Future of Health Services

The role of physician in disruptive era

Budi Wiweko
wiwekobudi@yahoo.co.id
budi.wiweko@gmail.com

Academic Health System Universitas Indonesia - Indonesian Medical Education and Research Institute
Faculty of Medicine Universitas Indonesia
Dr. Cipto Mangunkusumo General Hospital

Jakarta
 Outline of My Talk

1. Disruptive innovation
2. Consumer health informatics
3. Bioinformatics and precision medicine
4. Take home messages
A disruptive innovation is an innovation that creates a

new market and value network and eventually disrupts an existing

market and value network, displacing established market-leading firms,
products, and alliances.
Technological
advances
impacting
healthcare
and the
magnitude of
disruption
The virtual medical coach model with multi-modal data inputs and
algorithms to provide individualised guidance.
Ovarian aging is characterized by a decline in both the total number and overall
quality of oocytes, the latter of which has been experimentally tied to
mitochondrial dysfunction.

Clinical studies in the late 1990s demonstrated that transfer of cytoplasm

aspirated from eggs of young female donors into eggs of infertile women at the
time of intracytoplasmic sperm injection improved pregnancy success rates
AUtologous Germline Mitochondria ENergy Transfer = AUGMENT

Woods and Tilly. Semin Reprod Med, 2015

 SOCIAL EGG FREEZING:
A reproductive chance or smoke and mirrors ?

Lucia Martinelli et al. Croat Med J. 2015;56:387-91

 Disruptive

Lisa is 37 years old and she has just broken up with her long-term boyfriend.
She always imagined that this relationship would lead to marriage and children.

Lisa is stable and happy in her career. However, she is now worried that if she does not meet someone
new, and soon, her biological clock will be merciless with her and she will be left childless.

After a visit to a fertility clinic she decides to freeze her eggs, in order to remove the pressure of having
to rush into a new relationship.

She wants time and is not ready to date again.

She wants to raise a child with a committed partner and believes that freezing her eggs will offer her the
best chance of ensuring this.
 Disruptive

Some companies are even offering financial plans to support women to freeze
their oocytes in a venture which could turn out to be quite expensive
 He Jiankui defends 'world's first gene-edited babies'

Prof. He announced earlier this week that he had altered the DNA of embryos
twin girls to prevent them from contracting HIV.
 LEG STAT I Countries are grappling with how to appropriately regulate human germline editing. As of December, before a Washington DC meeting
organized by UK, US and Chinese scientific societies, at least 29
countries
have banned germline modification.

AL US

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The newest of the three main gene-editing tools, CRISPR--Cas9, has spread far and wide. Massachusetts-based Addgene, a non-profit
IT I plasmid
repository that distributes CRISPR-Cas9 editing kits to 83 countries, sends the largest proportion of its kits to US researchers.
POPU Y China
70,
Great Britain France Switzerland
5 2%
LAR % 2%

United States Japan Germany Canada Korea Rest of the world

48 9% 6% 3 2° 16%
Disruptive
We think that there is a need for an automatization or robotization of the ART lab. Evidence
in the literature shows that some steps in the ART lab procedures are already performed
automatically.

So the question is: What do we need to transform our way of handling fertilization of
human gametes and embryo development from a manual ART into an automated process
where a sperm and an oocyte come in at one end of the machine and out of the other
comes the best-quality embryo ?

Fertil Steril, 2012

Microfluidics and Medium Administration

IVF-Lab, which uses microfluidics in an automated cell culture device for IVF.
The medium is automatically controlled to a flow rate of up to 20 mL per hour,
and two types of medium can be used, which are automatically administered. In
this way, fresh medium can be added to each well and waste products removed.

Meseguer et al. Fertil Steril, 2012

 Proposed automatic cumulus
removal device
(Zeringe et al.2001).

A. The cumulus oocyte complex

passes through the narrowed
area, emerging with partially
removed cumulus cells.
B. By a fluid exposure and a suction
force the remaining cumulus
cells are stripped from the
oocyte.
C. The remaining cells are removed
in the second removal port when
suction is again applied.

Meseguer et al. Fertil Steril, 2012

 ARTIFICIAL INTELLIGENCE (AI) COULD BOOST IVF SUCCESS

A recent study discovered that AI is more accurate than an embryologist at

precisely identifying which embryos have the potential to result in a healthy birth.
To achieve higher precision in the evaluation of embryo viability and to reduce
the subjectivity that affects the process of embryo selection, digital image
processing and AI techniques were used in conjunction with Time-Lapse imaging.
Diagnostic and Research Center
(DIARC – FKUI)

EMBRIO BIOPSY

Iffanolida, Wiweko et al. Ina Repromed, 2015

 Diagnostic and Research Center
(DIARC – FKUI)

NGS

Aneuploidy detected, XXY

Microarray

Iffanolida, Wiweko et al. Ina Repromed, 2015

Doctor’s oriented health services

New Paradigm
 INTERNET OF THINGS (IOT)

CONSUMER HEALTH INFORMATICS

The use of internet-based and electronic resources to educate and improve

medical outcomes and healthcare decision making for patients, caregivers and
consumers.

The consumers has capability to retrieve information and

recommendation regarding disease, medication and treatments

Bosworth A, York C, Kotansky H, Berman MA.

An inventor's perspective on consumer health informatics. Am J Prev Med. 2011;40(5 Suppl 2):S241-4.
Patients are active participants in, NOT PASSIVE recipients of, the caring
process, and thus should be well informed about all aspects of their health,
wellness and diseases state to gain maximum health benefit

The Free Dictionary, 2016

TELEMEDICINE ACTIVITIES

Foguem et al. Telematics and informatics, 2015

MRCGP-certified NHS GPs

Now GP recrui ts highly-qualified, MRCGP-certified doctors, with each GP

carrying sever al years of practicing experience. Our Clinical Director, Dr
Andrew Thornber, leads a team of NHS GPs who are trained in the
delivery of app-based diagnoses and providing effective care and advice
remotely.

