"How China and India can help cut Western medical bills". The Economist, Jan 20th 2011.
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Introduction Here is my Prediction for the future. The ability to use predictive modeling will move health care form hindsight to proactive. The ability to predict future trends and events with reasonable accuracy will be crucial to improving of health care. And you won’t be able to do that without analytics. The problem with predictions in healthcare is that practices are based on what "physicians want" and not so much on what is available, is possible, and more importantly, what is needed. For the most part "Physicians" practice the same way today as they have for several hundred years. The Healthcare Industry is about twenty or more years behind other Industries in their use of electronic technology. Less than 20% of the USA physicians use computers in their practice while in the Nordic countries over 95% of the physicians use computers to manage healthcare. "A common root cause of the underuse and overuse of medical care is health care providers’ reliance on tradition and anecdotal personal experience. Patients deserve care that is based on the best science, rather than on tradition alone. It has been estimated that about half of all physicians rely on clinical experience rather than evidence to make decisions, even though physicians in most practices do not see enough cases of the same conditions over a long enough time to draw scientifically valid conclusions about their treatment." (IHI Organization, Across the Chasm Aim #2: Health Care Must Be Effective) E-Health is a "big" attention getter, however, I believe that most of the individuals that are writing/lecturing on this subject are completely missing the importance of the event. They still do not understand what is "possible" and what the future is most likely to bring (then maybe they do!). "Patients, health professionals and health systems would all benefit greatly if the existing health-related information of one individual might be made available by another health agent" Most of what these writings are advocating can just as easily be done with a fax machine or phone! Please read on. Technology Imaging is already going digital with automatic interpretation. ICU units have a multitude of automatic monitoring devices and the advances are accelerating. Soon the client will be connect to a mobile physiologic device that sends data in real time to automatic monitoring device. In-patients are connected to data aware ventilators, output devices, automatic blood chemistry analyzers, and others. This data is processed through a predictive modeling algorithm that issues automatic alerts, warnings, and commendation based on real time data. The data will be automatically made available to a massive data warehousing system in the cloud where research is performed. Networking The information relating to an individual patient is distributed across different databases and applications, frequently heterogeneous and running on diverse types of platforms. There is "serious requirements about the inter-operability between different diverse heterogeneous systems". This may soon be no longer true. The exponential rise in computing power and the corresponding decrease in cost has made electronic systems affordable to everyone. At the same time, there are greater changes about what may make the current "computer" and "IT" departments completely obsolete. What is the point in buying a computer or having a IT department when it is cheaper to have someone else do it? What is the point of being able to "communication between" providers when there is only one set of applications and one database that is being accessed...by everyone. There is no need for "easy transport of records when patients move or change care providers." There are no nodes of regional or national networks, and everyone no matter where they or who they are in the world has full access...with proper security and permission. Cloud computing/online services for business applications Cloud computing is the concept that both the "applications" and the "database" will be somewhere else...in the cloud. From your "web" connected device, wither it is your cell phone, note pad, or what ever they happen to call it, you will be connecting to your favorite application, entering the data or selecting the results that you want from a massive centralized database (somewhere) that has "everything" in it. Is always up-to-date (real time), 24x7 365 days a year with multiple backup copies, and ran by professionals that know what they are doing. Expert Data Analysis teams will be part of the Healthcare Intelligence Team. Users can implement the system almost immediately. Economics of scale makes this very effective, efficient, and cheap. We are not interested in Sharing….we are interested in using the same data…in real time…with predictive modeling. There is no need to transfer information. A patient can easily “give the Healthcare Professional the password to access the portal of the database where the data warehouse is maintained. The data can be copied if required. Many businesses today already use online services for business applications such as Customer Relationship Management, Accounting applications, Banking On-Line, On-line ordering any and everything (Amazon.com is one of the largest and most security network in the world!) or simply viewing GPS "Google maps" or sending live digital media through your webcam. Companies like Google and Microsoft offer "in the cloud" services that require hardly any additional software on your local computer, beyond the operating