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The October 17, 2005 Issue Provided by System Dynamics Inc.
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Hurricanes and Healthcare

Puzzled by the title of this article? We heard a lot about Hurricane Katrina in late September at a Boston symposium about healthcare and telehealth. "The Accelerating Use of Communication Technology in Healthcare" conference took place one month after Katrina’s devastation.

The conference was sponsored by Partners Healthcare, an integrated health care system affiliated with Harvard Medical School and founded by Brigham and Women's Hospital and Massachusetts General Hospital, two of the top teaching hospitals in the United States. The conference drew on healthcare thought leaders from the medical community, government and industry. Over two days, they were addressing each other, not outsiders like us, and we felt their talks were frank and honest.

The speakers overwhelmingly agreed that Katrina has changed people’s thinking, and many spoke of the likely impact on healthcare as a prime example. Although many factors are needed to create the future of health care, communications to and from the home is one of the important ingredients.

Key Messages

The overall conclusion of the conference was summarized by John Glasser, VP & CIO of Partners HealthCare: "It is inconceivable to think of a future ten years from now that does not include more than just face-to-face (health)care."

The main messages we heard can be summarized in three areas:

Pressures for changing the healthcare system:

  • The healthcare system, worldwide and especially in the US, faces a looming crisis from sharply rising costs, the aging of the population and a shortage of providers.
  • Access to the Internet has greatly increased consumer medical awareness and has already become a force for changing the doctor-patient relationship.
  • Thought leaders are seeking ways to speed changes and overcome resistance from medical institutions and individual doctors.

Application of communications technology to improving care:

  • Most initial applications of healthcare IT, including broadband communications, have been internal to the healthcare establishment.
  • Allowing "healthcare to follow the patient" is viewed as the next frontier.
  • The creation of electronic medical records is one of the crucial underpinnings for improving healthcare.

Where we go from here:

  • Activities sponsored by the US Federal and state governments, including public/private partnerships, are underway and are moving in a positive direction.
  • Katrina has provided a banner for accelerating the application of IT to healthcare, but whether this is sustainable remains to be seen.
  • The area of “wellness care” may be more easily addressed than some others, because it could be based on “self-pay”.

Pressures for Change

Lessons We Can Learn

With Hurricane Katrina fresh in everyone’s mind, Dr. Jeremy Nobel, from Harvard School of Public Health, drew some interesting parallels on the lessons we can learn from our preparation for it and the similarity to conditions facing healthcare today. His talk provided both some warnings and a call to action.

The first lesson learned was "Complex systems are always at risk of catastrophic failure." In New Orleans it was the levee systems that failed; for healthcare, the complexity stems from the tangle of relationships and incentives between and among physicians, insurers, governments and patients.

Lesson two: "In retrospect everything was pretty obvious." Studies had predicted the disaster that happened in New Orleans. Similarly, we’ve all heard the cries about the aging of the population, the expenditure of the majority of healthcare dollars on chronic disease and the warnings that the pressures on healthcare systems worldwide by those diseases will become an unsustainable burden.

Lesson three: “We were simply not prepared and could have done a lot better." For Katrina it is obvious. In healthcare, a 2003 Rand study of the care received by patients with chronic illnesses showed that 45% do not get the care called for in best practices. We should do better.

Resistance to Change

A host of impediments make it difficult to introduce technological solutions into the healthcare equation. These include a fear of obsolescence from the high rate of technological change, and the belief that anything "high tech" will take away from the "hands on" “high touch” environment that physicians are used to. Hospital boards understand what it means to buy a respirator, but spending dollars for electronic medical records, wireless networks or new user interfaces is outside their comfort zone.

Several speakers frankly acknowledged doctors' resistance to change. Speaking to an audience largely composed of his peers, Dr. Michael Jellinek, President of Newton Wellesley Hospital, observed that many of the changes physicians are being asked to make require using technologies that are foreign to them, and there have not been sufficient incentives to convince them to change their familiar behaviors.

The conference attendees were a self-selecting group that chose to spend two days discussing these issues. These professionals at the leading edge cannot imagine the future of healthcare without incorporating technology much more deeply into its fabric. But some are pessimistic that change will occur fast enough to cope with ever-rising costs.

