Disruptive Innovation: Patient Centred Healthcare and the Extinction of Dinoisaurs


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William Pascal
Canadian Medical Association
(Friday, 8.15am, Forum Room)

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  • I will provide an overview of the health care sector looking at the political, social and economic dimensions by using Canada as the context and the impact on the major stakeholders However this analysis has parallels in almost all developed countries Secondly I will provide a perspective on the health IT agenda that Canada has followed and comment on our successes and failures Finally I am going to provide you with my assessment where Canada needs to be focusing as we move forward given changes in technology capabilities This assessment I also see having implications for all developed countries
  • New Zealand - 268,700 square kilometers, 4,405,200 Canada – 9,970,610 square kilometers, 34,482,779 people Canada 37 times the size in land mass and 7.8 times the population However many similarities
  • Building a culture of patient-centered care Enhancing access and improving quality of care Enhancing patient access along the continuum of care Helping providers help patients = knowledge and tools Building accountability/responsibility at all levels Driving Out Cost Efficiencies
  • Let’s start with a look at the political dimension of the health care system While Canada is reality well off I is still very vulnerable to the situation on the US and Europe where the majority of its trade exists
  • Not a great deal of support, sympathy among editorials or pundits Most see fiscal proposal as a positive, given current economic conditions Likewise with the “no strings attached” provision; see it as opportunity for provinces, territories to create their own reforms Premiers still hoping to convince the PM to work with them
  • Health spending accounted for 11.4% of GDP in Canada in 2010, almost two percentage points higher than the OECD average of 9.5%. Canada also ranks above the OECD average in terms of health spending per capita, with spending of 4445 USD in 2010 (adjusted for purchasing power parity), compared with an OECD average of 3268 USD. Health spending in Canada increased in real terms by 4.6% per year on average between 2000 and 2009, but this growth rate slowed down to 3.0% in 2010 Despite the relatively high level of health expenditure in Canada, there are fewer physicians per capita than in most other OECD countries, although their numbers have been growing in recent years. In 2010, Canada had 2.4 physicians per 1000 population, well below the OECD average of 3.1. There were 9.3 nurses per 1000 population in Canada in 2010, slightly more than the OECD average of 8.7. The number of hospital beds for curative care in Canada was 1.7 per 1000 population in 2009, half of the OECD average (3.4 beds per 1 000 population). life expectancy at birth in Canada stood at 80.8 years, one year higher than the OECD average (79.8 years in 2010)
  • In 2010 OECD estimated that Canada could lower by 2.5% its spending on health care were the Canadian health care system to become as efficient as the best in the OECD A check up on the Canadian Health care system would point to five issues: The changing demographics and with it the increases in disease burdens and pressures on the current health care delivery system Increasing cost pressures where there is an insatiable demand for care and limited capacity and ability for governments to source and allocate more funding A delivery system built for a 1960 care model focused on hospitals and providers that needs to be completely re-engineered Roles and accountabilities of providers that need to realigned to maximize core competencies and A predominate focus on population health
  • Portrait of Medicare that emerges from the widely cited commonwealth Fund surveys is of an expensive, rather insensitive and inefficient system that fares poorly when tested against health care systems in comparable countries Canadians are paying for a world class health care system but for a variety of reasons they are not getting one – quote from Euro-Canada Health consumer Index – covers 34 countries We continue to go down the list of the 34 countries in the OECD
  • Since 2004 have invested over $41 billion into health care in part to bring down wait times We have not done a very good job
  • In 2009 Canadians spent 11.7% of their national income on health care It is estimated that the health care system is used 400 million times by 34 million Canadians David dodge former Governor of the Bank of Canada forecast health care will consume 15.4 % of the national economy in two decades assuming huge efficiency gains and 18.7 % without them –roughly in line with OECD Aging population will not cripple Medicare
  • Health deficits will become more burdensome for tomorrows generation Health care today consumes 42 to 45 % of provincial program spending If no changes it will be 55 to 65% by 2020
