Forces of change :The future of health
13 minute read 30 April 2019
The future of health will likely be driven by digital transformation enabled by radically interoperable data and open, secure platforms. Health is likely to revolve around sustaining well-being rather than responding to illness.
Twenty years from now, cancer and diabetes could join polio as defeated diseases. We expect prevention and early diagnoses will be central to the future of health. The onset of disease, in some cases, could be delayed or eliminated altogether. Sophisticated tests and tools could mean most diagnoses (and care) take place at home.
Today, the US health care system is a collection of disconnected components (health plans, hospital systems, pharmaceutical companies, medical device manufacturers). By 2040, we expect the consumer will be at the center of the health model. Interoperable, always-on data will promote closer collaboration among industry stakeholders, and new combinations of services will be offered by incumbents and new entrants (disruptors). Interventions and treatments are likely to be more precise, less complex, less invasive, and cheaper.
Health will be defined holistically as an overall state of well-being encompassing mental, social, emotional, physical, and spiritual health. Not only will consumers have access to detailed information about their own health, they will own their health data and play a central role in making decisions about their health and well-being.
What is the future of health?
The future of health that we envision is only about 20 years off, but health in 2040 will be a world apart from what we have now. Based on emerging technology, we can be reasonably certain that digital transformation—enabled by radically interoperable data, artificial intelligence (AI), and open, secure platforms—will drive much of this change. Unlike today, we believe care will be organized around the consumer, rather than around the institutions that drive our existing health care system.
By 2040 (and perhaps beginning significantly before), streams of health data—together with data from a variety of other relevant sources—will merge to create a multifaceted and highly personalized picture of every consumer’s well-being. Today, wearable devices that track our steps, sleep patterns, and even heart rate have been integrated into our lives in ways we couldn’t have imagined just a few years ago. We expect this trend to accelerate. The next generation of sensors, for example, will move us from wearable devices to invisible, always-on sensors that are embedded in the devices that surround us.
Many medtech companies are already beginning to incorporate always-on biosensors and software into devices that can generate, gather, and share data. Advanced cognitive technologies could be developed to analyze a significantly large set of parameters and create personalized insights into a consumer’s health. The availability of data and personalized AI can enable precision well-being and real-time microinterventions that allow us to get ahead of sickness and far ahead of catastrophic disease.
Consumers—armed with this highly detailed personal information about their own health—will likely demand that their health information be portable. Consumers have grown accustomed to transformations that have occurred in other sectors, such as e-commerce and mobility. These consumers will demand that health follow the same path and become an integrated part of their lives—and they’ll vote with their feet and their wallets.
Exponential change and innovation cycles While we don’t know with precision how the future will play out, we can look at signals in the market today—and the forces of change in other industries—to start to paint a picture of the future of health. In virtually every industry, fundamental shifts in innovation tend to occur in seven-year cycles (figure 1). Health is no different. By 2040, three of these cycles will have passed—each building off of the other. To determine where health might be headed, we should look back three innovation cycles and consider where exponential innovation has taken us. Figure 2 shares several examples. Why does the future of health matter?
Nothing is more important than our health. All of us interact with the health care system to varying degrees, and we will continue to interact with it throughout our lives. The cost of health care affects individuals, families, and employers as well as local, state, and federal budgets. In 2017, US health care spending topped US$3.5 trillion (17.9 percent of the gross domestic product). That translates to US$10,739 for every person in the country.6
An estimated 133 million Americans have at least one chronic disease (such as heart disease, asthma, cancer, and diabetes), and the number of people who have a chronic illness has been rising steadily for years.7 Hospital care now makes up about one-third of all health care spending in the United States, and chronic illnesses are tied to more than 80 percent of hospital admissions.8 While chronic diseases are typically incurable, they can often be prevented or managed.
Health care consumers typically interact with the health system only when they are sick or injured. But the future of health will be focused on well-being and prevention rather than treatment. As illustrated by figure 2, we predict that more health spend will be devoted to sustaining well-being and preventing illness by 2040, while less will be tied to assessing conditions and treating illness. Greater emphasis on well-being and identifying health risks earlier will result in fewer and less severe diseases, which will reduce health care spending, allowing the reinvestment of this well-being dividend to expand the benefits to the broad population. Along with helping to improve the well-being of individuals, health care stakeholders will also work to improve population health. Interoperable data sets will be used to drive microinterventions that help keep people healthy (figure 3).
In response to this shifting health landscape, traditional jobs we know today will undergo change. Health will be monitored continuously so that risks can be identified early. Rather than assessing patients and treating them, the primary focus will be on sustaining well-being by providing consumers ongoing advice and support.
We don’t expect disease to have been eliminated entirely by 2040, but the use of actionable health insights—driven by interoperable data and smart AI—could help identify illness early, enable proactive intervention, and improve the understanding of disease progression. This can allow us to avoid many of the catastrophic expenses we have today. Technology might also help break down barriers such as cost and geography that can limit access to health care providers and specialists.
Health systems, health plans, and life sciences companies have begun to shift some of their focus to wellness, but the overall system remains focused on sick care.
Interoperable data will empower consumers
Radically interoperable data and AI can empower consumers in ways that are difficult to visualize today. Data about individuals, populations, institutions, and the environment will be at the heart of the future of health.
Most of the care provided today is highly algorithmic and predictable. By 2040, high-cost, highly trained health professionals will be able to devote more time to patients who have complex health conditions. Data and technology will empower consumers to address many routine health issues at home. Consider a child who has an ear infection. Rather than taking the child to a clinic or doctor’s office, an at-home diagnostic test could be used to confirm the patient’s diagnosis. Open and secure data platforms would allow the parent to verify the diagnosis, order the necessary prescription, and have it delivered to the home via drone. Or maybe the ear infection never materializes because the issue is identified and addressed before symptoms appear. In this case, a prescription isn’t needed at all because the parents intervened early. In both scenarios, consumers address health issues at home while allowing physicians to focus on cases that truly require human intervention.
The consumer—rather than health plans or providers—will determine when, where, and with whom he or she engages for care or to sustain well-being. Over the next 20 years, all health information will likely become accessible and—with appropriate permissions—broadly shared by the consumers who own it.
But consumers might not be willing to share this information with organizations that don’t offer value, or that aren’t trusted. Consumers tend to trust hospitals and physicians more than other health care organizations, according to our 2018 consumer survey. While trust in health plans and pharmaceutical companies is relatively low, consumers are twice as likely to trust information from these groups as they were in 2010. Health stakeholders should consider ways to earn the trust of these empowered consumers.
How will technology help improve well-being?
Consumers are growing accustomed to wearable devices that track activity. Deloitte's 2018 US Health Care Consumer Survey shows that consumers are tracking their health and fitness data two and a half times more today than they were in 2013. Data-gathering devices will become exponentially more sophisticated and will continuously track activity, health, and environmental factors. This ongoing monitoring can help ensure that health conditions and risks are identified and addressed early. In rare instances when treatment is needed, it can be highly personalized.
Consumers can already remotely adjust thermostats, set alarms, and turn on lights in their homes. Cycle that forward to a home equipped with remote-monitoring biosensors. This might include a hyperconnected bathroom where the mirror and other tech-enabled appliances process, detect, and analyze health information. Highly attuned sensors embedded in a bathroom mirror, for example, might track body temperature and blood pressure, and detect anomalies by comparing those vitals to a person’s historical biometric data. Maybe this smart mirror even plays a skin care tutorial reminding the user to apply sunscreen based on that individual’s plan for the day together with the weather forecast. Analyses conducted by a tech-enabled toilet might be able to spot biomarkers that would indicate a potential change in health status long before symptoms appear.
Outside of the home, environmental sensors might detect UV levels, air pressure changes, and pollen levels. Such information could help keep consumers in tune with their health and quickly spot issues that could indicate the early stages of illness or disease. Rather than picking up a prescription at the pharmacy, personalized therapies based on a person’s genomics could be dropped off via drone when needed.