Patients Changing, Too

It isn’t only physicians who are undergoing change, it’s also patients. How many of you have gone online to understand symptoms or treatments for some condition you have? Increasingly, patients go to the doctor’s office armed with printouts from the Internet and a list of very specific questions. Some doctors are happy to have patients show such interest, while others view it as an affront to their expertise.

This trend toward the consumer being more actively involved in their own medical care stems from the wealth of medical information available freely on the Internet, and will only grow over time. One speaker described the doctor’s role as transitioning from “the priest" to "the guide.”

The Application of Communication Technology

“Care Follows the Patient”

Many of the conference discussions and presentations honed in on the delivery of "the right information, to the right person, at the right time." Communications is key, and high speed, always-on communications often provides the most value.

Several talks described applications focused on diagnosis and recommendations for treatment:

  • The “tele-ICU” application at Lehigh Valley Hospital connects board-certified critical care specialists to the three sites of this facility; the attending physician consults with the remote intensive care specialist, who can see both the patient and their medical records.
  • In the “telestroke” program at Mass General, an expert at a remote location views a patient suspected of having a stroke and their brain scan and converses with the attending resident to determine whether to use a clot dissolving medication.

Dr. Joe Kvedar --> Click for larger pictureDr. Joe Kvedar, Director of Partners Telemedicine and an early believer in the application of information technology (IT) to medicine, talked about Partners’ new "Connected Health Initiative". Partners has been active in implementing programs that leverage communications technologies to interconnect people within the medical establishment. Connecting medical professionals with residential consumers is the core of the new initiative, based on extending the care community outside of healthcare institutions by bringing healthcare to the places consumers and their families live and work.

In his talk on “Optimizing Care Through Communication Technologies”, Dr. Kvedar observed that the spectrum of care includes Prevention, Diagnosis, Monitoring, Communications and Treatment. While diagnosis and treatment tend to be within the medical community, monitoring and communications can be handled via communications between health care professionals and the consumer at home. Home monitoring has been shown to be very effective for Congestive Heart Failure (CHF) and wound care. Communications technologies are starting to be used for online visits and multimedia messaging.

Electronic Medical Records--Still Moving Slowly

The relationship of Hurricane Katrina to healthcare goes beyond the crisis analogies we’ve mentioned. Cheryl Austein-Casnoff, Director, Office of Health Information Technology at the US Department of Health and Human Services, made it very real when she painted a picture of Katrina evacuees showing up in 19 states without healthcare records, medication prescriptions or immunization records. She believes this is a wake-up call to have accessible Electronic Medical Records (EMRs) for all Americans.

The primary purpose of an EMR is to provide easy access to all important patient health/medical data by authorized personnel, independent of where the patient is located.

In an Executive Order more than a year ago, President Bush endorsed the goal of having widespread adoption of interoperable electronic health records within the next ten years. Following Katrina, the administration announced new regulations that support adoption of e-prescribing and electronic health records. Since every hospital and every doctor's office keeps its own records (often handwritten), a great deal of work still lies ahead.

Johanna Pittman --> Click for larger pictureJohanna Pitman, Vice Consul of the British Consulate, described the very different environment in the UK, where e-records and e-prescribing are well along in implementation. This is made simpler by having a single payer, the National Health Service (NHS). Another UK speaker said the government is spending billions of pounds for the implementation of the NHS Electronic Vision: "a health service designed around the patient." The electronic transfer of prescriptions is well underway in the UK and will be fully implemented by the end of 2007.

In the US, there appears to be a gap between the agreed need for electronic medical records and the pace of implementation. While everyone agrees EMR is a necessary underpinning for future medical services, it seems to be going slowly. People have been talking about portable interoperable medical records for more than two decades, but people still have to fill out the same form every time they visit a doctor, entering information about existing conditions and the drugs they are taking--probably differently each time. In private conversations, several attendees said it was difficult enough to break down walls in their own institutions, much less between institutions.

Home Care: Segments and Solutions

As we listened to speakers describing various applications of technology to home healthcare, it seemed useful to think of the addressable market in terms of the health status of the consumer. The following segmentation has helped us think about applications in terms of user type, appropriate technologies and how the solution will be paid for.

