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Misdiagnosis means unnecessary suffering and the loss of life
15% of all medical cases are misdiagnosed
44% of some types of cancers are misdiagnosed
Misdiagnosis results from the way doctors are trained

Can AI reduce medical misdiagnosis?

Inaccurate or delayed medical diagnosis is more widespread than often thought, and results in a staggering toll of harm and patients’ deaths.

Unnecessary suffering
Each year, in the US an estimated five per cent of all medical cases are misdiagnosed. ‘Not bad’, some might say given the millions of Americans who visit their doctors’ each year presenting thousands of different disease states each with multiple symptoms. But five per cent translates to 12 million annual misdiagnoses in the US alone, which is, “the tip of the iceberg” according to Professor Graham Neale, an expert in misdiagnosis from the Centre for Patient Safety and Service Quality at Imperial College London.

A 2012 study reported in The American Journal of Medicine suggests that 15% of all medical cases in developed economies are misdiagnosed. Professor Neale suggests that 15% of all UK cases are also misdiagnosed. The Mayo Clinic Proceedings suggest that misdiagnosis could be as high as 26%, and according to The Journal of Clinical Oncology, a staggering 44% of some types of cancers are misdiagnosed.

Misdiagnosis means unnecessary suffering, the loss of life, and unnecessary costs. For example, 33% of the $3trillion spent each year on healthcare in the US is considered “wasted” because of medical misdiagnoses. And data released in 2015 by NHS England’s Litigation Authority in response to a Freedom of Information request show compensation paid to people misdiagnosed rose from £56 million in 2009-10 to more than £194 million in 2013-14.

According to Sebastian Lucas, former Professor of Clinical Histopathology at King’s College London, the most common misdiagnosis found through post-mortem examinations are the over diagnosis of cardiac disease, the under diagnosis of pulmonary-embolism, the over and under diagnosis of cancer, and the under diagnosis of significant infections.

What are the most common misdiagnosis found through autopsy? By Sebastian Lucas

Medical misdiagnosis occurs when either a condition is undiagnosed, or where an incorrect diagnosis is made. An example of the former is when a patient with a health problem has visited their doctor over a period, and the doctor fails to diagnose the illness. An example of the latter is when, say, a fracture is diagnosed as a sprain.

Why misdiagnosis occurs
Reasons given for misdiagnosis include the fragmented nature of healthcare systems, and the over burdened, demoralised and scarce supply of primary care doctors. See, Curing the Problems of General Practice. In 2008 Eta Berner and Mark Graber published a paper in the American Journal of Medicine entitled, ‘Diagnostic Error: Is Overconfidence the Problem?’ which suggests that both intrinsic and systemically reinforced factors lead doctors to be over confident in their ability to diagnose, and once a diagnosis is made and a treatment pathway started, a momentum occurs, which is difficult to change.

Doctors trained to take short cuts
At the root of misdiagnosis is the way that doctors are trained, says Jerome Groopman, Professor of Medicine at the Harvard Medical School, and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center.

Groopman’s thesis is predicated on the concept of the availability heuristic developed by Nobel Laureate Daniel Kahneman, notable for his work on the psychology of judgment and decision-making. In his book How Doctors Think, Groopman suggests that doctors are trained to recall similar recent cases when making a diagnosis. For example, common infections picked up by children at school often affect entire communities. Once a doctor has seen, say, nine such cases, the information about them is immediately available in his subconscious, and creates a tendency for the tenth patient presenting similar symptoms to be diagnosed the same although the actual illness might be different.

Such mental shortcuts are indispensible in a medical setting. In A&E, for example, doctors are encouraged to use mental shortcuts to help them make rapid decisions often on incomplete information; failure to do so could mean the difference between life and death.

Will misdiagnosis increase?
Structural reasons suggest that misdiagnosis will not be reduced in the near term. According to the Royal College of General Practitioners the shortage of doctors in the UK is the worst it has been for 40 years. Established GPs are retiring early, and a significant proportion of newly qualified GPs are moving abroad where pay and working conditions are better. One hundred primary care practices, serving 700,000 patients across Britain, are facing closure, and the number of doctor-patient consultations is estimated to rise from 338 million in 2013 to 441 million by 2017.