system of the computer or device and a browser. Both also offers healthcare "Repositories for Personal Data. Microsoft’s has HealthVault and Google has Health. that data is available to anyone with the property permissions to access that data...immediately, without the requirement to transfer that data to their own computers. Interesting, if the Western Countries do not soon develop the system, it will be soon be in developing countries that cannot afford the existing systems. We already have "health tourism" Public Health Departments will all be using the same Healthcare Database. Medicare, VA, research data, immunization data, new born, laboratories, public hospitals, etc will have their data stored in the same database. All this will be controlled by the CDC. Data is update immediately, emerging disease can be spotted immediately, best practices can be developed, reference material is available. There is no requirements to "transfer" data, and the Cost is a fraction of what it now cost to maintain all the various computers and applications. With the onset of "cloud" computing, applications will be paid for as used. Increase or decreases in demand are deal with directly...when it occurs. There is no need to made a large investment for an IT department (or the human resources used to ran these costly machines), be concerned with "updates", or the healthcare applications. The cost to develop (and of having) new application is significantly reduced. For smaller healthcare organizations, cloud-based applications are extremely cost-effective. The healthcare organizations do not have to have a traditional IT staff, worry about "privacy" of data. security issues or "new updates." This will provide better continuum of care for the individual no matter where he goes for services. It will eliminate duplication and reduce the cost of care. All healthcare professionals will have access to this data wither it is the public health department, the large provider, the payee, the small practice physician or the home health nurse...with proper permission. The "cloud" makes it easier to access references and protocols and provides better access to individuals data. the massive databases that will be available makes it possible to use "predictive" analysis and to profile each individual (rather the individual likes it or not, it does provide better care). Predictive medicine enables the provider to forecast the disease "before it occurs" thus being able to implement preventive medicine sooner. Predictive care enables the provider to forecast the disease progression and to note when the treatment is not performing as it should...immediately...not after it is too late. "Cloud" data base...accessible anywhere....no need to move data...when the data is captured (web based application) it is automatically stored and formatted for presentation. Diagnosis and Health Research Massive database will allow data to be mined to determine what works and what does not work in the treatment of chronic diseases....for each individual profile type. All current research for any particular problem will be immediately available as references for providers. "Expert Systems" will provide the "answers" with better accuracy at less cost. Because the system will already have all the individual's medical data, as well as their family's data, and conditions of the environmental, It would be just a matter of keying in the current symptoms (or having the internal medical device, such as the heart monitors) read the data in real time into the system...and out comes:
Data that is required can be distributed by these "Gate Keepers" for:
Photograph and Video With the ability today to use "cam recorders" to photo objects, there is no need for "clinical drawings." A photo can not only take the actual picture but it can also record color... Ophthalmology is a good example where photographic "images" have complete replaced clinical drawings. Computer-aided detection (CADe) and computer-aided diagnosis (CADx) are procedures in medicine that assist doctors in the interpretation of medical images. It may be soon that the entire examination process is video recorded and read with special application programs. IT Roles and Business Intelligence IT managers will truly become "Information Managers." Instead of solely keeping the computers running, they will become managers of "Information." They will be responsible for the development of "Information Systems," of being the "Experts" on what is data is available and how to use "Business Intelligences" Development New and improved technologies continue to evolve. The availability of the pen computing has given room to the "touch" screens. Palm computers continue to evolve. Voice recognition is getting better and pattern-recognition software has made great strides forward. However, the development that seems to offer the most changes is "Cloud" computing and "Business Intelligences" ...which I call "Healthcare Intelligences". This prediction is based on the ability to accumulate mass-volumes of data into a database in "the cloud." Everyone will be accessing the same database and using more or less the same applications. Demand for Healthcare The demand for healthcare (eternal life, the magic portion, etc.) has always existed. Some of the earliest recorded history were wall paintings with scenes relating to the "ever after." Pharoses built large structures to protect them in their after life. Today, individuals still search the world for a "curse" of their illnesses and the patient who comes to the emergency room with a cigarette daggling from his mouth, dying from emphysema, that wants a "pill" to make him better.
