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The Future of Connected Health, Chapter 2

August 30, 2010

I was recently asked to predict what our Center would be like 10 years hence. Stated another way, the question was: “What is your ten year vision for your Center?” My initial reaction was, “Of course I should be able to articulate that.” After all, our very capable team does all of the work here, so the most effective way for me to add value is to articulate a clear vision. However 10 years is a long time and lots of intervening forces can influence the world.

In August 2000, the ‘smartest’ phone was a Kyocera model – the handspring Treo had not been released yet. The fastest mobile network was GPRS and about 50 kbps. Apple had not released the iPod yet. Videoconferencing was still predominantly done over dedicated ISDN telephone lines. On the healthcare delivery side, capitation had swept through the country and been largely declared a failure. In fact care was even less managed than in the 90s. At that time our Center was called Partners Telemedicine and we were thinking that the web browser could be a place where one accomplished transactions rather than simply gathered information. We were creating a website where we could do second opinions online. Our goal, as a group, was to extend access to Partners specialists around the planet. While we had dabbled in some remote monitoring projects, the concept of connected health was not formed yet.

You know the story today. mHealth is hot. 4G ubiquitous broadband is on the horizon. Sensors are embedded in so many products we touch and feel each day – they are small, accurate and affordable. People are monitoring their health in a plethora of interesting ways and using the Internet to share that information strategically with a number of parties, making the data more meaningful and actionable.

So what will the connected health space look like in 10 years?

Some things we can be reasonably certain of: Electronic health records will be adopted. Mobile computing will become commonplace and wireless networks both fast and robust. Pressure on health care costs will remain. The population will continue to have an increasing percentage of older individuals who are higher utilzers of health care services. Technologies of all types will get smaller and cheaper. Ten years from now, today’s teenagers (who constantly text and view voice calls as quaint) will be graduating medical school and today’s graduates (the first generation to grow up in an always connected world) will be assuming leadership positions.

It’s hard to imagine a scenario where connected health will not flourish. Both the provider community and the patients will be comfortable with an always connected, high speed, texting, social networked world. Monitoring and location awareness technologies will be ever-present.

You may be thinking two things….”Tell me something I don’t already know.” and “You still haven’t said where your Center will be in 10 years.“ And that is because I haven’t fully digested all of the potential wild cards yet.

  • For instance, how much will The Centers for Medicare and Medicaid Services (CMS) push true payment reform, and which models will predominate? It is clear that any model that preserves ‘fee for visit’-based revenue as part of the package will be a connected health deterrent. The Health Reform Bill has many passages in it directing CMS or another government agency to study new care models and new payment models. With only experiments to hang our hat on, this part of the future is quite uncertain. Likewise, a change in partisan leadership in Washington might result in a significant slowing of the experimentation around new models of care.
  • Will a truly disruptive care concept (such as retail clinics) gain enough traction to displace mainstream health care as the predominant provider of care? Yes, there are relative provider shortages and the mismatch between provider supply and care demand will undoubtedly grow. Yet, unless something really compelling comes along and begins to threaten the dominance of the traditional ‘physician is king’ model, everyone in healthcare will still be asking doctors’ permission before doing anything meaningful to the care process and that will slow care model innovation.
  • Just how much will the coalition of employers and health plans be able to ‘bend the cost curve?’ Right now, we providers feel like we’re being pressured, but the pressure is pretty light, really. Plans need us to provide care, so they have to tip toe around pushing the envelope too much. Will there be any way to loosen the financial relationship and interdependency that providers and plans have?

By now you’ve probably figured out that this post is meant to be a teaser. As I try to rise to the occasion of positioning our group for the next 10 years, I’m grappling with these uncertainties. In large part, our collective work will help drive the market for connected health. So, I would be most interested in your thoughs on the future of technology-enabled healthcare delivery. Which trends do you think will be the most important? Which are both certain and of high impact? Which are of potential impact but highly uncertain?

14 Comments leave one →
  1. Sandra Peters permalink
    August 30, 2010 2:16 pm

    Great teaser, Dr. Kvedar! I think that as ASO, medical home, comparative effectiveness, and hosp never events continue to flourish there will be continued emphasis on quality and cost savings. Emobile solutions will gain in popularity, I think some of these companies sprouting every day will have to merge, as a way to cut LOS and readmissions. I think there will be more data mining of large comprehensive data bases for predicting and interventions with high risk patients. I think telehealth will continue to grow given shortage of doctors, more people requiring coverage, older pop and more chronic disease.

    I see changes too with ICD 10 coming up soon…much longer super bill forms?