Similarly in the US, the Association of American Medical Colleges predicts increasing shortages of doctors: 130,600 by 2025. One reason for the shortage is the aging of both doctors and their patients. According to a 2012 Physicians Foundation survey, nearly half of the 830,000 doctors in the US are over 50, and approaching retirement.

Thus, fewer doctors in both the UK and US face having to diagnose an increasing number of aging patients presenting complex conditions, at a time when the volume of medical data are doubling every 73 days. Under such conditions it seems reasonable to assume that the incidence of misdiagnosis will not decrease.

Increased role for cognitive computers in medicine
Will the increased pressure on doctors to diagnose more accurately be helped by artificial intelligence (AI)? Although there are some challenges for AI in a medical setting, it is well positioned to play an increased role in diagnosis. This is confirmed by Google’s DeepMind AlphaGo computer’s landmark defeat of Lee Sedol, a 33-year-old grandmaster of the ancient Asian game GO in March 2016. Let us explain.

AI: the complex algorithms that analyze and transform electronic medical data, into clinically relevant medical opinions for health professionals has developed significantly as the demand for healthcare increased, healthcare costs escalated, and the supply of doctors decreased.

What is the next "big thing" in healthcare? By Devi Shetty

The relationship between the game GO and medical diagnosis
For some time, cognitive computers have been able to defeat the world’s best human players of games such as draughts and backgammon by enumerating every possible move, and drawing up rules for how to guarantee that a computer will be able to play to at least a draw. Although more complex, chess computers rely on a modified version of the same tactic. In 1997 for example, when IBM’s Deep Blue computer defeated former world chess champion Garry Kasparov, it could evaluate 200 million possible moves in a second.

But GO is different: its simplicity belies its astonishing complexity. There are more legal board states for a game of GO than there are atoms in the universe, and just like in medical diagnoses, reaction and intuition are important. These intangible aspects of the game GO, and diagnosis, make them resistant to the tactic by which games in the past have been “solved” by computers. Experts predicted that it would take another 10 years before a computer program would stand a chance even against a weak GO player. This is why a computer’s defeat of Lee Sedol, signaled a landmark moment for AI, and has implications for medical diagnosis.

GOis played by two people on a 19-by-19 grid-board, with 361 black and white stones, 181 black and 180 white. Each player takes turns placing their stones in an attempt to surround and capture their opponent’s pieces. The player who controls more territory is the winner. The first move of a game of chess offers 28 possibilities; the first move of a game of GO can involve placing the stone in one of 361 positions. An average game of chess lasts around 80 turns, while on average GO game lasts for some 150 turns, which leads to a staggering number of possibilities.

Cognitive computing and diagnosis
Cognitive computing systems that understand, reason, and learn, also are able to see health data that were previously hidden, and do more than we ever thought possible. Doctors have access to such computers, which provide them with collective knowledge gathered from thousands of healthcare providers, millions of patients’ records, and millions of treatments other doctors have prescribed to people presenting similar symptoms and disease states. Such computers are capable of analyzing in seconds these data and identifying patterns that humans cannot.

Further, unlike doctors, computers work 24-7, 365 days a year, they never get tired or demoralised, and they never leave. Also, computers are faster and more thorough than doctors, and can analyse vast amounts of patient data, identify trends in seconds and consistently make more accurate diagnoses. One example is IBM’s Watson, a computer, already being used in medicine, which can attain high levels of cognitive behaviour. Watson uses natural language processing to analyse structured and unstructured data common in clinical notes and reports, and can read 40 million medical documents in 15 seconds, understand complex questions, and identify and present evidence based solutions and treatment options. In the US similar computer programs have stopped making clinical recommendations based on the most popular therapies prescribed by its users, to providing doctors with clinical recommendations based on patient outcomes.

Challenges for AI in medical diagnosis
Despite the fact that AI systems are getting smarter there are still significant challenges associated with the compatibility of computer systems, the integrity of medical data; and data security and access. Further, as AI systems get smarter so the line between computers recommending and deciding becomes blurred. Healthcare providers are wary not to allow their AI systems to make clinical decisions because this would mean that they would be viewed as “medical devices”, and require FDA approval, which can be a costly and lengthy process to obtain.

