Dr. Spiegel Interviewed on Onalytica: Interview with Brennan Spiegel, MD, MSHS

Originally published in Onalytica.

Brennan Spiegel, MD, MSHS –Professor of Medicine and Public Health

Director of Health Services Research, Cedars-Sinai Health System
Director, Cedars-Sinai Master’s Degree Program in Health Delivery Science
Cedars-Sinai Site Director, Clinical and Translational Science Institute (CTSI)
Assistant Dean, David Geffen School of Medicine at UCLA
Co-Editor-in-Chief, American Journal of Gastroenterology

Key Topics: Digital Health, Health Tech, Therapeutic Virtual Reality, AI, The Cost-effectiveness of Health Technology,
Location: Los Angeles, USA
Bio: Brennan Spiegel, MD, MSHS directs the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), a multidisciplinary team that investigates how digital health technologies – including wearable biosensors, smartphone applications, virtual reality and social media – can strengthen the patient-doctor bond, improve outcomes and save money. CS-CORE unites clinicians, computer scientists, engineers, statisticians and health services researchers to invent, test and implement digital innovations, always focusing on the value of technology to patients and their providers.

How did you get to become an expert in health tech?

First and foremost, I am a physician. I take care of patients. This clinical orientation colors everything I do in digital health, because when I see a new wearable sensor, AI program, mHealth app, or any other digital health product or service, I ask one question: How do we know that it helps patients?

I am also a Professor of Medicine and Public Health at Cedars-Sinai and UCLA, so I spend a lot of time teaching, asking questions, and conducting research. I am trained in health services research, which focuses on how to improve the value of healthcare while reducing the cost of care. This training also affects how I think about digital health; I am always focused on understanding the cost-effectiveness of health technology.

I got into health tech because I started creating apps and sensors to help my patients. I invented a device, called AbStats, that was FDA approved in 2015 as the first wearable device for monitoring human digestion. AbStats is a little sensor you stick on your abdomen. It has a small microphone inside the sensor that listens to you digest your food. A computer constantly monitors the sounds and makes sense of them, and then gives the user feedback about whether and how much to eat – or not eat. It can also help doctors diagnose serious conditions, particularly in the postoperative period. I also created an app called MyGiHealth that my research team discovered could outperform a doctor at taking a meaningful medical history. In addition, I got heavily involved in medical virtual reality (VR), and have now treated over 500 patients with VR and published several papers about our experiences. So, all this got me interested in health tech, and now I have a team at Cedars-Sinai Medical Center that is focused on rigorously testing new technologies in the clinical trenches.

What areas of health tech are you most passionate about?

• Proving whether health tech actually improves clinical outcomes in everyday patient care. For example, we are completing a new meta-analysis revealing that the existing literature does not really support the effectiveness of remote sensor monitoring for improving health outcomes. We need more and better data to support the growing field of digital health.
• Therapeutic virtual reality (VR). Not so far in the future, in lieu of popping a pill, your doctor might prescribe a virtual beach vacation to ease your aches and pains. Cardiologists might offer scenic tours of Icelandic fjords to lower blood pressure, instead of doubling up on drugs. Psychiatrists might treat social phobia by inviting patients to virtual dinner parties. Hospitals might immerse children in fantastical play lands while they receive chemotherapy or undergo frightening medical tests. It’s all starting to happen now because of VR – the mind-bending technology that tricks our brains into thinking we are somewhere else. By observing how VR nudges the brain for good, we are learning new and surprising ways to optimize health choices, reduce the need for medications, train doctors to be more skilled and empathic healers, battle the opioid epidemic and modify our experiences of reality to become virtually better. This is a major area of research for me.
• Cost-effectiveness of health technology. I teach cost-effectiveness analysis in our Master’s Degree program at Cedars-Sinai, and this is a skill that needs to penetrate the health tech community. Innovators should ask, up front, whether anyone would ever pay for their product. They should project price points that are sustainable, and understand how to prove effectiveness in a way that supports the health economics of their big idea. I don’t mean to throw a wet blanket on digital health, but running a few cost-effectiveness models every now and again is probably a good idea for this industry.

Which health tech influencers influence you?

I thought about the idea of AbStats, my FDA-cleared wearable digestion monitor, while watching one of Eric Topol’s TED Talks 4 or 5 years ago. Topol has done a lot for this field and I admire his insights, knowledge, and unabashed focus on clinical care.

I am also inspired by David Albert, inventor of AliveCor, who is a fellow doctor that had an idea and brought it to fruition. Dave is also focused on clinical validation, which I admire, and he puts his money where his mouth is by conducting clinical trial after clinical trial using his tech. I love that.