What are the impacts of the future of health?
The future of health will impact incumbent stakeholders, new entrants, employers, and consumers. Many incumbents are understandably hesitant to drive change in a marketplace that they currently dominate. Given their strong foothold in the existing ecosystem, and their ability to navigate the regulatory environment, these organizations may be well-positioned to lead from the front.
Technology-focused companies such as Google, Amazon, and Apple9 are beginning to disrupt the existing market and reshape the model. Legacy stakeholders should consider whether to disrupt themselves or isolate and protect their offerings to retain some of their existing market share. Incumbent players that are able to reinvent themselves could help usher in the future of health, while some could succumb to competition coming from outside the traditional industry boundaries.
We anticipate that by 2040 successful companies will identify and compete in one or more of the new business archetypes illustrated in figure 4, taking into consideration their existing capabilities, core missions and beliefs, and expectations for the future.
Largely replacing the siloed industry segments we have now (such as health systems and clinicians, health plans, biopharmaceutical companies, and medical device manufacturers), we expect new roles, functions, and players to emerge. In the future of health, we expect three broad categories to emerge (data and platforms, well-being and care delivery, and care enablement). Within these categories, we envision 10 archetypes. Organizations might exist in more than one category, but they typically will not take on all archetypes in a category.
Data and platforms. The future of health will require that data be collected from multiple sources to enhance research, to help innovators develop analytic tools, and to generate the insights needed for personalized, always-on decision-making. Organizations focused on data and platforms can capture an increasingly significant share of the profit pool as they provide the infrastructure to engage consumers, facilitate data access and analysis, and connect stakeholders across the industry. These archetypes will serve as the backbone for the health care ecosystem of tomorrow.
Data conveners (data collectors, data connectors, and data securers). These organizations will have an economic model built around aggregating, storing, and securing individual, population, institutional, and environmental data. This data can be used to drive the future of health.
Science and insights engines (developers, analytics gurus, insight discoverers). Some organizations will likely have an economic model driven by their ability to derive insights and define the algorithms that power the future of health. These organizations can use machine-led activities to conduct research, develop analytical tools, and generate data insights that go far beyond human capabilities.
Data and platform infrastructure builders (core platform developers, platform managers and operators). This new world of health will need infrastructure and platforms that can serve highly empowered and engaged individuals in real time. (Someone will need to lay the pipes.) A limited number of large-scale technology players will develop core platforms, interfaces, and infrastructure to enable data sharing, virtual health, and consumer-centric health. They will also develop standards for platform and application integration, architecture, and user experience.
Well-being and care delivery. Community health hubs, specialty care operators, virtual communities and care-delivery mechanisms, and product developers will work in partnership with one another to drive a tailored promotion of health and well-being. These virtual and physical communities will provide consumer-centric delivery of products, care, and well-being. Health stakeholders that focus on well-being and care delivery today typically capture a majority share of the profit pool as direct providers of care. However, they should embrace new ways of working, new ways of engaging consumers, and new ways of delivering well-being services and care to compete effectively.
Health products developer (application developers, inventors/innovators, manufacturers). The economic model of these organizations are driven by their ability to enable well-being and care delivery. Medical products might no longer be limited to pharmaceuticals and medical devices. They could also include software, applications, wellness products, even health-focused foods. The home bathroom of the future, for example, might include a smart toilet that uses always-on sensors to test for nitrites, glucose, protein, and pH to detect infections, disease, even pregnancy. A smart mirror equipped with facial recognition might be able to distinguish a mole from melanoma. Breath biome sensors in a smart toothbrush might detect genetic changes that indicate early stages of disease. Foods might be modified to contain cancer-killing bacteria that integrate into the consumer’s biome.
Consumer-centric health/virtual home and community (virtual health providers and enablers, and wellness coaches). Along with companies that develop health products, other organizations will provide the structure that supports virtual communities. These communities could be defined by geography, or they might be communities made up of people with a certain health condition. A community could also be comprised of a patient, his or her family members, and supporters.
Specialty care operators (world-class health centers, event-specific facilities). Two decades from now, we will still have disease, which means we will still need specialty care providers and highly specialized facilities where those patients can receive care.
Localized health hubs. While there will be some specialty care, most health care will likely be delivered in localized health hubs. The brick-and-mortar hubs will serve as shopping centers for education, prevention, and treatment in a retail setting. Additionally, local hubs will connect consumers to virtual, home, and auxiliary wellness providers.
Care enablement. Financiers and intermediaries will facilitate consumer payment and coordinate supply logistics, respectively, but they could experience decreases in margins and share of profits, driven by advanced analytics and risk assessment.
Connectors and intermediaries (enterprise tool developers, supply chain designers and coordinators, delivery service providers). These are the logistics providers that will run the just-in-time supply chain, facilitate device and medication procurement operations, and get the product to the consumer.
Individualized financiers (N of 1 insurers, catastrophic care insurers, government safety net payers). Similar to health insurers of today, these organizations will create the financial products that individuals will use to navigate their care, but these products will offer more specific, tailored, and modular products, as well as catastrophic care coverage packages. Some individual financiers will include noninsurance financing products (for example, loans, lines of credits, subscriptions). They will drive reductions in care costs by leveraging advanced risk models, consumer incentives, and market power.
Regulators (market leaders and innovators, government regulators and policy makers). While we will still have regulators, we probably won’t view them as governmental traffic cops. They will set the standards for how business is transacted. The regulators of the future will influence policy in an effort to catalyze the future of health and drive innovation while promoting consumer and public safety (they might be as much collaborators in transformation as stewards).
How do we expect incumbent players to change?
We envision an era of unprecedented change and opportunity. New business models will incorporate these archetypes and redefine the health landscape. Organizations should choose where they want to play across these archetypes. For example:
Hospitals and health systems. The acute-care hospital will no longer serve as the center of gravity. Instead, the center of gravity in this new system will be consumers. Organizations that want to play a role in the delivery of care should determine how they can expand their points of access to get closer—both physically and digitally—to their customers. Health care providers should also find ways to decrease delivery costs to maintain margins. Near-term strategies might include enabling patient self-service, creating more remote and virtual health solutions, digitization, and advanced population management.
Health plans. Health plans will likely develop new business models that move beyond claims processing to focus on members’ well-being, according to Deloitte research on the health plan of tomorrow. We expect health plans to become data conveners, science and insight engines, and/or data and platform infrastructure builders. Using the wealth of data they possess, health plans could develop new revenue streams based on consumer insights, monetization of data, population health initiatives, and customized offerings.
Medical device companies. An increased focus on prevention and early intervention—combined with advances in biosensors and digital technology—can create new opportunities for medical technology companies. But they might not be able to take advantage of those opportunities on their own. Over the next two years, more than 80 percent of medtech companies expect to collaborate with organizations from outside of the health sector, according to a survey by the Deloitte Center for Health Solutions and AdvaMed.
Drug manufacturers. Biopharmaceutical companies are set to develop hyper-tailored therapies that cure disease rather than treat symptoms. Individual drug prices could rise as therapies become more efficacious and applied in more targeted populations. However, overall drug spending could decrease as the unit volume falls. Advanced early intervention and enhanced adherence could also help ensure the effectiveness of these new therapies.
The health industry is on the cusp of a transformation that will affect all stakeholders. Incumbent players can either lead this transformation as innovative and well-connected market leaders or they can try to resist this inevitable change.
A wide range of companies—from inside and outside of the health care sector—are already making strategic investments that could form the foundation for a future of health that is defined by radically interoperable data, open and secure platforms, and consumer-driven care.
As stakeholders prepare for the future of health, they should consider the following actions:
Build new businesses. The incidence and prevalence of major chronic diseases (for example, type 2 diabetes, hypertension, COPD) will likely decline dramatically. In response, health organizations should adjust their business models to stay competitive.