  • Diabetes – 41,500 deaths, 1 in 10 will be affected by 2020 = $12.2 billion Heart Disease – leading cause of death 71,000+, 1 in 5 aged 50-64 with 2 or more risk factors = $22 billion Hypertension – 1 in 5 Canadians aged 20+ = $2.4 billion Asthma – 3 million - $600 million Mental illness – 1 in 5 Canadians affected, second leading cause of premature death = $14.4 billion Cancer – leading cause of premature death = $14.2 billion
  • Political point of view touching health care to make changes is like touching the third rail of a subway system Touch it and you die
  • Healthcare Challenges for administrators and–more issues than money - Health care is a complex adaptive system Difficult to determine what an intervention will cause to happen Clinical Chronic Disease Management Prevention Medication management Continuity of care System Access Wait times Public health surveillance Cost management Less money for health care sector Pressure to re-engineer delivery of health care as other sectors already have Funding models will change Will create more tension amongst Ministries of Health and provider groups
  • For providers and administrators change is hard In health care particularly so given different roles and responsibilities
  • For vendors particularly in Canada it is a frustrating and byzantine market place Micro markets No consistent standards Long and costly procurement cycles
  • We have built data repositories but little connectivity and therefore little value
  • New 4-lane divided Highway 11 near Huntsville, Ontario, Canada This is what we hoped for when we started our building our health information highway
  • This is what we started to see as the years rolled on
  • Rockfall on Trans-Canada Highway, near Yale, British Columbia, triggered by heavy rains on November 9, 1990 And this is what we see from time to time and depending on who you are
  • We have had a series of controversies with our e-Health agenda They have become very political and now we have a a tarnished image that needs some cleaning up Has created an environment that is over cautious and highly sensitive to any whiff of bad media All anathema to implementing large IT initiatives where failure is routine
  • Top down Enterprise approach Pan Canadian collaboration –trying to address federated country dilemma Medium to Long term ROI Good work on standards agenda albeit not inclusive and too expansive High risk agenda –large dollar projects Little attention to point of care – starting to change but we are a long way to being successful Patient value low Little innovation Little attention to mobile EMRs around 50%
  • I believe that it is time to shift gears We have realities on the political, economic and social fronts that require different approaches and different solutions We have technology advances that are opening up possibilities that were not around 10 years ago So let me take you through a line of argumentation that points to a new focus and a need to shift gears f
  • The vectors forward A focus on health and well being and not just health care Moving care delivery to the most appropriate and effective setting Building health care delivery around the patient Increased use of measurement and with it accountability and Adapting the health care sector to the new consumer reality; personalized health focused sector
  • Procurement cycles that are 10 years long with solution cycles of 3 years Privacy governance that is not current with social media trends A belief that medicine requires complex highly specialized information technology systems with doctors becoming increasingly bound to documentation and communication products that are functionally decades behind those thy use in their civilian life A belief that monolithic EHR and EMR solutions are the answer Care delivery that can now be carried out in lower cost settings but resistance of institutions and groups to allow it to happen Health care sector with anti-bodies to sound management principles( clear accountabilities and measurement) and private sector involvement A desire for innovation but with no appetite for failure Trying to build a comprehensive standards environment
  • 2/3 of the costs in our health care system are due to 5% of our population We know who they are and yet we continue to focus on the population rather than the high cost and risk patients
  • Next, let us look at how we need to view the broader context of health, rather than just focusing on health care. If we are serious about improving quality in our system, we do have to look more widely. As you can see, the impact of health care on health is quite small in the larger scheme of things. We can now start to see how a taking a broader view of both the challenge, and the potential solutions, could make a difference. This approach was important to the IHI when they developed the Triple Aim framework for quality improvement in health care.