  • People with an acute condition (one that is severe and comes sharply to a crisis).
  • People with a chronic condition (one that requires medical treatment and supervision for a continuous period).
  • People concerned about their health, but are basically well and want to stay that way (sometimes called the “worried well”).

Acute Care

One example of acute care is patients released early from the hospital, receiving close monitoring and supervision at their homes by healthcare professionals. The equipment at the person’s home typically includes specialized "medical grade" devices similar to those in a hospital, provided by the healthcare establishment. This type of care is often paid for by insurance, just as a hospital stay would have been, at a lower cost and with a patient happier to be at home. This was the scenario for Hospital Clínico San Carlos in Madrid discussed in our September 2003 article Home-based Health Services: Telefónica’s Pilot.

Chronic Care

Liverpool trial in the UK --> Click for larger pictureWith the worldwide aging of the population, a large piece of the focus of trial projects has been on the care of chronic conditions. This was the subject of Intel’s research described in Eric Dishman’s article Repurposing Broadband: Home Health Technologies for the Worldwide Age Wave, and the focus of work on both diabetes and congestive heart failure described in the case studies at last year’s Healthcare Unbound conference.

At this conference, Kerstin Nettekoven of BT described a project in Liverpool in which elderly people with chronic conditions are passively monitored, using non-invasive sensors to assist in supportive home care for their independence and safety. Similar projects are underway in the US, often funded through the Centers for Medicare and Medicaid Services (CMS).

The "Worried Well"

Many articles have described the US "baby boomers" who are approaching retirement age and often have a proactive view of healthcare. Many have seen their parents in nursing home situations and want an alternative solution. Searching for ways to stay healthy longer, they spend money on gym memberships, foods and supplements bought at health food stores. These "worried well" have a strong interest in monitoring their health and finding ways to maintain it.

Amir Nashat of Polaris Ventures thinks this segment represents a good opportunity for implementing "self-pay" models for wellness care. This approach would circumvent the thorny questions of "who pays" raised when seeking venture money for telemedicine projects.

Dr. Nat Sims, Harvard Medical School, is particularly interested in the development of monitoring devices appropriate to this segment. These could be high volume/low cost sensors and actuators which might connect with mobile phones to provide "untethered physiologic monitoring across the continuum of care." In this segment, it could be acceptable to use lower-cost "consumer grade" devices to record longitudinal data and deviations--an example would be the consumer measuring blood pressure with an automatic cuff at different times of the day to provide data for the doctor to see if hypertension medication needs to be adjusted.

Looking Forward

Mobile phones appeared in several presentations --> Click for larger pictureSince we came to this conference with a bias toward using broadband communications between healthcare professionals and the home, we were surprised that no speaker mentioned broadband. Several focused on mobile phones as the "break-through enabler" for home communications. It was not clear whether the speakers were referring to the wireless communications channel, the portable personal device, or both. Mobile carriers were far more visible at the conference than fixed-line carriers, and appeared to have paid far more attention to the home healthcare opportunity.

Many speakers made clear that although there are some technology challenges, technology is not the major impediment in moving forward with telehealth. The challenges come from laws and regulations, the need to align rewards and incentives with desired behaviors, and the organizational complexities in the current US system.

Dr. Nobel’s speech presented a view of the evolution of telehealth in which the first generation will focus on solving "the distance and time problem;" the telestroke application described above is an example of this category. The second generation will be more transformative; roles and accountabilities will have to be re-designed and chronic diseases are one of the major challenges to address.

After attending several conferences on the application of technology to healthcare over the past several years, our assessment is that forces are starting to align to disrupt the inertia of the current system. Hopefully the spotlight Hurricane Katrina has focused on major deficiencies in the US healthcare system will provide a positive benefit from the terrible catastrophe.

[Postscript: After completing this article we viewed a TV interview by Charlie Rose of Andy Grove of Intel. Grove has written an article Efficiency in the Health Care Industries -- A View From the Outside which appeared in the July 27, 2005 issue of the Journal of the American Medical Association. We have not yet read the full text of the article, but Grove made very interesting points in the interview, especially the urgent need to take small steps quickly. For EMR, he advocated solving a smaller part of the problem as quickly as possible, then addressing the larger problem over an extended time.]

Presentations from the conference are available at the Partners website

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