Forge partnerships. Technology giants, start-ups, and other disruptors are new to the health care landscape but are incentivized to drive change. What they lack is health care expertise, regulatory expertise, a targeted consumer base, and existing partnerships with other incumbents. Disruptors will likely be more willing to partner with incumbents that are seen as driving innovation.
Appeal to the newly empowered health consumer. Stakeholders should develop tactics to engage effectively with consumers. They should also work to earn their trust and demonstrate value. Consumer attitudes and behaviors are malleable in the future of health. Interoperable data, machine and deep learning capabilities, always-on biosensors, and behavioral research can enable personalized and real-time AI-driven behavioral interventions that shape consumer beliefs and actions.
In the future of health, incumbents and industry disruptors will share a common purpose. While disease will never be completely eliminated, through science, data, and technology, we will be able to identify it earlier, intervene proactively, and understand its progression to help consumers effectively and actively sustain their well-being. The future will be focused on wellness and managed by companies that assume new roles to drive value in a transformed health ecosystem. If this vision for the future of health is realized, we could see healthier populations and dramatic decreases in health care spending. If we’re right, by 2040, we might not recognize the industry at all.
The Future of HealthThe health industry is on the cusp of a major transformation that will affect all stakeholders. Incumbent players can either lead this transformation as innovative and well-connected market leaders or they can try to resist this inevitable change. A wide range of companies—from inside and outside of the health care sector—are already making strategic investments that could form the foundation for a future of health that is defined by radically interoperable data, open and secure platforms, and consumer-driven care.
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he sets of technologies people use are now so integrated into their lives that they have become a part of their identities. Data captured in the digital and physical worlds, along with related data sets (e.g. demographics, sociographics), can converge to create a technology identity for an individual. Healthcare leaders can use people’s technology identities to create a new generation of offerings and experiences.
The digital revolution introduced technology identities as part of an emerging feedback loop, one that first began to show potential via personalization efforts. Thanks to ecosystem connections, healthcare organizations are increasingly using these identities to deliver more personalized and individualized services. For instance, Kinsa’s connected thermometers let customers track their fevers via a smartphone app; Clorox paid to license the information, using it to direct ads to US ZIP codes where people had more fevers (and potentially more need for disinfecting wipes). No personally identifying information was ever shared.1 Now, in the post-digital era, organizations have greater opportunity to use technology identities and insights to shift from one-off transactions to ongoing customized relationships with individualized experiences.
Innovative thinkers in healthcare predict the future of care delivery.
It’s 2025. Do you know what your profession looks like?
Try to imagine how the practice of medicine will transform in the next 10 to 20 years — not an easy exercise considering recent healthcare reform efforts and scientific discoveries make even a six-month view into the crystal ball a little cloudy.
Will there be high-tech full body scans, an iPad in the hand of every practitioner, and hologram versions of yourself being beamed into the homes of your patients?
Not likely, but rising costs and increasing demands on the healthcare system will surely force a transformation in the role of today’s physician. More than just universal EHR adoption or smartphone use, the practice of the future is likely to reinvent the care-delivery model, rethink reimbursement, and retool technology.
Here, some of healthcare’s innovative thinkers and practitioners aim to reimagine the doctor of the future, as signaled by some of the innovations taking root today.
A new way to deliver care
The traditional, one-size-fits-all, office visit model of medicine has reigned for decades. Physicians are locked into a system that requires they see patients in their office every 15 minutes, and alternatives like e-mail consultations have been slow to catch on.
Healthcare has been stuck here because of the payment structure, says David Moen, a physician and medical director of care model innovation at Minneapolis-based Fairview Health Services. Moen’s job is to rethink the traditional model and find ways to make the alternatives work. The current financial structure limits this innovation, he says, and fails to take into account patient engagement and drive efficiencies.
But at Fairview, they are initiating care reform, Moen says, which will in turn inform payment reform. Moen says the future of care includes different delivery models (think phone, Internet, and group visits), a greater focus on patients’ behavior, and a far more team-oriented approach.
“This is probably the most opportune time in decades for physicians to provide leadership to the change taking place,” he says.
Moen’s colleague, Eric Christianson, an emergency department physician at Fairview, has been trying his hand at what some believe will become a new tier for healthcare delivery: online visits.
As part of a pilot program with BlueCross BlueShield of Minnesota, Christianson has started seeing some patients via the Internet, using a Web cam and a telephone. Already, after only about 40 visits, Christianson says he can see how this method would make him more efficient, and give him some flexibility in his schedule.
“It seems to me to be a very common sense, logical step,” he says. “The technology is out there. There are still things that need to be worked on, but as it’s being developed and being refined, it’s clear to me that it could be utilized for betterment of patient and physician experience.”
Not only will the online care model extend healthcare access to people in rural or underserved areas, but it can offer the physician a unique way to control her schedule. Imagine spending half of the day in the office seeing patients, then returning to work — perhaps from the comfort of your home — in the evening after your child’s softball game or dinner with the family. Any down time between patients, such as a last-minute cancellation, can be filled with another appointment.
A patient can go online to find out which physicians are available for an online visit, says Roy Schoenberg, CEO of American Well, which provides the online system.
The physician can review records, communicate, and write a prescription — and actually get paid (albeit less than for an office visit).
Minnesota is one of only a few areas using the online care model, but Schoenberg envisions the system evolving to allow for other disciplines to participate and for physicians to consult with each other.
Christianson also sees the mode taking off. “There’s no question that online care is something that is going to grow,” he says. “This is just another layer we can utilize and help with the efficiencies of the whole system.”
Perhaps the ultimate move toward more efficiency would be seeing more than one patient at a time. Imagine if you could corral a half-dozen of your patients with similar conditions into a single visit, allowing you or your staff to give the information and guidance once. For some physicians, this is already a reality, and many see group visits as a new model for the practice of the future.
Although group visits have been around for several years, the concept is gaining in popularity, and more payers are beginning to reimburse for them.
The concept started around patients with a similar condition, such congestive heart failure, who are in a rehab program, says Erica Drazen, managing director for the emerging practices division of CSC Healthcare Group, a planning and performance improvement consulting firm in Waltham, Mass. In a group visit, there may be a facilitated discussion about diet or exercise, after a nurse or physician has evaluated each patient individually.
“Patients listen to what is going on with every patient, as well as talk amongst themselves,” Drazen says, which provides them with greater insights into their condition and builds support among the group.
“As you hear questions and answers, you learn a lot about yourself,” she says. “Patients love the visit experience.”
Surprisingly, privacy concerns don’t seem to be a barrier to such visits, Drazen says, and of course any exam is done in a separate room.
This can allow the physician to be more efficient, and it also gives her some insight into the condition she might not otherwise get in one-on-one visits.
Group visits tend to be limited to organized systems of care, such as an HMO or large clinic that allows for reimbursement, Drazen says, but “where they are introduced, they spread pretty quickly.”
Rather than being uncomfortable for patients with chronic illnesses, group visits can be empowering, says David Ehrenberger, a family-practice physician at Bloomfield Family Practice, which has conducted group visits and is participating in a patient-centered medical home pilot project.
“That group dynamic is extremely powerful,” he says.
For some physicians, the answer to declining reimbursements has been a migration to so-called concierge medicine, in which patients pay a retainer fee for highly personalized care and greater access. The benefits for physicians are clear — no more payer headaches and more time to care for patients. Many, however, reject the idea of asking patients to pay even more for care and dropping those who can’t afford it.
But like other models of care delivery, the concierge model is sure to evolve, and Susan Wilder thinks she has tapped into the future of concierge.
Wilder, a primary-care physician at LifeScape Medical Associates in suburban Phoenix and a well-known advocate for patient-centered healthcare, practices what she calls hybrid concierge. Only those patients who want to pay for the extra access (usually about 5 percent) do so, allowing the physician to continue to see the other patients as well. As medicine adapts to be more patient-centric, Wilder says, this hybrid concierge model can be one solution.
