, the pediatrician said why don't we sequenced them come his dna. we've never seen anything like this before. maybe we can find out what it is. and, indeed, they did. they found a specific mutation in a gene called xiap, and this led to successful therapy and this is nicholas volker now india six years old and he is cute. and is doing badly. this is the first case of sequencing to save a life. you have been hearing about this human genome project since 2000, at the white house, bill clinton and francis collins, they'll stood there and said we have the book of life. it took all this time to get to appoint where it can save lives. and out came. here is a family from san diego, the twin study terrible movement disorder. they were recently sequenced. scripts had a course march 1 and 2nd. the whole family can. they presented their story. it wasn't a dry eye there. what's amazing is these teenage twins are barely get around. now he is a soccer star. she is a track star. this sequence he has led to appropriate therapy. not just the actual diagnosis of the specific mutation. were doing a project and working with complete genomics era in mountain view. it's interesting about idiom, this is a first possession, a 15 year girl who is wheelchair-bound and we hope that we can do what they've done for nicholas volker and the theory them and i just showed you. she is a wonderful girl who was exceptionally bright and she blogs. going thing is she can't get around and we hope we can find out what that is. if you know of people who have this type of serious condition where no diagnosis, that's what we are trying to do. but this term common idiopathic, the medical term, fancy term for we don't know. why don't we just say we don't know? instead of using these kind of terms. no, no. we're going to get over that. that's the last part. it is coming quickly. now another area where genomics is having amec impact as we speak is in cancer. the war on cancer that was declared decades ago but now there is the real deal. this is a patient with a scam, a pet scan of a patient who has metastatic malignant melanoma. that carries a mortality in one year of 97%, something like that. with a drug that is directed to the mutation that is driving this cancer, two-thirds of people having mutation in a gene with this type of cancer, two weeks of oral therapy, there's no evidence of any cancer. that's an 85% of the people who have this type of condition. this is another one. this is a patient who was riddled with metastasis with a basal cell carcinoma with the mutation, a pathway called the hedgehog pathway. an inhibitor to that. all 30, two weeks, no evidence of any cancer on the repeat scan. that's also being used in brain canter, particularly occurs in kids because it has the same type of mutation profile. that drug was just approved. the problem we have today, if you know someone who has cancer, what happens to their biopsy specimen or their surgical specimen is they are ruined, ruined. it is put into formula and that destroys the specimen and you can't do appropriate sequencing. [inaudible] >> that's right. and that's why it's wrong. it's ritualistic and that's the medical community. it's pathetic because now we want to be sequencing we have to a part of that specimen frozen. we have to get rid of it. i called up the f-word. that is -- after a pathologist or a cancer specialist, everything goes ffpb. were you as a patient or a family member, fun, you have to say i want some of that specimen put in the freezer. because if it doesn't happen, if you don't request it will not happen. if we get fresh frozen, flash frozen and we can sink once and that sets a whole different cascade of possibilities to get the right therapy. then there's this cystic fibrosis is a condition that has been since 1989. we knew they genome is causing this but on in the last couple years did we specifically see a drug that was directed to a mutation which occurs in about three to 4% of cystic fibrosis, which these kids can now, this is a g