Doctor’s resistance to AI systems
A doctor’s raison d'être has been to diagnose and treat illnesses, which ordinary people cannot do because it requires expertise, intuition and interpersonal skills. Some doctors argue that computers will never be able to provide such skills. But medical knowledge, which previously resided in the minds of the few doctors, has become readily available to everyone over the Internet, and doctors have changed from being the sole processors of that knowledge, to being the interpreters of such knowledge; in this scenario AI has an important role.

Takeaway
Professor Stephen Hawking and other leading scientists have warned of the dangers of AI becoming “too clever”. There are also concerns about data security and privacy, and some doctor’s fear cognitive computers could diminish their role. However, the defeat of Lee Sedol by AlphaGo has demonstrated that computers can attain high levels of intelligent behavior, and this has significant implications for medicine in general and diagnoses in particular.
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9 years ago

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The Future of Healthcare

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The Future of Healthcare

Fahad Aziz

Co-founder of Caremerge, which provides comprehensive web and mobile communications and care-coordination solutions for senior living communities. Fahad is the author of several technical papers, and the recipient of Pakistan’s prestigious Performance Excellence Award.

How will machine learning, virtual reality, the Human Genome Project, and the Internet of things change healthcare?

Will technology result in a healthier future full of empowered patients?
Will big data strategies help physicians perform their jobs better?
Will 3D printing be used to replace tissue and organs?
Will VR allow scientists to experience physical and psychological challenges rather than observe them?

Living in Silicon Valley I have a front row seat to the in technology poised to reshape the future of humanity. Machine learning, Virtual Reality, the Human Genome Project and the Internet of things will undoubtedly impact our lives in general, but they can also have a major impact on the Healthcare industry in particular.

To visualize the future of healthcare, I took a look at what’s trending in Silicon Valley and applied them to the healthcare industry. If the possibilities seem farfetched today, remember the iPhone is less than a decade old and has spawned countless industries that have shaped our daily existence, and will continue to do so. Technology moves fast and these four trends can potentially disrupt all aspects healthcare.

Machine learning
Artificial Intelligence (AI) is not new to the technology world, but with machine learning, AI has taken on an open-ended form rife with endless opportunities for technology in general and healthcare in particular.

Machine learning enables computers to identify patterns and observe behaviors based on empirical data, and use all that to ‘learn’. In other words, machine learning is a set of self-learning algorithms that can eventually become smarter than any human being on this planet.

In 2012, Vinod Khosla, an American businessman and a co-founder of Sun Microsytems, predicted that in time, “Technology will replace 80% of what doctors do”; sparking outrage and umbrage within the healthcare industry. Physicians overlooked what Khosla was really saying: that big data, properly harnessed and utilized, had the potential to help physicians perform their jobs better. Farfetched at the time, big data and machine learning have come far enough in just four years to provide levity to Khasla’s argument.

When given access to a trillion gigabytes of patient data collected from devices, electronic health records (EHRs), laboratories, and DNA sequencing - alongside surrounding factors such as weather, geo-location, and viral outbursts - computers learn quickly, and they learn everything. The depth of information provided at such a scale suggests patients will not need to consult with various specialities to figure out what’s ailing them in the future. Instead, consolidated data will create and provide a fully coordinated treatment plan.

If you are thinking this sounds crazy, consider the fact that IBM acquired Truven Health for $2.6 Billion in early 2016. Truven delivers information, analytic tools, research, and services to the healthcare industry, and gives IBM access to data of some 200 million patients to feed Watson, which is IBM’s machine learning product that is a powerful question answering computer system capable of answering questions posed by natural language.

I can only imagine what Watson will offer after digesting this massive data, but one thing is for sure: the result is nothing but good news for patients and their care plans.

The Internet of things
Gartner, a US IT research and advisory firm, estimates six billion devices will be “connected” by 2020; collecting data for consumption, analytics and a whole lot more.

Healthcare has historically been a sucker for devices, embracing hardware that captures data, provides diagnostics and even treats patients. Previously, these devices have been in use only at hospitals and other healthcare locations, but in the future this technology has the potential to become a part of every single home; marking a new era in care.

How can the NHS innovate? - Mike Farrar, former NHS Confederation CEO

In the future, doctor’s visits will begin before we even head out the door. Our vitals will be captured at home and sent to our doctor. In some cases, we may even receive treatment in the comfort of our home. Further, once treatment begins, a real-time feed of our vitals and conditions will be shared and analyzed automatically via set protocols, which will trigger alerts if our health declines and requires a change in treatment.