Wilder likens the model to the airline business: customers who want to pay first-class rates for additional services can do so, but you’re not going to kick the coach passengers off the plane.
“We hold the keys to our own shackles,” Wilder says, adding that physicians are responsible for allowing the rising overhead and declining reimbursements. Physicians have accepted the current payer-centric system, and it’s time to take control of the practice and try something different, she argues.
Wilder says she was ready to abandon medicine entirely, as she found she was unable to devote the appropriate time and energy to her patients. The hybrid model gives her flexibility without locking her into one model that might not be sustainable in the future. Her practice isn’t based solely on concierge patients (who may opt out of the model if it becomes too costly), or on insurance plans, whose reimbursement rates are declining.
“We really tried to think ahead, and we really are patient centered,” she says.
Many healthcare practitioners and observers predict a major shift in the role of the traditional solo or small practice primary-care physician as the main provider. The primary-care doc won’t go away, but instead take the helm as the care organizer, coordinating care increasingly provided by midlevel providers such as nurse practitioners and physician assistants, a model already being explored in the patient-centered medical home pilots.
“The physician plays a central role, as a team leader, not as the central provider,” says Harry Jacobson, who served as vice chancellor of health affairs at Vanderbilt University and director of Vanderbilt University Medical Center. “Medicine is a team sport, and we need to find a way to learn how to train people as teams.”
This shift will be predicated by the increase in demand for primary care and the shortage of primary-care physicians. As the healthcare system begins to reward outcomes and focus on prevention, a care coordinator will emerge. That coordinator will come up with the plan and delegate how it’s executed.
“That person needs to be a physician, because the medical care of patients will be more complex,” says Aaron Michelfelder, a family practice doctor and head of curriculum development for Loyola University Chicago Stritch School of Medicine.
The entire healthcare workforce will evolve, mainly because technology will expand the capabilities of midlevel professionals and prompt physicians to take on new roles, says Jason Hwang, a primary-care physician and executive director of healthcare at the Innosight Institute, a nonprofit think tank focused on healthcare and innovation.
Hwang predicts that technology will enable this shift in duties via a process the business world calls “disruptive innovation” through “commoditization of the work or the experience.” New technologies commoditize skill by making the job more easily taught and performed, Hwang says. This is true in any industry: As new tools are developed, lower-level professionals can perform a skill once relegated to the more highly trained.
In healthcare, “what was done by specialists will be done by generalists, and what is done by generalists will be done by nonphysicians,” he says.
Of course, some primary-care physicians will be more interested in taking on the position of the care coordinator, as seen already in patient-centered medical home pilots, rather than the duties of the specialist. But Hwang issues a warning about that path. “If technology can help physicians coordinate care better, you could imagine it wouldn’t take long for that same piece of software technology [to] help a nurse practitioner coordinate care. If you are progressing down that path, and you’re placing all your eggs in the primary-care basket, it’s time-limited.”
Tech tools of the future
The root of physicians’ transforming role is technology, for both diagnosis and for organizing the exponentially growing amount of patient information.
“The physician of the future is going to be faced with making decisions with so many data points that they cannot make the best decisions without computer-assisted support,” says Jacobson.
You think there’s pressure to adopt EHRs, e-prescribing, and patient registries now? In the next decade or two, healthcare information technology promises to become even more advanced — and necessary. The burgeoning field of personalized medicine that is using patients’ genetic information to better tailor treatments and protocols to each individual patient will continue to grow, meaning even more information.
Having an EHR that collects and presents that information for the physician is just half the battle, Jacobson says. Then the information will need to be better organized in a way that is useful for decision support.
Most experts envision the current push for EHR adoption and integration to continue. The CDC’s National Center for Health Statistics says that about 44 percent of doctors are using full or partial EHRs, up from about 41 percent in 2008. But only 6.3 percent were using systems described as “fully functional.”
With the federal government’s initiative aimed at encouraging all practices to achieve so-called “meaningful use” of EHRs, that number may rise steadily over the next several years, but there is still a long way to go. So if you’re imaging a future of physician holograms beaming in for exams, think again. More likely, the next 10 or 15 years mean more EHRs and more integration of systems so they can better share data.
“Right now our EMR cannot talk across healthcare institutions,” says Loyola’s Michelfelder. “The first thing is that it’s going to be a lot easier for us to take care of patients because we are going to have better access to records.”
Emerging technologies will also expand the options for where patients are seen. Doctors will be less tethered to the hospital and able to perform more procedures in the office, making care more convenient and accessible, Hwang says. For example, MRI machines, portable ultrasounds, and EKG machines can be brought out of the hospital and into the doctor’s office.
Similarly, online visits, like those already being tested by Christianson in Minnesota, will free up physicians to see patients and consult with other physicians regardless of their location.
Finally, technology will enable patients to take a more active role in their care, says Fran Turisco, a research principal for CSC’s Emerging Practices group. More patients will have access to home-monitoring technologies that allow them to be more proactive in their own care.
“We are finding that there are things like the iPhone with an unbelievable number of applications on it to help [patients] adhere to medication schedules,” Turisco says.
But those applications will only be useful if you connect all the dots, Turisco says, making sure the patient and the entire healthcare team is tapped into the same software to coordinate care.
So what happens to the smaller practices that are resisting the adoption of technology or who don’t envision a day when they will communicate online with their patients or other providers?
“Their days are numbered,” Hwang says, noting that around the corner there will be another business model — say, a retail clinic or larger integrated health system — that is connected and moving light years ahead of the old model.
Trying to predict when all these changes will happen really becomes a study in physician reimbursement. Perhaps unsurprisingly, for any new care-delivery model or technology to take hold, there will have to be a change in the current reimbursement structure.
“The primary constraint of change is not necessarily technology, but how the financing mechanism for primary care reimbursement will be evaluated and modified going forward,” says Alex Hunter, president of EthosPartners, a healthcare and management consulting firm in Suwanee, Ga.
And it’s going to take more than federal EHR incentives, Hunter says. It will take real reimbursement reform.
So what will it look like?
“There are 544 people in the House and Senate who are debating that today,” Hunter says, adding that ultimately, the reimbursement system will focus on qualitative management of patients’ health and outcomes.
Already payers are starting to reimburse for less traditional models of care, such as e-mail consultations and group visits.
Several experts predict an even greater increase in the number of physicians opting for hospital employment. Integrated health systems like Kaiser Permanente will dominate the employment landscape, as physicians seek refuge in steady salaries, and younger physicians reject the private practice path for more stability.
These integrated health systems can also more easily bear the heavy load of financing the technology, and support full integration of the electronic systems, he says.
What’s clear is the fee-for-service model’s days are likely numbered. Another option could be more of a lump-sum, per-capita model.
“I definitely see the piecemeal system going by the wayside,” Hwang says. “Ordering a McDonald’s hamburger or your typical retail purchase — that’s the only instance where a piecemeal rate really works.”
In the future, the private-practice physician will be operating a truly independent business free from insurers. Or there won’t be any private practices; instead virtually all physicians will work as employees in hospitals or health systems. The role of the primary-care physician will evolve into that of team leader — the hub of the care management team, coordinating with a number of midlevels and specialists for each patient. Or the primary care physician will go the way of the dodo.
Depends on whom you ask.
But what’s clear is that change is coming. The current landscape is starting to transform, and the future promises a continued acceleration and utilization of technology and a greater focus on patient outcomes.
As a physician who has embraced the less traditional model of care known as hybrid concierge, Wilder suggests all physicians start planning for the future by deciding their true values and goals. Talk with family and friends, or hold focus groups to find out what your patients value, she says.
“Then,” she says, “think creatively about how you can come up with a model practice.”
By Sara Michael
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Healthcare leaders can use people’s technology identities to create a new generation of offerings and experiences.