    • August 30, 2010 4:21 pm

      thanks Sandra. did you mean ACO?

      • Sandra Peters permalink
        September 2, 2010 8:50 pm

        Yes, meant Accountable Care Org. Sandra

  2. September 2, 2010 11:05 am

    Ditto to Sandra’s comments and jkvedar’s post.

    As a healthcare/technology blogger, RN, CCHIT Co-Chair AWG, and Clinical Solutions Exec for Nuvon, I supposed there is much I could contribute on this topic…. but I will condense and respond…

    The migration from paper to electronic records has promises of improved productivity and better information to improve delivery of care to patients.

    A “next wave” that will also support EMR ROI investment is the ability to directly transmit data from patient devices to their electronic record. This has several benefits: 1) improved accuracy, 2) improved availability, 3) improved nursing workflow, and 4) costs savings for workflow improvements and reduced liability for inaccurate patient records.

    I see this “next wave” as a precursor to the HIEs and RHIOs because if a facility is unable to gather and collect patient data in a single location efficiently, data exchange external to the facility with become onorous.

    That said, the “next phase” of health IT is “The Medical Home” where care and monitoring for patients will occur at home. When this happens, I believe the patient and/or family/caregivers will most definitely become more involved and vocal about their treatments and progression back to wellness.

  3. September 2, 2010 12:59 pm

    Excellent post. I wonder how disruptive healthcare can be if health insurers and hospital chains also become vendors and/or V/V. What does that do for trust? Regarding MDs being king, remember that the laws of physics and economics eventually trumps guilds. As is often the case the level of disruption will rise in conjunction with protectionist barriers. Clearly the status quo is not sustainable. Other models are being developed, the question being primarily whether the culture will devolve or evolve. In this regard this industry is no different than many others.

  4. Brigitta U. Mueller permalink
    September 9, 2010 8:38 am

    Although there will undoubtedly be changes in medicine here in the Westren world, what about Africa, Asia and other rapidly growing but very poor populations? Will they be left behind due to an ever growing gap between healthcare options here and there? Or will the development of technology enable them to catch up (and perhaps surpass us)? Cell phones or the next generation(s) of smart phones that are able to connect healthcare providers with patients over long distances, including the easy transmission of pictures, could transform medicine as we know it today. Intelligent drug design might eliminate some deadly diseases (we can only hope!). And how will these changes affect us in the western world? We already have medical tourism; will that expand? help us with physician shortages? Make MDs obsolete in certain settings? I think we are at the threshold of a major change and it is not only CMS or insurance companies that will influence what will be….

    • September 9, 2010 11:20 am

      I confess that i am sometimes too U.S. focused in my thinking. This global perspective is very helpful

  5. September 10, 2010 5:37 am

    Improvements in connected health do not need to await the day of universal 4G networks and RFID chips in our underwear. We could do more with what is available today. It requires more a change in thinking than the development of new technology.

    One of the most obvious examples is to use available Web 2.0 technologies to communicate with patients and patient proxies. The industry’s technical focus to date has been back-office related: electronic medical records for exchange among health professionals; invoicing data for use by Medicare, insurers, and providers, etc. Patients and their proxies do not relate to health care professionals the way they relate to their financial institutions or other service providers. This could change now without developing new systems or technologies.

    Improving two-way information flow — beyond simple appointment confirmation and invoice presentation — out to patients and their proxies can raise compliance with plans of treatment, reduce unnecessary readmissions, reduce costs, and improve patient outcomes. Health care professionals and related providers like home care agencies (of which I am an owner) should do more here without awaiting a new technical development.

    NPR’s recent series Aging at Home tried to point out some of the ways this can be done, but I think also tended to focus on emerging technologies for the next 5-10 years rather than on ways we could make significant changes at large scale today. The Buck Rogers stuff is fun for people in the industry but we have unexploited opportunity now, and for most families, that is the bigger issue.

    NPR also linked to our Concord, MA-based agency as one of four expert resources in this area. For a white paper describing some ways we could use technology better today, and examples how we currently deploy it with our clients, use this link:
    http://info.caringcompanion.net/secrets-to-successful-elder-care

    Jim Reynolds, CEO
    Caring Companion Connections
    http://www.CaringCompanion.Net
    Concord, MA

  6. September 10, 2010 2:15 pm

    Excellent question, Joe K: Which trends in technology-enabled healthcare will end up as the real game-changers? It’s wise to hem and haw and qualify predictions every which way from Sunday, of course, so please consider the following statements hedged. That said, here’s what I expect to see:

    • Growth in the health-to-medicine ratio. In other words, the resources – money and time — we devote personally to staying healthy are going to expand a lot faster than the resources we hand over to medical professionals towards the same end. Technology-assisted doctors’ work will grow in absolute terms (due to population aging) but technology-assisted self-help will take a growing share of the total market.