The Internet of things has implications elsewhere for the healthcare industry. Pharmaceutical research could bid farewell to clinical trials once they can access millions of patients’ data to accurately analyze behaviors and outcomes.

Challenges facing immunizations could also be solved using simple, digitized solutions. Currently, vaccinations are rendered ineffective by temperature changes during their transport; a simple tracking device with a thermometer could solve that problem. Similar challenges with manufacturing, delivery and tracking of vaccination can also be digitized to make the immunization programs successful globally.

Last but not least, I foresee nano devices embedded within the human body to monitor glucose, blood pressure, temperature, and more; to allow for swifter, more effective decisions to be made so treatments can begin as soon as needed, significantly increasing positive outcomes.

The Human Genome Project
One of the greatest breakthroughs in healthcare this last decade was decoding the human genome to understand the DNA sequencing. It took over 10 years and a staggering US$2.7bn to crack the code of one human being. Just a decade later, it takes US$1,500 and a couple of hours to run the genome for any person.

The more we learn about DNA and its sequencing, the more accurately we can treat patients for their illnesses. There will be no guesswork involved, instead, a complete technical report will show exactly what went wrong since last time, and what can be done to fix it.

The future is closer than we think. I suspect human genome machines will be deployed at healthcare locations in the near term. The appetite for this type of information will grow, and eventually, we may live in an age where small genome devices are installed under your sink or inside your toilet seat to analyze changes in your DNA sequencing several times a day.

Today, researchers in Europe are using 3D printers and DNA sequencing to create human body parts that can potentially replace limbs or ailing organs. Prototypes already exist. DNA sequencing will help people take more control over their bodies, allowing them to make better informed decisions about their lifestyle, illnesses and treatments. This means that doctors’ roles will change, potentially allowing for a complete shift in the healthcare paradigm.

Virtual reality in healthcare
Mark Zuckerberg, chairman, CEO and co-founder of Facebook, takes every opportunity he can to promote his latest US$2bn acquisition, Oculus VR, an American virtual reality company, whose product, Oculus Rift, is a virtual reality (VR) headset. I had the opportunity to try Oculus Rift, and was blown away. Market analysts say Zuckerberg was crazy to bet on this, but I know he has discovered a platform with the potential to be larger than Facebook.

Virtual reality transports you into another world by creating an artificial environment, deceiving your sense of sight and touch, so your mind believes you are part of that environment. At a recent Aging2.0 conference, I watched a man in his 30s struggle to walk while wearing an Oculus Rift headset. A moment after putting it on he experienced the physical shortcomings of someone in there 80s. These types of experiences open up a new world for researchers by providing them with the ability to directly experience physical and psychological challenges rather than rely on observations.

Doctors' resistance to change - Devi Shetty, founder of Narayana Hrudayala, Bangalore, India

The environment created by VR is artificial and programmed, at least for now. But fast forward three to four years, and you will likely be in a real environment. Consider this: a doctor could be transported to a hospital in Kenya while sitting in the relative comfort of his clinic in San Francisco. VR would allow the user to move around and interact with people enabling participation in treatments, research or even surgery.

I suspect Zuckerberg will combine social networking and virtual reality, allowing people from any part of the world to meet up with one another, to visit places they have previously only dreamed of, and go on adventures their body would never allow in the real world.

In healthcare, innovators are already leveraging VR for treating post-traumatic stress disorder (PTSD), autism, social cognition, meditation, and help with exposure therapy and surgical training. And this is just the beginning.

Takeaways
The day is fast approaching when I will be able to virtually go to hospital to meet with doctors and specialists, share my vitals through various devices and a video camera to gain assessment and treatment plans from the comfort of my own home.

Healthcare information and management systems (HIMSS) have never disappointed me in terms of their participation and size, and I am hopeful that innovations will continue to shock, whispering promises of a healthier future full of empowered patients.

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9 years, 2 months ago

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Will Devi Shetty have a major influence on global healthcare?