  • From a systems engineering point of view do not try and solve all problems Look for the 80% 85% of Health Delivered Care at Community Level Care is delivered locally and does not need large system integration to drive out value 5% drive costs 20% of Cost of Infrastructure is at Community Level 60 - 70% of Value of Automating Office Gained without Connectivity Connectivity, Drug & Labs give largest value Lowest Risk for IT Build & Standards Innovation Thrives
  • Innovation is driven by solving what I call “pain points” Innovation is integrating ideas into practice; could be small or large but small has a higher degree of success Therefore driven by end users Need an eco system that favors innovation which provides “mad” money, protection, positive working relationship with entrepreneurs and acceptance of failure Also needs to be supported by a means to gather knowledge and share it
  • Building a digital society; 5 themes;
  • Everything will be digitally enabled
  • Main take away was that we have now made the impossible possible Ongoing minor adjustments can lead to large gains in effectiveness and efficiency Todays technology capabilities is opening up new capabilities We now have more flexibility, lower cost, faster implementation and return on value and a better end user experience
  • Consumerization of healthcare (providers & patients) • User experience advancements • Convenient, efficient, social • Consumer friendly • Low cost • Implications: − User experience and usability enhancements create new opportunity and may advance adoption − Support of care coordination and collaboration − Support of home care and self care − Changes to clinical process and scope of practice − Changes to reimbursement models
  • Consumer products support an eco system approach We are buying an integration platform and then build our own eco system through apps This is where we need to go with our IT eco systems in health care Take a look at the SMART project in US – Substitutable Medical Applications, Reusable Technologies – view of SMART project team that proprietary HER offerings currently on the market tend to be architected monolithically, making modifications difficult for hospitals and physician practices
  • Agility - Systems will be • Distributed • Decoupled • Small, agile applications and services • Implications: − Leverage the enterprise services − Requires robust strategic planning − Requires more robust governance − Agile systems can be transformed quickly to support changes to the business − Quicker and cheaper deployment
  • Connectedness • Pervasive networks • Every healthcare device will be a networked device • Interoperability and clinical information definition advancements • Implications: − Medical device capability and information regardless of where you are − Care coordination and collaboration − More cost effective, usable and flexible home care, remote care and self care devices
  • In order to improve care, reduce costs and optimize performance need to become more data driven Many organizations already have data they need, but lack the foundational practices and capabilities to get the most out of these assets it is true there is a lot data being generated but not the right data Need data on individual performance, need it in a timely manner, What is clear from the history of change in the Canadian health care system is that the strongest forces for change came not from within the system but from without especially in the period of government restraint in he mid 1990’s Claude Castonguay who carried out a review on one of our provincial health care systems said it bets in my view; Our health care system is a monopoly installed at every level with the culture inherent to monopolies, , whether public or private. The culture is based on regulation and budgetary controls closed to the outside world impermeable to real change, adaptation and innovation . It I a cultural that favours inefficiency
  • Data trends: • Data from many sources • Data is ubiquitous and fluid • Data is “big” • Data is free form and ambiguous • Clinically complex • Implications: • Data is the fuel for business and clinical value • Requires IT to aid the human, e.g. to analyze • Interoperability and semantic challenges Analytics on data and innovative uses of data • Analytics will drive the business • Gaming logic applied to data • Analytics on social networking data sources • Artificial intelligence – question and answer • Implications: There is a very strong trend from health data to: • Health knowledge • Insights • Action
  • The Creative Destruction of Medicine Now Eric Topol has now written a book that calls for the "creative destruction" of the current medical paradigm, which he believes has failed to keep up with the digitized world of interactivity, social media, computers, apps, and advanced engineering and electronics. In the book, written in that same half-smile style of good humor and authority, Topol blasts current-day medicine as being archaic and wasteful, making his case with a compelling blend of statistics, anecdotes, and barbs aimed at health care's Ancien Régime. All others parts of our lives have Schumpetered (Shoom paytered) popularized term creative destruction to denotes transformation that accompanies radical innovation Health thus far has ben largely unaffected, insulated and almost compartmentalized from this digital revolution Clayton Christensen – Innovator ’s Prescription - If at times he seems a whiff too optimistic about the transforming impact of new medtech in the short term, he does a good job of explaining subtleties to a lay audience -- such as why some genetic testing for predicting disease is valid and useful, and why much is not. he key is to enable the disruptive innovation that drives costs down and accessibility up, just like in other industries: the telephone disrupted Western Union offices to make communication less expensive and easier to access, and cell phones returned the favor by disrupting telephones in their turn; microcomputers disrupted mainframes and were themselves disrupted by PCs (which are now being disrupted by smartphones and tablets). In health care, Christensen predicts, general hospitals will be disrupted by specialty providers focused on single procedures (like angioplasty or organ transplants), specialty providers will themselves be disrupted by general practitioners, general practitioners will be disrupted in turn by nurse practitioners and doc in the box type services, and nurse practitioners and doc in the box services will be disrupted by online communities of care and automated self-service tools. All this, for Christensen, is the way every industry lowers cost and increases accessibility–health care will be no different. Most government intervention and regulation, in his opinion, has historically served only to slow the progress of disruption, so he is bearish on the government ’s role in all this.
