Volume 75, no. 9 

Dr. Robot is visiting patients in some places but could be displaced by Dr. Alexa, the virtual assistant in Amazon smart speakers, who is already able to perform certain health-related tasks. "She" can track blood glucose levels, describe symptoms, access post-surgical care instructions, monitor home prescription deliveries, and make appointments at an urgent care center.

Amazon has big ambitions. It thinks Alexa could help doctors diagnose mental illness, autism, concussions, and Parkinson disease. Alexa, the iPhone 5s, and the Samsung Galaxy S4 can correctly identify agonal breathing, an early warning sign in about half of all cardiac arrests, in 97% of instances, while registering a false positive only 0.2% of the time. The smart phone is constantly listening. Patented technology from the University of Washington  differentiates coughs and sneezes from other background noises;  Alexa could discern when someone is ill and suggest solutions.

Since Alexa won permission to use protected patient health records controlled under the Health Insurance Portability and Accountability Act (HIPAA), vast new opportunities are open. It could listen in on patient-physician interactions to take notes on visits, even suggesting possible treatments and writing up medical notes automatically.

Alexa could potentially combat loneliness. It is "learning" how to make conversation.

In 2018, private equity and venture capital firms have invested a record $10 billion in startups touting the benefits of virtual doctor visits and telemedicine. A startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic, which is not actually a physical place, offers online medical guidance and personal advice focusing on women's health needs.

Amazon now has a deal with the British National Health Service (NHS) to provide patient access to "reliable, world-leading N.H.S. advice from the comfort of their home," freeing up more doctors' appointments. An NHS spokesman said no patient data would be shared. Amazon insisted that it is not building health profiles, that no health information will be used to sell merchandise or make product recommendations, and that none of the information will be shared with third parties. But given past concerns about how Alexa-enabled devices handle their users' information, social media users expressed caution or disdain. Big Brother Watch calls Amazon "one of the most aggressive corporate data guzzlers" and worries about people being profiled and targeted based on health concerns. The data "gives Amazon an opportunity to understand much more about people's illnesses, behaviors and problems," and could help it start a health-related business or a pharmacy.

"Facilitated Self-Service"

"The physician-patient encounter is health care's choke point," write David Asch et al. from the University of Pennsylvania and Cornell University. "So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors."

Authors cite automated teller machines, online travel booking, TurboTax and other do-it-yourself replacements for workers.

Common problems like hypertension, hyperlipidemia, diabetes, and anticoagulation "might be far more efficiently managed by a bot than by individual clinicians whose practices often deviate from guidelines," they write. Information technology and value-based payment won't enable transformation "until they move past facilitating care with a doctor and move toward facilitating care without one" (NEJM 5/10/19).