    • Health technology that goes beyond mobile to embedded and ubiquitous. Sensors and electrodes will collect data and generate feedback whenever and wherever we choose to locate them — in, on and around the body, and on objects both mobile and immobile.

    • Breakthroughs in what we might call compliance engineering. What comes to mind is some combination of Sunstein’s and Thaler’s description of choice architecture; Christakis’ and Fowler’s dissection of the influence of social networks; and – on an even grander scale – the British inquiries into the health effects of social class. For the next ten years we’re going to be teasing out causative effects and attempting to neutralize them. Many of the compliance features we engineer will be technology-based and self-engineered, with opt-ins and opt-outs galore. But often compliance engineering will amount to social engineering, which means there will be political reverberations (see below).

    • Physical structures built to be not only “green” but “blue” – conducive to good health. As an aspect of compliance engineering, architects, planners and designers will lay out smart buildings, campuses, public spaces and public services, one that encourage physical exertion and monitor and measure results, though individuals will be able to opt in or opt out.

    • Neuroscience that changes everything. We’ve just started to plumb the results of fMRIs and other tools for studying the brain. My favorite finding of the moment comes from “How the Opinion of Others Affects Our Valuation of Objects” in this past July’s issue of Current Biology. Campbell-Meiklejohn et al report that the mere experience of agreeing with experts and authority figures lights up the brain’s ventral striatum – that is, confers psychic rewards. With findings like these, neuroscientists will begin to color in the outline we have of human decision-making and motivation. If we make radical progress in understanding technology’s users – that would be us – technology will have to change radically as well.

    • Health data that still ends up in siloes. Doctors will adopt electronic health records, no question, but the feds will continue to redefine the NHIN out of existence, and institution-specific EHRs will never catch up with the numbers generated by the various technologies referenced here.

    • Payment systems that treat most of connected health IT as infrastructure or overhead. Today’s concerted push by vendors to wrangle specific fee-for-service reimbursement for uses of their products will largely fail, supplanted by a common-sense view of IT as part of healthcare’s woodwork. IT expenditures, in other words, will be treated not as add-on services but as business expenses, to be covered by global or capitated payments. This is by far the best way to ensure that such expenditures either reduce costs or enhance outcomes — if they don’t, capped providers won’t lay out the money for them.

    • Re-alignment of responsibility and risk. We will all navigate uneasily between the science of decision-making (above), where personal volition is provisional but still matters, and genomics and other disciplines focused on disease predisposition, where the influences beyond our personal control rank high. In the end, driven by financial worries and cultural norms, the public will acquiesce to rate-setters and payers — insurers, employers and governments – who routinely differentiate in their charges between insureds with healthy habits and insureds without. As each of us does what we can to land in the right camp, connected health technology will thrive.

    • Technology trend smash-ups occasioned by all of the above. The Nanny State tint to some of the technology developments I’m talking about will breed continuous popular ambivalence and periodic popular eruptions. As health care professionals and technologists, we need to prepare ourselves for the distinct possibility of political black swans – low-incidence but trend-ending disruptions in the public mood. In hindsight such disruptions will appear understandable, even inevitable, but when they’re happening they will seem inexplicable. Trends will arrive, trends will disappear, and every so often, connected health technology will get caught up in the mishegas.

    • Carmen permalink
      September 17, 2010 5:17 pm

      Mike:

      Your comments are on the mark. With the increased use of wireless technologies and their increasing sophistication, it would be long before such devices are reading our moods along with our vitals. I see the home health model abetting this trend, as such tech tools allow for affordable and closer patient monitoring. The collected data can be added into larger consortium efforts for refining treatment models where everyone wins.

      You hinted at black political swans, but I suspect that technological black swans are what may end up upsetting the apple cart in ways we have yet to see. I can imagine that we’ll be able to perfrom some fMRI scan on a person’s brain to determine likelihood of medical treatment adherence and based on their “type” recalibrate their insurance rates. While that’s a nutty thought, it isn’t so nutty that it doesn’t make me nervous.

      • September 17, 2010 6:10 pm

        very thoughtful!! I believe we should make most of these programs opt in so that privacy is preserved.

Trackbacks

  1. ICMCC News Page » The Future of Connected Health, Chapter 1
  2. Kvedar: Three “wild cards” for connected health | mobihealthnews

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