When healthcare organizations gain the ability to create one-to-one relationships with individual healthcare consumers, they become each individual person’s ongoing, trusted healthcare partner. Organizations will achieve this by understanding the technology people use and how they use it, creating the insights needed to integrate seamlessly into the person’s life.
Healthcare has an ongoing data stream from medical records, technology devices, claims, past preferences for services, biology and more. This data is the cornerstone of delivering personalized healthcare on a person’s own terms.
Think of the possibilities for personalized medicine with the help of genetic sequencing. The human genome comprises more than 3 billion DNA pairs. The genome can be used to identify abnormalities, genetic variants, disorders and more within a matter of hours. Clinicians can interpret the genomic data to target interventions and therapies for that individual.2
Imagine if a healthcare provider has a “digital phenotype” for every patient3—one snapshot that captures indirect healthcare data from technology-based interactions (e.g. online search history, app usage, social posts) and correlates it with health events. The digital phenotype has the potential to help providers predict health-related behaviors and risks and also diseases for that person and others like them.
For example, a multinational technology company partnered with an academic medical center to examine the health relatedness of searches in the remote past and within seven days of an emergency room visit. Interestingly, more than half of those who participated in the study had searched online for content related to their chief complaint within the week prior to their emergency room visit.4 By tapping into people’s digital phenotypes, providers and other allied health organizations can anticipate needs and intervene with care at the time of need, potentially preventing an emergency room visit.
The digital phenotype has the potential to help providers predict health-related behaviors and risks and also diseases for that person and others like them.
Healthcare startup Ginger.io years ago began studying the potential of passively connecting data from an individual’s smart phone to ultimately create a personal health profile. Healthcare and academic leaders quickly began piloting the technology to monitor and support mental health patients with digital interventions, to identify post-operative patients that require the most follow-up care and to predict the pain levels of patients with arthritis.5 Now, the Ginger.io app is using data to provide virtual mental healthcare the moment patients need it via coaches and clinicians.
Imagine if providers could use a person’s digital identity to deliver care in context—even beyond traditional location-dependent care settings. When shopping, an app could tell a person with chronic lung disease (i.e. COPD) that it’s time to sit down and take a break. When walking into a restaurant, a mobile alert would inform the individual of healthy meal selections to consider on the menu. Each environment provides an opportunity to use those moments that occur to add value in context of health.
Clearly technology identity presents amazing potential for detecting the need for care at home (or on the go) and delivering care where and when people need it, but it also has some pitfalls when it comes to capturing information while maintaining individual privacy.
Clearly technology identity presents amazing potential for detecting the need for care at home (or on the go) and delivering care where and when people need it.
There is a gap in expectation between how healthcare is delivered today and how patients think it should be.6 People want their needs met, but they also want control over their privacy preferences. And as healthcare organizations strive to meet these needs, they must understand that the line between “useful” and “creepy” will vary for each person.
Technology can allow healthcare enterprises to maintain ongoing, experience-driven relationships with individual consumers in ways that were impossible before. But the possibilities come with new ambiguity and complexity—tailoring offerings and experiences to the individual also means figuring out just how much tailoring to do in the first place.
Among them, healthcare organizations must recognize that there are times when consumers want more technology in their lives, but also times when they do not want it at all. Understanding this dynamic is critical to successfully creating ongoing, intensely individualized relationships with consumers.
Healthcare organizations across the ecosystem must proactively take steps to earn trust with consumers by being clear about their intentions related to data privacy, data stewardship and consent. These steps include making sure data is clean and its origin is known. Physical devices must have proper security embedded. Products and services must be designed with privacy in mind. When organizations make privacy a priority and communicate the actions taken, they will build trust and loyalty among increasingly discerning healthcare consumers.
of healthcare IT and business executives believe that digital demographics give their organization a new way to identify market opportunities for unmet customer needs.
of healthcare executives believe that consumers’ digital demographics (vs. traditional demographics) are increasingly becoming a more powerful way to understand their organization’s customers.
Mental health care meets smartphone
Mindstrong uses artificial intelligence and remote monitoring to continuously measure cognitive function and mood, allowing providers to detect changes and intervene at critical times. Digital phenotyping collects data from a user’s smartphone to provide measures of cognition and emotion. Mindstrong uses machine learning to identify which digital phenotyping features might be most useful to clinical assessment. The company has a patient-facing app that allows users to access help through their smartphones, and a provider-facing app that augments care models.
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How Physicians Can Change the Future of Health Care
Michael E. Porter, PhD, MBA; Elizabeth Olmsted Teisberg, PhD, MEngr, MS
JAMA. 2007;297(10):1103-1111. doi:10.1001/jama.297.10.1103
Today's preoccupation with cost shifting and cost reduction undermines physicians and patients. Instead, health care reform must focus on improving health and health care value for patients. We propose a strategy for reform that is market based but physician led. Physician leadership is essential. Improving the value of health care is something only medical teams can do. The right kind of competition—competition to improve results—will drive dramatic improvement. With such positive-sum competition, patients will receive better care, physicians will be rewarded for excellence, and costs will be contained. Physicians can lead this change and return the practice of medicine to its appropriate focus: enabling health and effective care. Three principles should guide this change: (1) the goal is value for patients, (2) medical practice should be organized around medical conditions and care cycles, and (3) results—risk-adjusted outcomes and costs—must be measured. Following these principles, professional satisfaction will increase and current pressures on physicians will decrease. If physicians fail to lead these changes, they will inevitably face ever-increasing administrative control of medicine. Improving health and health care value for patients is the only real solution. Value-based competition on results provides a path for reform that recognizes the role of health professionals at the heart of the system.
Results from a program in Connecticut.
By Paul Di Capua, Jay Mathur, Vivek Garg, and Sachin H. Jain
May 16, 2019
It’s common knowledge that health care spending in the United States is on target to reach 20% of GDP — and that the 5% of patients who are the most expensive to treat account for 50% of all health care spending. These patients tend to be frail and elderly and have multiple chronic illnesses; many have unmet behavioral and mental health needs as well. A CareMore Health program in Connecticut has proven that an approach can reduce the expensive hospitalizations that largely drive the high cost of caring for these patients. How? By treating these patients at home.
For more than a quarter century, CareMore Health, the care delivery organization where we are physicians, has successfully built a model to treat high-cost, high-needs patients. In communities across the country, CareMore invests the capitated payments it receives from Medicare and Medicaid in prevention and early intervention programs, and on supplemental benefits that fee-for-service programs typically don’t cover. Under this model, CareMore spends half of what traditional Medicare programs spend on the sickest patients. Much of the savings result from keeping patients healthy enough to avoid high-cost hospitalizations.
In 2017, CareMore entered the Connecticut market with the goal of bringing our model to high-cost, high-needs patients in the Nutmeg State. As we’d done in other markets, we looked at opening office space in locations that would be convenient for our patients. So we mapped our patients’ home addresses. That’s when we noticed an interesting trend: Many of them lived in clusters, often within a 30- to 45-minute drive of one another.
The map sparked an idea. High-cost, high-needs patients tend to spend almost all of their time at home. They’re often elderly seniors who live alone. Many lack access to reliable transportation or report that they can’t get convenient, immediate appointments with doctors. We asked ourselves: Instead of demanding that patients come to us to receive care, what if we instead went to them?
In doing so, we reasoned, we could eliminate barriers to access. But to be successful, we’d have to restore the lost practice of making house calls. After all, gone are the “Marcus Welby, MD” days of charming doctors showing up on doorsteps with black medical bags in their hands. Except for the basic services offered by home care agencies, health care in the United States has largely abandoned using the home as a viable site for care.
Under CareMore’s model, which we launched in Connecticut in 2017, the members of what we call the “Home Team” provide integrated physical and mental health care to our patients in the space where everyone feels most comfortable — their homes.