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Narayana Hrudayalaya (NH) is an innovative Indian healthcare provider
In just 15 years NH has become one of India’s leading hospital groups
Founded by Dr Devi Shetty, a heart surgeon, NH treats nearly 2m patients a year
NH has built an international reputation for affordable quality healthcare
A number of large institutional investors are betting that NH can grow
Is NH’s model of affordable quality healthcare replicable outside of India?

Will Devi Shetty have a major influence on global healthcare?

PART 1

Dr. Devi Shetty, founder and chairman of Narayana Hrudayalaya (NH), an innovative Indian healthcare provider, wants to transform the way healthcare is delivered across the world. Can he do it?

This Commentary is in three parts. Part 1 is a general introduction to NH and its 2015 initial public offering. It describes some of NH’s internal challenges and suggests that it is reasonable to assume that these will be overcome given its position within a buoyant Indian healthcare market. Part 2 describes some key aspects of NH’s model for affordable quality healthcare. In particular, it shows how Shetty has embraced information technology and some aspects of scientific management to create mega hospitals in India that delivers sustainable high-volume affordable quality care. Part 3 discusses some of the challenges associated with replicating the NH model outside of India. It briefly describes Shetty’s initiative to create a medical city in the Cayman Islands to capture share from the North and South American healthcare markets. It discusses some of the barriers to replicating the model in the UK and other developed markets and suggests that besides India; Africa, - despite its complexities and challenges - might offer NH growth opportunities. It also suggests that NH could play a leading role in training a new generation of healthcare professionals specifically attuned to the vast and escalating healthcare needs of developing economies, and this could be commercially valuable.

London-based financial institution CDC and a number of others think Shetty can provide the world with a new model of affirdable healthcare. In December 2015 the CDC Group, owned by the British government, with an investment portfolio valued at £2.8bn, backed NH’s initial public offering (IPO) with an investment of US$48m. The IPO valued NH at US$1bn. The issue was 8.6 times oversubscribed, with most of the demand coming from foreign institutional investors. Beside CDC, other anchor investors included the government of Singapore, Morgan Stanley, Nomura, BlackRock, and Prudential.

Dharmesh Mehta, former managing director and CEO of Axis Capital, one of the bankers to the issue, said: “We got one of the best anchor books, with several long-term investors supporting it. Investors are bullish about the Indian healthcare space, especially hospitals, and Narayana Hrudayalaya has a unique business model, and the backing of good quality management.”

In the video below Shetty argues that, “Healthcare of the future will not be an extension of the past.” Shetty has a good understanding about how technology is revolutionizing the way healthcare is delivered and changing its structure and organization to such an extent that the future of healthcare will be dramatically different from what it is today. Healthcare is moving beyond the hospital towards patient self-knowledge and empowerment. Home-healthcare services facilitate enhanced doctor-patient connectivity where it had not been previously possible.

(click to play the video)

Narayana Hrudayalaya

Shetty, who has more than three decades of experience as a cardiac surgeon both in the UK and India, founded NH in 2000. Since then, it has become one of India’s leading healthcare service providers; with a network of 23 multi-specialty, primary and tertiary healthcare facilities, eight heart centers, and 25 primary care facilities, across 32 cities, towns and villages in India. Currently, NH has 5,600 operational beds, which it intends to increase to 30,000 by 2020. NH employs some 12,500 people, including 818 doctors, 5,400 nurses and about 1,660 visiting consultants.

In fiscal year 2015, Narayana provided care to nearly two million patients and undertook more than 51,456 cardiology procedures, 14,000 cardiac surgeries - which accounted for 10% of the national figure - and 184,443 dialysis procedures. Narayana posted revenues of US$219m for fiscal year 2015 and profit after tax of $2m. For the four fiscal years that ended March 31, 2015, the company’s revenues grew at a compounded annual rate of 30%.

Access to healthcare for millions of poor people

NH has one of the world’s largest telemedicine networks with 150 centers including 50 in Africa, where Shetty sees further expansion opportunities for NH. The service is free-of-charge and enhances the connectivity between remote health facilities and consultants at Narayana. Shetty, a vocal advocate of affordable healthcare, helped design the Karnataka State government Yeshasvini scheme, which is one of the largest self-funded micro healthcare insurance programs in India. It covers about 2 million people who previously did not have access to healthcare. Participants pay US$1.40 per year, which provides them with free access to over 800 surgical procedures in 400 hospitals. In the past 10 years, 85,000 peasant farmers have used the insurance to have surgery.