There is no wonder that the medical industry wants "consumer empowerment." There is not enough resources in the world to satisfy the demand for healthcare services. As David Walker, head of the U.S. General Accountability Office put it: “If there’s one thing that can bankrupt the country, it’s healthcare. It’s out of control … affecting our economic and national security.” Yet, the purchase of cigarettes is still legal, as well as "sugar favored" drinks that are created to resemble real orange juice (my peeve at the moment). There is little effort to control the "products" that affect our health. Mexico still consumes the highest quantity of sugared drinks (Coke Cola) in the word and has the highest increase in diabetics of any country in the world (It is forecasted that diabetics will bankrupt the country in the next 10 years!) While health care centered on the individual and his real needs and "patient-centered care," is appropriate, "consumer empowerment" may not be. Communication between healthcare providers In the very near future there will be no "data sharing" nor "communication and data exchange" between providers. A "Central Application/Data Authority" (example see Microsoft Health Vault) in the "Cloud" will make all current efforts to communication between computer vendors and their platforms mostly irrelevant....Please read on. The efforts underway to create systems where by data can be exchanged is no longer required (even today). Everyone developing their own in-house IT system in not required. In actual use, everyone will be using the "same database". Health Knowledge Healthcare is moving too fast for any one individual...highly trained or otherwise...to know or be able to assimilate the new information being created. In order to deliver evidence-based medicine, healthcare professionals must stay informed of all advances in practice. Considering the amount of medical data that is now being produced, this is impossible. The only solution is to let the computer do it. In one older study (probably it is even more true today), in an outpatient clinic, the physicians could recalled only 50% of patient information 5 minutes after the patient left. Sixty percent of the physicians surveyed did not know the names of their patients' drugs, and 20% did not know why the patient was receiving the drug. [WoW!] Consumers, in many cases, now know more than the physician. The Consumer has had time to "research" his problem over the Internet. He is better prepared than the provider. Consumers of healthcare are getting tired of the healthcare professionals making mistakes... Expert Systems Early "Expert Systems" were developed over long periods of time by armies of researchers creating manual "rules." Today, with access to Massive Databases and Data Mining rules can be created automatically and updated automatically as new combinations of medical events occur. Consultations It is expected that the next logical step after being able to view your personal health information, is the ability to enter data into the system (which is already discussed as the objective...) Now if you can do this, what is the point in going to a healthcare professional??? Individuals can enter most if not all of the Medical history, "current problem", symptoms, System Review Data, and view possible "problems" where additional information may be required. As an example, if an individual has a "head ache", a decision support system can offer a yes/no path and offer suggestions for either more information or a solution. Computer decision support systems (Expert systems) have more time to ask you questions, have a bigger database of cases, have a larger reference library, can give you probabilities of outcomes...and certainly prescribe the best medicine based on your profile and probable problem...and actually be informed of the contradictions, adverse reactions, and "price" of the drug...with alternates choices. Other benefits are that you do not have to take time (and suffer) to travel to the healthcare organization, sit in a room where there are other sick people (and your chances of getting a "bug" from one of these people goes up significantly), and wait, and wait, and wait....having the healthcare professional rush in...ask you a few questions...give you a prescription...and hurry out! Individuals are already using the Internet to do their research. In most cases, when they go to see their healthcare professional...they know more than the professional about their problem. The problem with computers is that they may not give you what "you want"....but then they can also be programmed to "lie"! Service Level and Health Costs Medical spending per head has nearly tripled since 1990, yet most indicators of health have barely budged. However, Medical equipment is getting cheaper (finally!). China, India, Brazil and other countries are producing equipment for up to one-tenth (1/10) the cost of the same equipment in the USA. Scanners that cost $10,000 rather than $100,000; portable electrocardiographs that cost $500 instead of $5,000. A night in an American hospital typically costs 25 times as much as a night in an Indian, Brazilian or Chinese one; a night in a European hospital typically costs four times as much. It is cheaper to fly to any of a number of places...and receive care from a healthcare professional that has time to spend with you....see the sights...and return home having spent less money. With Cheap and Powerful Medical Devices, it is possible that Healthcare "Consultations" will become a commodity. Examinations (Scans, Lab tests, Diagnosis) will all be performed without Physicians in a "drive through" kiosk or grocery store. After the examination is performed, a computer system will give you recommendations. Public Health Emerging infectious diseases that affect livestock and man alike are a threat to health and prosperity. Scientists spot a new disease roughly every four months. Most are trivial but a minority, such as HIV, bird flu and SARS are grave threats. Smallholdings near or in urban areas may be especially vulnerable. Humans in such places are crammed close to their animals, helping viruses to spread. Elsewhere farmers may encroach on forests or other virgin land. That exposes them and animals to once-isolated bugs. More trade in livestock helps to pass along nasties too. For humans, booming towns—those of 250,000 people or more—with big slums are ideal spots to share disease. (Reprinted in Part from "The Economics, Feb 10 2011). As an example, the H1N1 Virus which the World Health Organization had declared it to be a pandemic. Schools, businesses, airports where all closed down. And it is still popping up from place to place and the governments still do not know where or how it started, or if in the future it will become more virulent by recombining their genetic material with that of other strains. More troubling is "how did it move so fast"? The greatest benefit may be the data that will be available for Public Health. Instead of all the public health departments buying computers, developing applications and trying to communicate, it is very likely that everyone will be using the same application and connecting to the same database. There is no need for each public health or stakeholder organization to have their own computers and databases. In the future these organizations will simply have a "web based" component that connects directly to a "Massive Public" application and database. Structure/Locations Telemedicine will provide medical services to service areas that are either too poor and too sparely populated to justify their own medical services. Example may be Kiosks placed in convenient stores with on-line measuring devices or home health stations. The reading and processing of digitalized imaging, radiographic pictures, or computerized axial tomography (CAT) scans, can be read from the "cloud" with sophisticated "pattern recognition software.