We treat the patients we see at home just as we would in a medical office setting. We fine-tune medications, examine and dress wounds, and make diagnoses. But Home-Based Integrated Care is so much more than that. Our care teams are made up of primary care physicians, nurses, case managers, medical assistants, social workers, and other professional caregivers who work in concert to provide comprehensive preventive, chronic condition, urgent, and post-discharge care. When we visit patients, we assess their mental and physical health. We ensure that they’re filling prescriptions and taking their medications appropriately. If they’re not, we’ve developed strong relationships with local pharmacies who deliver pre-packaged medications to our patients and can ensure timely alterations in medication regimens.
Seeing patients at home adds a certain familiarity to the doctor-patient relationship, often with positive results. Prior to meeting us, Oscar*, who suffers from multiple chronic diseases, including advanced kidney disease, was in the emergency room almost weekly. At our initial visit with Oscar, we used his kitchen strainer to explain how his kidneys filter blood. During a series of conversations in Oscar’s living room, we spoke with one of his close friends from church, his personal care assistant who is with him every weekday, and his brother in Puerto Rico. Together we created a medical regimen focused on aggressively managing Oscar’s diabetes and blood pressure, two factors that often cause kidney damage. Today, Oscar’s kidney function has stabilized.
In our patients’ homes we can readily view the “social determinants of health” — the economic and social conditions that can significantly influence a patient. In her home, we learned that Lucy* is socially isolated, with no regular contact with others. We surmised that her social isolation was at the root of many of her behavioral health issues and introduced a social worker to connect her with community-based organizations that brought her into contact with others. In the 18 months that she has been our patient, Lucy has yet to be readmitted to the hospital. Had we not visited Lucy at home, it’s not clear that we’d have recognized the underlying social dynamics that were affecting her health.
These anecdotes demonstrate our success; so do the numbers. We recently compared the 10-month period after we launched Home-Based Integrated Care in Connecticut (from September 1, 2017 to June 30, 2018) to the previous 10-month period (from September 1, 2016 to June 30, 2017) for the 105 patients who had engaged with CareMore and continuously had the same health plan throughout the whole period. During that time, hospital admissions and emergency room visits were down 12.5% and 27.2%, respectively. Those numbers demonstrate that we are succeeding in our goal to reduce hospitalizations and produce better outcomes at a lower cost. Today, CareMore serves 2,100 patients in Connecticut solely under the Home Integrated Care model.
Obviously, one’s home is not the perfect setting for all medical care. If you break your arm, you should get it x-rayed in an urgent care center. And if you need open-heart surgery, there’s no question that it should be performed inside a controlled operating room environment.
Nevertheless, our health system has created a hospital-based delivery system focused on acute illness at the expense of growing and building systems of care to manage chronic illness. As the cost of caring for the frail and elderly approaches 10% of our GDP, we as a country need to reflect on how our health system is largely failing these patients at great expense. The vast majority of hospitalizations, which cost $3,000 to $4,000 per day or more, are for exacerbations of chronic illness that could have been treated more effectively and less expensively had the patient’s care team taken a personalized approach to managing the patient’s condition.
What we’re doing in Connecticut is actually quite old-fashioned. Doctors used to make house calls all the time. They were comfortable walking into their patients’ homes; they and the members of their community knew each other and trusted each other. What the modern, transactional health system has done is more than just create a cumbersome system riddled with inefficiencies, high costs and mixed results; it has removed health care from our communities.
So we’re putting it back. And pretty soon, we think others will too.
*All names have been changed.
Paul Di Capua
Paul Di Capua, MD, is regional medical officer in Connecticut at CareMore Health, a division of Anthem, Inc. He was previously medical director of primary care innovation for a Florida-based health system and a health systems researcher at UCLA. Follow his work with CareMore on Instagram @cmontheroad.
Jay Mathur, DO, is the associate regional medical officer in Connecticut for CareMore Health, a division of Anthem, Inc. He previously was a medical director at Iora Health and an assistant professor at the Yale University School of Medicine.
Vivek Garg, MD, is chief medical officer at CareMore Health, a division of Anthem, Inc. He previously was director of medical operations at Oscar Health, clinical assistant professor at Weill Cornell Medicine, and medical director at One Medical Group.
Sachin H. Jain
Sachin H. Jain, MD, is president and CEO of the CareMore Health System, a division of Anthem, Inc. He is also a consulting professor of medicine at the Stanford University School of Medicine. He previously was the chief medical information and innovation officer at Merck. Follow him on Twitter at @sacjai.
The former can collect data; the latter can sift through it.
By Moni Miyashita and Michael Brady
May 28, 2019
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In southeast England, patients discharged from a group of hospitals serving 500,000 people are being fitted with a Wi-Fi-enabled armband that remotely monitors vital signs such as respiratory rate, oxygen levels, pulse, blood pressure, and body temperature.
Under a National Health Service pilot program that now incorporates artificial intelligence to analyze all that patient data in real time, hospital readmission rates are down, and emergency room visits have been reduced. What’s more, the need for costly home visits has dropped by 22%. Longer term, adherence to treatment plans have increased to 96%, compared to the industry average of 50%.
The AI pilot is targeting what Harvard Business School Professor and Innosight co-founder Clay Christensen calls “non-consumption.” These are opportunity areas where consumers have a job to be done that isn’t currently addressed by an affordable or convenient solution.
Before the U.K. pilot at the Dartford and Gravesham hospitals, for instance, home monitoring had involved dispatching hospital staffers to drive up to 90 minutes round-trip to check in with patients in their homes about once per week. But with algorithms now constantly searching for warning signs in the data and alerting both patients and professionals instantly, a new capability is born: providing healthcare before you knew you even need it.
The biggest promise of artificial intelligence — accurate predictions at near-zero marginal cost — has rightly generated substantial interest in applying AI to nearly every area of healthcare. But not every application of AI in healthcare is equally well-suited to benefit. Moreover, very few applications serve as an appropriate strategic response to the largest problems facing nearly every health system: decentralization and margin pressure.
Take for example, medical imaging AI tools — an area in which hospitals are projected to spend $2 billion annually within four years. Accurately diagnosing diseases from cancers to cataracts is a complex task, with difficult-to-quantify but typically major consequences. However, the task is currently typically part of larger workflows performed by extensively trained, highly specialized physicians who are among some of the world’s best minds. These doctors might need help at the margins, but this is a job already being done. Such factors make disease diagnosis an extraordinarily difficult area for AI to create transformative change. And so the application of AI in such settings — even if beneficial to patient outcomes — is unlikely to fundamentally improve the way healthcare is delivered or to substantially lower costs in the near-term.
However, leading organizations seeking to decentralize care can deploy AI to do things that have never been done before. For example: There’s a wide array of non-acute health decisions that consumers make daily. These decisions do not warrant the attention of a skilled clinician but ultimately play a large role in determining patient’s health — and ultimately the cost of healthcare.
According to the World Health Organization, 60% of related factors to individual health and quality of life are correlated to lifestyle choices, including taking prescriptions such as blood-pressure medications correctly, getting exercise, and reducing stress. Aided by AI-driven models, it is now possible to provide patients with interventions and reminders throughout this day-to-day process based on changes to the patient’s vital signs.
Home health monitoring itself isn’t new. Active programs and pilot studies are underway through leading institutions ranging from Partners Healthcare, United Healthcare, and the Johns Hopkins School of Medicine, with positive results. But those efforts have yet to harness AI to make better judgements and recommendations in real time. Because of the massive volumes of data involved, machine learning algorithms are particularly well suited to scaling that task for large populations. After all, large sets of data are what power AI by making those algorithms smarter.
By deploying AI, for instance, the NHS program is not only able to scale up in the U.K. but also internationally. Current Health, the venture-capital backed maker of the patient monitoring devices used in the program, recently received FDA clearance to pilot the system in the U.S. and is now testing it with New York’s Mount Sinai Hospital. It’s part of an effort to reduce patient readmissions, which costs U.S. hospitals about $40 billion annually.