Challenges

NH faces some challenges. Its profit margins are low and its revenues are mainly derived from three of its largest hospitals, which concentrate on cardiac care and cardiology. As of March 2015, the company’s recent acquisitions and expansion into the Cayman Islands, where it opened a 130-bed tertiary hospital, were making losses.

However, NH’s acquisitions and expansion are strategic and their pay-offs are expected to accrue over the next four years. Also, higher yields from value-added therapies such as oncology, neurology and gastroenterology are anticipated to improve Narayana’s average revenue per operating bed (ARPOB). The company’s strategy to focus on the mid-income segment of the market is predicted to increase its utilization, given that this is a large, rapidly growing and immediately addressable market. Narayana is also advantaged by its history of efficient use of capital: it has a debt-equity ratio of only about 0.3.

Market drivers

In 2015 investors might have been influenced by the falling gold, oil and real estate markets and the relative attraction of the Indian healthcare sector, buoyed by changing demographics, rising incomes and a large and expanding middle class, greater health awareness, changes in disease profiles and a rising penetration of health insurance. By 2020 India is expected to be the world’s third largest middleclass consumer market behind China and the US. By 2030 India is projected to surpass both countries with an aggregated consumer spend of some US$13 trillion. A 2019 study by the McKinsey Global Institute (MGI) suggests that if India continues to grow at her current pace, average household incomes will triple over the next two decades, making the country the world’s fifth-largest consumer economy by 2025, up from the current 12th position.

While recognizing the challenges for India’s healthcare sector, investors must have thought that NH is well positioned to take advantage of the expected explosion in India’s middleclass consumer market. Narayana has a strong brand name and it is one of India’s leading healthcare companies, with significant revenue growth over the past four years. Its services appear cheaper than those of its competitors, such as Chennai’s Apollo Hospitals Limited, which has about four times the revenues of NH and Delhi’s Fortis Healthcare, which is about three times bigger in revenue terms. This suggests that NH has scope for substantial growth.

PART 2

International attention

Healthcare systems worldwide consume a large and escalating share of national incomes and costs and quality of care are the two most hotly debated issues among healthcare professionals. Does Shetty have an answer?

For many years, Shetty has attracted international attention. For example, in 2010 a UK prime ministerial delegation visited NH’s Medical City in Bengaluru. Vince Cable, then the UK’s Business Secretary, said: “What we're trying to do in the UK is to get more for less. Dr Shetty has shown us a model by which we do not need to accept inferior healthcare because there's less money, but actually how to get more out of the system for less resource,” Cable described his visit as “inspirational” and went on to say, "I just found it overwhelming. NH combines what we always see in a good health system, which is humane humanitarian behaviour, with sound economics."

The Henry Ford of heart surgery

Worldwide, the demand for healthcare services is rising faster than its supply. By focusing on an endeavour to make doctors more effective, NH has demonstrated that it can deliver what healthcare systems need: enhanced patient outcomes for less money. “We have invested in infrastructure. Similar infrastructure in the UK and the US is used for about eight to nine hours a day. Ours is used for 14 to 15 hours a day, which allows us to perform the high volume of procedures,” says Shetty. In 2009 the Wall Street Journal referred to him as “the Henry Ford of Heart Surgery”.

In a similar way Henry Ford used large factories and mass-production techniques to manufacture a large number of quality cars, which many ordinary people could afford; so, Shetty developed large hospitals and a significant skill base, which he used to improve the quality of surgical procedures and reduce costs. This enabled him to offer large numbers of people access to affordable high-quality healthcare.

NH doctors, who are on fixed salaries, work in teams. Each team comprises a specialist, a number of junior doctors, trainees, nurses and paramedics. A bypass surgery typically takes about five hours. The actual grafting, which is the critical part, takes only an hour and is performed by an experienced specialist surgeon, while harvesting of the veins/arteries, opening and closing of the chest, suturing and other procedures are carried out by junior doctors. Nurses and paramedics handle the preparation and the aftercare of the patient. This Henry Ford-type process leaves the specialist free to perform more surgeries. As the volume of surgeries increase, outcomes improve, and costs are reduced. A heart surgery at NH costs less than US$2,000 per operation.