The Now GP p latform has been designed to provide high-quality

healthcare for an increasingly on-the-go society. This has been achieved
by combining the expertise and knowledge of experienced medical
professionals with industry-leading, secure technology which offers
patients ultimate convenience.

Patients have full control of which doctor they speak to, with our vast • -
pool of GPs, nurses, counsellors and consultants filterable by gender,
language and areas of expertise.
 Home page Log in page
Article page
News page QnA page About page
 This study is a mixed method study conducted from January – June 2016 at Yasmin IVF
Clinic, Dr. Cipto Mangunkusumo General Hospital; and SMART IVF Clinic, Jakarta.

Qualitative analysis highlighted two issues: the information regarding infertility services in the
available multimedia and the OSG; use of the available information by patients when deciding
to use infertility services.
 The Indonesian Test-Tube Babies Facebook Club is a type of OSG
which was evaluated in this study

“Honestly doc, initially I was embarrassed to come here. To seek treatment for
infertility, because how do I explain to you how I felt. However, I tried browsing
here and there before finally deciding to come here, and one of the pages I
opened was the Indonesian Test-Tube Babies Facebook Club. I read the
comments, the moral support, and I was touched. Initially, I feel embarrassing
as I thought I was the only one with this infertility problem, but it turns out
there are so many people going through the same thing. Also, they all do not
feel embarrassed to fight, it is fascinating, and finally decided to come here.”
(Respondent 11).

Wiweko et al. ISBE, 2017

 Chronological Age AMH Level Biological Age
25 years old 5.4 ng / mL 25 years old
25 years old 0.5 ng / mL 42 years old

n = 1616 Wiweko. Ina Repromed, 2015

 Tindakan yang dilakukan setelah mengetahui
hasil AMH & Umur Biologis
60

*p = 0.008
50 *
40

30

20

10

0
Ingin segera Oocytes Embryo Tidak
Ingin segera Tidak dapat
memiliki cryopreservat cryopreservat melakukan
menikah memutuskan
anak ion ion apapun
Jawaban pasien 51 36 2 0 10 7

Promotive and Preventive Approach

n = 106
Wiweko et al, 2018. Submitted
 HIEALTH
PART 0

UNLOCKING

Healthcare
Potential
WITH BIG DATA

Data is the lifeblood of

organizations,
and life
sciences/pharma
is no exception.

====
=-
® RAPID
TECHNOLOGICAL
ADVANCEMEN S
 Big data: the next frontier for innovation in therapeutics and
healthcare
Naiem T Issa, Stephen W Byers, and Sivanesan Dakshanamurthy

The digital revolution in healthcare is now. The amount of data is exploding from
basic science to clinically based genomics and personalized medicine, and continues
to evolve in healthcare at both the population and the individual levels.

Clinical phenotypes are being described more quantitatively and biochemically

using genomics, transcriptomics, proteomics and metabolomics.
 How Big Data is Collected

Components of big data along with the actions that can be taken with big data
Bioinformatics is the use of computational tools to interpret information from
genomes and their derivatives (e.g., transcriptomes, proteomes, and
metabolomes).

Bioinformatics approaches can readily identify molecules or cellular components as

targets of clinical interventions, allowing for better knowledge of the

mechanism of the disease.
The diagram of genetics-lifestyle-environment interaction. Besides genetic

factors, the lifestyle and environment can affect people health through
epigenetic modification.
Understanding the
interactions between
genetics, lifestyle, and
environmental factors
provides deep insights
into disease
pathogenesis and is
helpful for the early

diagnosis and
treatment of human
diseases.
 PROMOTIVE AND PREVENTIVE APPROACH

Understanding and balancing genetics-lifestyle-environment interactions

are essential for systems health
The synergistic relationship between smart healthcare and the
translational biomedical informatics subdisciplines
Precision medicine (PM) can be defined as a predictive, preventive,
personalized, and participatory healthcare service delivery model.

4 P’s approach
“PRECISION MEDICINE’’ refers to medical treatment adapted to the
individual characteristics of each patient.

Concept:
Ability to classify individuals into sub-populations that differ in their susceptibility
to a particular disease, in the biology and / or prognosis of those diseases or in
their response to a specific treatment.
Personalized medicine

Angelina Jolie

Mutation on gene BRCA 1 and BRCA 2 were found

GENES RELATED TO DIABETES MELLITUS
Bioinformatics concepts particularly amenable to public outreach are those that
focus on molecular biology and its impact on public or personal health, as well as
those that address ethical consequences and policy considerations affecting
daily life.
Genomics and
bioinformatics for
the clinical audience
What should
everyone know
about genomics and
bioinformatics ?
 Convergence
Will Accelerate
Discovery and
Innovation

New Biology, which focuses on the life sciences, draws on integration of multiple
scientific fields in the creation of biology-based solutions to societal challenges

National Academic of Sciences, 2014

 TAKE HOME MESSAGES

1. Disruptive innovation in health care are aligned with the

development of AI, machine learning, robotics, IoT, digitalization and
genomics.

2. New paradigm shifting in patients-physician relationship are relevant

with consumer health informatics.

3. The development and knowledge of bioinformatics are very crucial to

support establishment of precision medicine.

4. Electronic health records of personal data, including genetics,

proteomics and metabolomics play important role in precision
medicine.

5. Precision medicine looks very promising to increase the accuracy,

safety and efficacy of promotive, preventive, diagnostic, and
treatment approach.