  • Keep thing simple –products, services and standards ( Direct Project) – reference to Job’s Job one help deliver better care - deliver value locally before creating value elsewhere but have a strategic plan Generalize not specialize - allow for self designed eco systems –leverage capability arising in consumer market space Deliver value not IT systems Before investing in IT be pragmatic about who can do what best –core competencies – this is for those who will do the implementation and those who will use the eco system All stakeholders have to win but not necessarily at the same time Build in innovation into RFP process We need a distributed environment: bring questions to data Think like a system engineer 80/20 rule Leverage mobile capability and service high users
  • Why not an utility model for the health care sector Why not buy a mobile eco system for the high cost users All funding of IT systems whether small or large should be based on performance
  • Balancing of top down and bottom up Leveraging standards and registries Increased value to patient Shorter time to demonstrate value Lower risk Lower cost More flexibility More innovation
  • Disruptive Innovation: Patient Centred Healthcare and the Extinction of Dinoisaurs

    1. 1. Disruptive Innovation: PatientCentered Healthcare and the Extinction of Dinosaurs William Pascal CTO Canadian Medical Association November 9th, 2012
    2. 2. Tough Road Aheadfor Premiers
    3. 3. Fiscal MeltdownDemographics -Growing costs
    4. 4. Health Care Costs Per Working Age CitizenSource: Statistics Canada and Provincial Budgets & Deloitte report entitled Provinces in Transition
    5. 5. $65.8 billion
    6. 6. Targeted Investment Areas EMR Program296 active and completed projects with an estimated value of $ 3.0 $1.527 billion as at March 31, 2010
    7. 7. Investment Programs 20
    8. 8. Availability of information for authorized users Client Dispensed Demographics Drugs 99.8% 54% Provider Lab Test Demographics 2012 Results 99.9% 71% Clinical Reports Diagnostic or Immunizations Images 83% 99% Telehealth Videoconferencing in 90% of HospitalsNote: Availability does not measure the extent of use by providers, but rather the information and systems that are in place.
    9. 9. The Current Agenda EHR Infostructure $$$ Drug Lab DI Reports Telehealth Info Info & Images The Return on Health Care HIAL Point Of Point Of Service Service EHR Viewer Applications ApplicationsLess than 10% of IT spending is at the point of care
    10. 10. SYZYGY Fiscal Health ICT Awareness Risk Aversion Shared Risks
    11. 11. Health Care TransactionsSource: White, William, Greenberg, New England Journal of Medicine 1961
    12. 12. Who are we innovating our health systems for? Figure 1. Health Care Cost Concentration: Distribution of health expenditure for the Ontario population, by magnitude of expenditure, 2007 Ontario Population Health Expenditure 0% 1% Expenditure 5% Threshold (2007 10% 10% Dollars) 20% 34% 30% $33,335 40% 50% 50% 66% 60% $6,216 79% 70% $3,041 80% 99% 90% $181 100% On average, health care spending is highly concentrated with the top 5% of the population (ranked by cost) accounting for 66% of expenditure
    13. 13. Determinants of Health and TheirContribution to Premature Death Social circumstances 15% Genetic Environmental predisposition exposure 30% 5% Health care 10% Behavioral patterns 40% Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93.
    14. 14. Source: Morgan Stanley 37
    15. 15. Categories of Use Better healthcare and improved health for Canadians Health System Use Clinical Health Care to the Program System Public Health Research Patient Management ManagementUse of data toUse of data to Use of data to Use of data to Use of data to Use of data to Use of data to Use of data to Use of data for Use of data forprovide direct provide direct improve front- improve front- improve the improve the understand the health research understand the health research care to the care to the line health care line health care effectiveness effectiveness health of the health of the patient patient programs and programs and and efficiency and efficiency public and for public and for services services of the health of the health public health public health care system care system activities activitiesNote: Health information is also used to support other uses of information as permitted by law, such as ensuring food safety and complyingwith regulatory and medical certification requirements. Better Information for Improved Health: A Vision for CanadaNovember 15, 2012 44
    16. 16. Dr. Clayton ChristensenDr. Eric Topol
    17. 17. Discussion