Bob Wachter is another one of my heroes in digital health. Wachter is a doctor, through and through, and that resonates with me as a clinician. His book, “The Digital Doctor,” is absolutely full of insights about whether, how, and when to use health tech in patient care. I actually assign that book as required reading for my class on digital health science at Cedars-Sinai.

Joe Kvedar at Harvard is also someone I really look up to in this space. He’s another doctor (you can see a trend here) who understands how to intersect clinical care with health technology. He’s been at this longer than most and has incredible insights. I especially love his focus on social sciences in digital health, something he explores masterfully in his book, “The Internet of Healthy Things.” That’s worth a careful read and I also assign it to my students.

There are many other influencers I follow closely; too many to list here. But some of my favorites, in no particular order, include Maneesh Juneja, John Torous, Arshya Vahabzadeh, Daniel Kraft, Kate Donovan, Justin Barad, Skip Rizzo, Steve Steinhubl, Lisa Suennen, David Shaywitz, Matthew Holt, and, well, so many others I’m afraid to leave out names. Lots of great thinkers out there in health tech.

Outside of health tech who else influences you?

Daniel Dennett: World famous philosopher of mind who was an early influencer of mine as a student at Tufts University. Check out his Ted Talks and his most famous book, Consciousness Explained. Dr. Dennett forced discipline in my thinking, compelled me to weigh evidence in a structured and rigorous manner, and taught me to be critical of widely held, but often erroneous, beliefs. I use that all the time in my health tech research and in clinical care.

Malcolm Gladwell: Most people know of Gladwell’s books, including Outliers, The Tipping Point, Blink, and others. Outliers is perhaps the most influential book I have ever read. I believe in its core premise, that intelligence is necessary, but by no means sufficient, for success. Success is the result of hard work, 10,000+ hours of practice, and absolute grit. That’s how I approach my research, sometimes to my detriment!

Daniel Kahneman: Daniel Kahneman, the Nobel Prize winning innovator of behavioral economics, has dedicated his life to explaining how we think. Kahneman famously describes two systems of thinking, simply called System 1 and System 2. System 1 refers to intuitive thinking; it is the system that generates rapid and automatic impressions, gut feelings, and inclinations. System 2 is different. We use System 2 when there’s more time to review the evidence at hand, craft an empirical argument, and generate a rational conclusion. System 2 takes brainpower; it is the analytic, slow-thinking, attention-consuming, evidence-churning part of our consciousness. Kahneman is so influential because he’s forced me to consider how combine System 1 and System 2 in balancing the human art of medicine with the empirical insights from health technology. Doctors often use System 1 instincts to solve clinical problems, and that often works well. But we also need to rely on System 2 insights from computers, AI, devices, and so forth. I spend a lot of time thinking about these two systems of thinking and evidence, and lecture about Kahneman in the context of my digital health science class.

Which brands or products stand out for you in health tech?

Kardia by AliveCor: This is a medical-grade EKG that runs off a smartphone. Invented by Dave Albert, it’s been validated by more research studies than any other digital health product I know of (potentially with exceptions, but few).

Samsung Gear VR: Although there are other VR headsets out there and more to come, the Samsung Gear VR was among the first lower cost, portable, and scalable headsets to allow penetration of virtual reality to the front lines of clinical care.

Muse: The Muse headset is a terrific device that promotes mindful meditation through EEG biofeedback. The app is sophisticated, easy to use, and effective. The science behind the device is legitimate and the company is serious about supporting its product through evidence.

Fitbit: Although Fitbit is a consumer-grade product, our team has used it in several of our remote monitoring studies with great success. I realize it’s not always accurate, but on the whole, Fitbit products work. The battery doesn’t die right away, the app is reliable, and patients (generally) keep the device on their wrist long enough for us to measure meaningful data. We’re finding the device is helpful, but will continue to learn more as we conduct further research.

Apple: Of course. The app store is revolutionary and is home to my own mHealth app, MyGiHealth. The Apple Watch needs a longer battery life, in my opinion, but the company continues to be serious about digital health and I look forward to testing new products and services.

IF A BRAND WANTED TO WORK WITH YOU, WHAT OFFLINE / ONLINE ACTIVITIES WOULD YOU BE MOST INTERESTED IN?

My team is principally focused on clinical research. We work in the largest hospital in the Western United States, which serves as a massive test laboratory for new digital products. We are efficient at developing and executing high-quality clinical trials for a wide range of health technologies, including mHealth apps, wearable sensors, clinical decision support software, EHR interventions, social media interventions, online decision tools, and so forth. Our team includes clinicians, biostatisticians, health services researchers, social scientists, and computer scientists, among others. Brands might come to us if they want their products tested, in a rigorous, peer-reviewed manner, on the front lines of clincial care.

What would be the best way for a brand to contact you?

You can email me on mailto:Brennan.Spiegel@cshs.org or call my office on: 310-423-6784