Investments will be made in "Business Intelligence" personal. These are the people that know how to use this new data. Future of Medical Care So...if the Information Systems can give you all this information...why do we need the primary physicians?...I see Medical Examinations and Care Plans being provided, "mostly", by technicians, not highly educated and trained physicians. It is already the case that many Providers are reimbursed based on their levels and extent to which they comply with Evidence Based Medical standards. Primary Physicians will not be needed, because: Medical care will be delivered based "what works the best for the price" and may have nothing to do with what the individual wants. Treatments are more accurate. These protocols will be "Evidence Based Medicine" gathered from massive databases with data mining techniques. Decision making will use techniques such as optimization techniques, game theory, and probabilistic modeling (used to predict missing data and reduce uncertainty)...all automatic. The individual will be "profiled" in detail based on a very large number of variables. By being profiled, the individual receives more individual care...not based on "general" guidelines as is being done today. The health status of Individual patients can be monitored everywhere they may go. Specialty Hospital. The new-build (greenfield) specialty hospitals that are conceived of as an advance, highly automated facility will will be the hospitals of chose. InHCc forecasts that the future structure of the healthcare system will be a system of highly specialist hospitals. Instead of having every hospital have "all" the equipment, specialists, of every type, the future structure will be that each hospital will be part of a network of hospitals that concentrates in only one specialty. It is easier to move patients from location to location (which is already happening) than to fully support every type of medical device there is. They will be designed to provide for the special needs of patients with special problems. As an example: the Aravind Eye Care System in India is one of the best Eye clinics in the world and they perform their care one-tenth the cost of other locations. Their Laser Survey is performed expertly and efficiency. Bumrungrad International Hospital in Bangkok is a JCI Accredited International Hospital Heart Hospital. Bumrungrad serves over a million patients annually. Over 400,000 are internationals Research We believe that research will move outside the US. The privacy laws, liability, government regulations and politics in the US have made it difficult or impossible for advances to be made. Many of the existing large medical centers will have to compete as care and clinical research move to less expensive locations. Pharmaceutical companies will continue their trend of moving clinical trials offshore. Administrative Appointment Most if not all appointments (when needed) can be booked over the Internet. Based on the data that is already available in the individual's database and new information that is entered into the system by the individual, the individual will be assigned to the best service organization required for their needs at the closest location. It is estimated that 95% of the problems of the individual can be solved "without" going to see a healthcare professional. The individual will be get better on his or her own. An example is the common cold... Transfers from healthcare organization to healthcare organization will also follow the same procedures. Again, since all of the individuals data will be immediate available to the receiving organization, care can be continued without any loss of time or care. Payer Insurers are expensive and inefficient. Today, many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing. Under the New Affordable Care Act, new regulations require health insurers to spend "ONLY" 80 to 85 percent of consumers’ premiums on direct care for patients and efforts to improve care quality, rather than on administrative costs, starting in 2011. If they don’t, the insurance companies will be required to provide a rebate to their customers starting in 2012. Wow...Only 20% of our healthcare expensive go to pay for executive salaries, overhead and marketing. And just why do we need marketing? This is a over-head that can not be maintained. Insurance companies have very little incentive to "police" healthcare costs (they work on margins...the higher the price, the higher the absolute profit...i.e the "percent" can only be 20%...that means the more the insurance company charges, the more absolute money they can take out as salaries. Healthcare costs can only be provided by a "non-commercial" provider...more than likely, the Government. The USA is the only wealthy industrialized nation that does not provide universal health care, has healthcare costs 50% higher than the next highest country and has a health rating of 47% when compared with other OECD countries....Interesting. Privacy issues. Public health...the good of all..."Externality of benefits" In many cases healthcare is NOT based on free market or what the individual alone wants....When you are vaccinated against whooping cough you are not the only person to benefit. Other people also gain because they are now protected against catching whooping cough from you. This extra or externality benefit is missed by the free market. See the Section on Patient Privacy of Information...now this is really good! Recent Experience While writing this article, I made a trip to Guadalajara, Mexico. Having arrived early for my meeting, I took the opportunity to visit the local Gallerias Shopping Mall. To my surprise, I found a very large "booth" manned by at least a dozen individuals with "white coats" set up by a major drug company offering to "Examine" you for free. There was an extensive list of the "examinations" that they would give you (the list included at least 95% of the examinations you would normally get going to a physician)....but said nothing about what they would do if they found a "problem." Since I was running out of time, I was not able to take advantage of this "golden opportunity." I will go back! Links: Just in case you think this is really far out...read:
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