The early success of such efforts drives home three lessons in using AI to address non-consumption in the new world of patient-centric healthcare:
1) Focus on impacting critical metrics – for example, reducing costly hospital readmission rates.
Start small to home in on the goal of making an impact on a key metric tied to both patient outcomes and financial sustainability. As in the U.K. pilot, this can be done through a program with select hospitals or provider locations. In another case Grady Hospital, the largest public hospital in Atlanta, points to $4M in saving from reduced readmission rates by 31% over two years thanks to the adoption of an AI tool which identifies ‘at-risk’ patients. The system alerts clinical teams to initiate special patient touch points and interventions.
2) Reduce risk by relying on new kinds of partners.
Don’t try to do everything alone. Instead, form alliances with partners that are aiming to tackle similar problems. Consider the Synaptic Healthcare Alliance, a collaborative pilot program between Aetna, Ascension, Humana, Optum, and others. The alliance is using Blockchain to create a giant dataset across various health care providers, with AI trials on the data getting underway. The aim is to streamline health care provider data management with the goal of reducing the cost of processing claims while also improving access to care. Going it alone can be risky due to data incompatibility issues alone. For instance, the M.D. Anderson Cancer Center had to write off millions in costs for a failed AI project due in part to incompatibility with its electronic health records system. By joining forces, Synaptic’s dataset will be in a standard format that makes records and results transportable.
3) Use AI to collaborate, not compete, with highly-trained professionals.
Clinicians are often looking to augment their knowledge and reasoning, and AI can help. Many medical AI applications do actually compete with doctors. In radiology, for instance, some algorithms have performed image-bases diagnosis as well as or better than human experts. Yet it’s unclear if patients and medical institutions will trust AI to automate that job entirely. A University of California at San Diego pilot in which AI successfully diagnosed childhood diseases more accurately than junior-level pediatricians still required senior doctors to personally review and sign off on the diagnosis. The real aim is always going to be to use AI to collaborate with clinicians seeking higher precision — not try to replace them.
MIT and MGH have developed a deep learning model which identifies patients likely to develop breast cancer in the future. Learning from data on 60,000 prior patients, the AI system allows physicians to personalize their approach to breast cancer screening, essentially creating a detailed risk profile for each patient.
Taken together, these three lessons paired with solutions targeted at non-consumption have the potential to provide a clear path to effectively harnessing a technology that has been subject to rampant over-promising. Longer term, we believe the one of the transformative benefits of AI will be deepening relationships between health providers and patients. The U.K. pilot, for instance, is resulting in more frequent proactive check-ins that never would have happened before. That’s good for both improving health as well as customer loyalty in the emerging consumer-centric healthcare marketplace.
Moni Miyashita is a partner at the strategy and innovation consulting firm Innosight working with industry leaders in life sciences.
Michael Brady is an associate at the growth strategy consulting firm Innosight.
Make sure to consider local context.
By Margaret M. Luciano, Thomas A. Aloia, and Joan F. Brett
August 2, 2019
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Evidence-based practice is held as the gold standard in patient care, yet research suggests it takes hospitals and clinics about 17 years to adopt a practice or treatment after the first systematic evidence shows it helps patients.
Why such a long delay when patient health is on the line? Part of it is the challenge of adapting practices to fit the environment. Attempting to simply “plug in” a new practice to a different hospital or clinic often conflicts with existing practices and meets resistance from care providers. But deviating from the evidence-base can weaken the effectiveness of the practice and lessen the benefits. Leaders have to balance two conflicting needs: to adhere to standards and to customize for the local context.
Based on our research on organizational change and our conversations with hundreds of healthcare providers, we’ve outlined four approaches to help health care leaders adapt evidence-based practices while staying close to the foundational evidence. These approaches are based on an organization’s 1) data; 2) resources; 3) goals; and 4) preferences. Each of these approaches has its own opportunities and challenges, and for any to succeed, it is necessary to understand the local context and the people in it. It is also important to consider any legal or professional guidelines that may restrict options. In practice the move to standardization and best practices reduces rather than creates risks, as they often replace idiosyncratic or outdated practices and preferences.
Understand the data: How relevant is the evidence-base to our local context?
Sometimes you need to adapt a practice because the data behind it doesn’t match your own context. What if the evidence-base is constructed from different patient populations, hospitals with different structures or cultures, or countries with different regulatory environments and payment structures? Some practices will be more generalizable than others (e.g., the evidence to support the importance of hand hygiene applies across most contexts), and understanding the data helps to objectively determine appropriate modifications (e.g., changing certain medication dosages based on patient age and BMI). When adapting evidence-based practices to the local context, it is important to consider what is similar, what is different, and why those might matter.
Leaders should also consider whether existing data is sufficient to support implementing a new practice (either in the original or modified form), or if additional data should be collected to verify the efficacy before a widespread roll-out. For example, enhanced recovery practices advocate for early patient ambulation after surgery. However, most of the initial research was conducted on young-adult patients, as opposed to elderly patients. Therefore, additional research was needed to understand whether the practice needed to be modified for a patient population that tends to be more frail and have a higher risk for falls. Notably, even after the adapted evidence-based practice is implemented, more data should be collected to enable ongoing reassessment and making adjustments if needed.
Look at your resources: How can we make substitutes without compromising results?
Sometimes organizations need to adapt based on resources. Are the specific resources used in the original implementation not feasible or desirable in one’s local context? Resources include infrastructure, supplies, space, and staff. For example, for many smaller hospitals, costs prohibit administering the same brand name drugs as major academic research hospitals. Accordingly, they may need to substitute and/or pair other medications to achieve equivalent effects.
Resource-related adaptations shift the reactions to evidence-based practices from “we don’t have the resources to do that” to “how can we apply these practices with the resources we do have?” Adaptations require understanding the purpose or goal of the new practice to determine the appropriate substitutes. For example, hospitals lacking sophisticated electronic health records may not be able to implement electronic patient smart order sets, but could still attain similar improvements in care coordination by using paper checklists. In making resource-based adaptions, collecting additional data on the customized resources can also help assure that substitutes achieve similar results to the initial evidence-based research.
Define your goals: What are our goals and how can we meet them?
The goal of implementing an evidenced-based practice should not be the implementation itself. Defining your goals in terms of a patient-centered outcome will help you generate appropriate modifications. For example, many hospitals have the goal of reducing inpatient length of stay. If the change leaders focus just on the inpatient length of stay itself, they may create a program that rushes the patient out of the hospital before they are ready. If instead the goal is to optimize recovery from illness or surgery, the focus shifts to the patient experience, and reduction in inpatient length of stay is simply the residue of a provider and patient-friendly program.
Sometimes there’s little data to guide local adaptations, but understanding the overarching goals of the new practices can help. Take for example how innovations in dynamic pain control developed for major in-patient procedures can be adapted for minor out-patient procedures. Still focusing on the goal of dynamic pain control, providers can prescribe different preoperative pain medication for minor outpatient procedures that manage pain without the drowsiness associated with the medications used for in-patient procedures.
Identify your preferences: How can we make adoption more comfortable?
Personal preferences of powerful individuals or coalitions of care providers too often becomes the motivating force behind whether or not to adopt evidence based practices. A health care system moving to a standardized set of tools and equipment found that physicians preferred specific tools (e.g. surgical staples or scalpels) because those were what they had been trained on. Physicians continued to request those tools despite evidence showing they cost three times more and had no effect on patient outcomes.
Preferences driven by subjective, idiosyncratic reasoning inhibit adopting new approaches that can attain better health outcomes, reduce expenses, and decrease errors. So health care leaders need to determine why providers have certain preferences. Some preferences focus on how the evidence-based practice is enacted, rather than what it is.