NH’s lower costs have not come at the expense of quality. Narayana’s mortality rate for coronary artery bypass procedures is 1.27% and its infection rate 1%, which are as good as that of US hospitals. Incidence of bedsores after cardiac surgery is anywhere between 8% and 40% globally, whereas at NH it has been almost zero in the last four years.

It can’t be done!

“When we started our journey, we were discouraged by people saying that, ‘there is no such thing as low-cost high-quality healthcare’, and that ‘healthcare is expensive and will always be expensive’. Only when people become wealthy, they can afford quality healthcare . . . . . When I grew up, I looked at some of the richest countries in the world, struggling to offer healthcare to its citizens and quickly realized that even if India became a rich country, it still would not be able to guarantee healthcare to everyone. We had to change the way we were doing things and this is what we’ve done,” says Shetty.

Socializing the P&L

UK doctors and health providers often talk about reducing the costs of healthcare, but, says Shetty, “doctors usually have no idea how much they are spending”. In contrast, at noon every day all NH doctors receive an text with NH’s previous day’s revenue, expenses and EBIDTA (earnings before interest, depreciation, taxation and amortization). According to Dr. Ashutosh Raghuvanshi, NH’s CEO, “When you look at financials at the end of the month, it’s a post-mortem. When you look at them daily, you can do something to change things”. The daily data doctors receive describes their operations, and the various levels of reimbursement. “It’s not just a cheap process, it’s effective,” says Raghuvanshi.

In the video below Shetty suggests that a key factor for the future success of NHS England will be its ability to re-invent itself, increase its focus on costs and outcomes, benchmark key functions with successful international comparators and instil strict financial discipline in doctors, “because they represent the biggest spend in healthcare systems,” says Shetty.

(click to play the video)

Information technology

Healthcare systems require radical change at every level in order to reduce the vast and upward trajectory of unsustainable costs, improve patient experiences and outcomes, speed the translation of research into therapies and make healthcare accessible to everyone. Information technology helps in these regards. NH regularly mines data to raise the quality of care and patient outcomes. Its business intelligence activities manage real-time data on 30 different parameters that track and support efficiency improvements. Those related to clinical outcomes are then reviewed at a weekly meeting, where all major clinical procedures are discussed among doctors and best practices shared. This way NH maps the cost effectiveness of each doctor.

PART 3

Affordable quality healthcare outside India

An example of Shetty’s model of affordable quality healthcare working effectively outside of India is Narayana Health Cayman Islands. The Cayman government has given Shetty a 200-acre site and New York investors have backed him to develop and operate a Health City. In 2014 NH opened its first phase, a 130-bed tertiary hospital targeting the elective surgery markets of North and South America. “Narayana Health City Cayman will demonstrate how over-priced and inefficient US hospitals actually are and show that lower costs and better outcomes can be achieved outside of India just as well as in Bengaluru,” says Shetty.

The UK

There are numerous barriers to adopting the Shetty model in the UK and in other developed economies. NHS England has its innovators and there are efforts to roll-out innovations nationally, but they have limited success, mainly because innovations tend to be isolated and local and not widely known across different NHS functions or beyond sector boundaries. The lack of centralised expertise in NHS England skews perspectives and limits resources. This presents a significant obstacle to the adoption of compelling healthcare innovations, such as those demonstrated by Narayana.

Further, there is doctor-resistance to innovations in the UK. Doctors are trained to identify and implement proven and recommended treatment protocols for various disease states. To deviate from this is to run the risk of litigation. Further, health professionals in the UK are increasingly time-pressed, with the result that acquiring and adopting new and innovative pathways of care takes a back seat. See, Meeting the challenges of affordable quality healthcare . and, The end of doctors.

Medical tourism

"Medical tourism" refers to traveling to another country for medical care. The world population is aging and becoming more affluent at rates that surpass the availability of quality healthcare resources. In addition, out-of-pocket medical costs of critical and elective procedures continue to rise, while nations offering universal care, such as the UK, are faced with ever-increasing resource burdens. These drivers are forcing patients to pursue cross-border healthcare options either to save money or to avoid long waits for treatment.

In 2015 it was estimated that the worldwide medical tourism market was between US$50bn and US$65bn and growing at an annual rate of between 15%-25%. In 2015 some 1.5 million US residents travelled abroad for care, up from 0.5 million in 2007. Two of their top destinations were Costa Rica and India. Costa Rica can yield savings on standard surgical procedures of between 45% and 65%, and India, between 65% and 90%.