For example, care providers may be happy to use specific equipment for a procedure if it is easily accessible. To avoid surgical site infections when inserting a central venous catheter, providers should clean the skin with chlorhexidine antiseptic, use a sterile drape/dressing, and wear a sterile mask, hat, gown and gloves. Why not help care providers use all of these items by packaging them together in an easy to access location? Similarly, offering training on new tools or techniques can give care providers the opportunity to ask questions about them and get more comfortable using them.
When leaders make compliance with the new practices as easy as possible, they can encourage adoption without unnecessarily revising the core elements of the evidence-based practices.
When weighing if and how to adapt evidence-based practices, within legal and professional guidelines, you need to consider both the technical and human elements involved.
In our experience, start with the original source data as it has the most fidelity to the desired outcomes and will enable objective decisions about customizations. Then, guide conversations about how a given practice should be adapted locally. If responses from the providers include resistance about available resources, consider substitutes that would address these concerns, yet still attain the results the evidence supports. Engaging users in how to best utilize existing resources to implement the new practices creates ownership of the process.
If staff react to the new best practice with asking “why are we doing this,” reaffirming the higher-order goals may help explain why adopting the evidence based practice is crucial. Alternatively, if resistance is rooted in language such as “I like” and “I want”, try to understand the underlying preferences and values. For preferences related to how the practice is enacted, consider alignment with other practices and try to create innovative solutions. For preferences related to the content of the practice, discuss the higher order goals and what the research supports. Shared commitment to these goals makes users more open to how “we could achieve our goals” by using what “the research shows”.
Listen, understand the context and your people, and then revise the new practice when necessary. Leaders that can move fluidly across these approaches create a disciplined and adaptive way to implement evidence-based practice — one that fosters joint-problem solving, facilitates agreement, and relieves the tensions associated with customizing research recommendations.
Margaret M. Luciano
Margaret M. Luciano, PhD, is an assistant professor in the WP Carey School of Business at Arizona State University, Tempe, AZ.
Thomas A. Aloia
Thomas A. Aloia, MD, MHCM is the Chief Value and Quality Officer in the Office of the Chief Medical Executive and a Professor in the Department of Surgical Oncology at the University of Texas – MD Anderson Cancer Center, Houston, TX.
Joan F. Brett
Joan F. Brett, PhD, is an associate professor in the WP Carey School of Business at Arizona State University, Tempe, AZ.
Lessons from Brigham and Women's Hospital.
By Yvelynne P. Kelly, Diane Goodwin, Lisa Wichmann, and Mallika L. Mendu
July 1, 2019
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A patient we’ll call Bonnie has been on dialysis for five years, making the difficult trip three times a week to a clinic to sit for hours hooked up to a machine that filters toxins from her blood. Bonnie is 65 and suffers from end-stage renal disease (ESRD), the gradual failure of her kidneys. She has chronically low blood pressure, which complicates the dialysis, and ingests a lot of salt which causes weight gain between treatments. Often, she wakes up breathless and ends up in the emergency department. The ED and dialysis unit don’t have a shared electronic health record, and on discharge there is little communication between the two sites about her care. Nor is there communication between the dialysis unit and her primary care doctor (PCP). When she’s hospitalized, her medications are sometimes changed, but that critical information often doesn’t get back to her many providers. Bonnie is hoping for a kidney transplant, but she doesn’t know where to start, and she has yet to undergo an evaluation to see if she’s eligible.
This type of siloed, uncoordinated ESRD care has serious consequences for Bonnie and thousands of patients like her. On a national level, ESRD takes a huge toll on patients, families and caregivers, and society. Transplants are exceedingly scarce, and so for the vast majority of the 750,000 people affected by ESRD in the US each year, dialysis is the only viable treatment. For patients on dialysis, hospitalization rates and risk of developing related medical problems, and of dying, are high. Finally, while ESRD patients make up less than 1% of the Medicare population, they account for more than 7% of the Medicare budget – a staggering $50 billion annually.
Fragmented care is an important part of the reason for the high costs and utilization and often poor outcomes associated with ESRD. Patients receive care through a patchwork of providers at various sites — outpatient dialysis units, primary care practices, specialty clinics, hospitals and others – which often don’t communicate. Gaps in care are inevitable, and opportunities to intervene before problems arise are often missed.
That’s why in 2016 we launched a coordinated ESRD program within Partners Healthcare, based at Brigham and Women’s Hospital (BWH) in Boston, one of the first to bring the care-coordination principles that are increasingly common in primary care to disease-specific specialty care. While other programs, like the CMS ESRD demonstration projects, have piloted care-coordination models with large dialysis organizations, ours is the only such program that we’re aware of that coordinates care across all stakeholders (dialysis units, hospitals, primary care providers, and others) rather than focusing on care within the dialysis unit itself. Further, unlike other programs, ours extends beyond dialysis-based care to facilitate transplant evaluations and, when needed, palliative care.
At the start of the program, a nurse care coordinator (co-author Diane Goodwin) connected with Brigham and Women’s ESRD patients weekly at four dialysis units, identifying those at risk for deterioration and increased utilization (ED visits and hospitalizations) and implementing strategies to reduce utilization and improve clinical outcomes. These included face-to-face visits to provide self-care education and guidance on avoiding the ED, medication reviews, dialysis-treatment monitoring, tracking immunizations, assuring reliable vascular access, and working with the dialysis unit, visiting nurses, PCPs, specialists and others to coordinate care and assure that all involved had the same information about the patient’s history and status. (Today we have three nurses in this care-coordination role.)
For patients who are admitted to the hospital, a nurse within the program conducts a post-discharge assessment which includes documenting all medications the patient is on, and the dosage, frequency and route, and communicating this and other key information to the patient’s PCPs, the dialysis unit, and others. When patients do go to the ED, a nurse likewise reaches out to the ED team to share information, help guide care and ensure appropriate follow up. Finally, program nurses communicate directly with transplant coordinators to facilitate evaluations and assure that eligible patients are placed on transplant wait lists.
To date, the program has engaged with a total of 100 patients and is currently coordinating care for 54. The results three years out are encouraging. Among these high-risk patients (those who among other indicators have missed treatments, required transfusions, or habitually used the ED for non-urgent issues) we’ve seen on average 5 fewer ED visits or hospital admissions per patient per year than would have been typical before our intervention. Close to one-fifth of the patients in the program have been referred to palliative care, and several who otherwise wouldn’t have received transplants have had them as a result of the program’s enrollment efforts.
By reducing healthcare utilization and facilitating transplantation we’ve thus far saved twice the amount that it costs to run the program. In one slice of the data, we calculated $428,000 in savings from 74 avoided ED visits and 34 avoided admissions, and over $1 million in savings attributable to facilitated transplantations. Feedback from patients and providers has been overwhelmingly positive. In an email, one nephrologist praised the program as a “GREAT addition to ESRD patient care,” citing “improved communication, improved integration of care between providers, [and] avoiding admissions.”
Going forward, we’ll be evaluating the impact of the program on costs and utilization relative to those of a matched control group, and are expanding this work to other Partners hospitals and outpatient dialysis units. Ultimately, as we establish the positive impact of the program and the ability to translate it to other settings within Partners, we hope to disseminate it to other institutions. The goal is a future where silos are broken down in ESRD care delivery and patients, providers, and society share in the benefits.
Yvelynne P. Kelly
Yvelynne P. Kelly, MD, MSc, is a Clinical Research Nephrology Fellow at Brigham and Women’s Hospital.
Diane Goodwin, BSN, RN, CNN, is the End Stage Renal Disease Care Manager for the Integrated Care Management Program at Brigham and Women’s Hospital.
Lisa Wichmann, RN, MS, ACM, NC-BC, is the Nursing Director for Ambulatory Care Coordination at Brigham and Women’s Hospital.
Mallika L. Mendu
Mallika L. Mendu MD, MBA, is Medical Director for Quality and Safety at Brigham and Women’s Hospital, and Associate Medical Director of Partners Population Health Management. Dr. Mendu is also a practicing nephrologist.