Beyond the US, the OECD estimates that there are up to 50 million medical tourists worldwide annually. The most common procedures that people undergo on medical tourism trips include heart surgery, dentistry and cosmetic procedures. People are attracted to well-known, internationally accredited hospitals, which have a flow of medical tourists, internationally trained experienced health professionals, a sustained reputation for clinical excellence and a history of healthcare innovation and achievement.

Already, NH attracts medical tourists from over 50 countries, it has an international reputation for excellence, many of its top health professionals have been trained and have gained clinical experience in the US and Europe and it has a significant track record in high demand areas, particularly heart surgery. This suggests that NH is well positioned to take advantage in the future growth of medical tourism and this is probably something taken into account by NH’s anchor investors.

Africa

Because of entrenched obstacles to change in the healthcare systems of developed economies, Shetty has indicated an interest in Africa. In the past, private healthcare providers have neglected African healthcare; it has been underserved by governments, and mostly reliant on irregular help from abroad. However, this is about to change, and there is some evidence to suggest that healthcare reform in Africa is beginning. A 2016 African Healthcare Summit suggested that African healthcare spending is expected to grow to 6.4% of GDP in 2016, making it the second highest category of government investment. A Report from the International Finance Corporation (IFC) of the World Bank suggests that, over the next 10 years, there will be, “considerable African demand” for investment in hospitals, medicines and health professionals and meeting this demand, “can deliver strong financial returns.”

Healthcare providers also can take heart that a number of African countries are trying to establish or widen social insurance programs to give medical cover to more of their citizens. Further, there are six African countries with projected compounded annual growth rates (CAGR) for 2014 through 2017 of between 7.12% and 9.7%. These are: Rwanda, Tanzania, Mozambique, Cote d’Ivoire, the Democratic Republic of the Congo, and Ethiopia.

Notwithstanding, Africa is facing a dual challenge of communicable and parasitic diseases such as malaria, TB and HIV/AIDS and growing rates of chronic conditions such as diabetes, hypertension, obesity, cancer and respiratory diseases. Increased urbanisation in many African countries, along with growing incomes and changing lifestyles, have led to a rise in the rate of chronic conditions, which are projected to overtake communicable diseases as Africa’s principal health challenge by 2030. This suggests that despite the fledging signs of change, over the next decade African healthcare will still be challenged. However, over the past 15 years, NH’s has demonstrated capabilities to meet and overcome similar challenges in India, which positions it well to succeed in Africa where it already has a non-trivial telemedicine presence.

Training health professionals

The healthcare and wellness sectors are positioned to be significant drivers of the world economy in the 21st century. Healthcare is about a US$6 trillion global market, which is increasing. Advances in medical technology, public health and governance have improved healthcare for about 30% of the world’s population. But billions of people still have no access to healthcare.

The WHO estimates that there is a shortage of nearly 13 million healthcare workers globally, but Shetty believes these shortages could be significantly higher. According to the Royal College of General Practitioners the shortage of doctors in the UK is the worst it has been for 40 years. One hundred primary care practices, serving 700,000 patients across Britain, are facing closure and the number of GP-patient consultations is estimated to rise from 338 million in 2013 to 441 million by 2017. UK experts warn that primary care doctors with too many patients will fail to provide adequate healthcare through current delivery methods and they say that this is expected to further drive patients to search online for health-related issues. See: Curing the Problems of General Practice.

Such shortages concern Shetty, who believes that the situation will only be improved with a radical change in the way healthcare is delivered. “This”, says Shetty, “will only be achieved with a change in the way health professionals are trained.” Future health professionals need to be trained for a world of e-patients. Digital classrooms will create new connections between students and health professionals and allow for access to the most current information and resources. Shetty advocates the development of a virtual global medical university, with features that include a cross-country curriculum and a reduced training period. “This is the only way we will increase the much-needed pool of healthcare talent,” says Shetty.

Takeaways

While change in Western healthcare systems will neither be quick nor easy, NH’s near to medium term growth will most probably come from India, the Caymans, Africa and other developing countries where the need for quality healthcare is high and growing fast, and the barriers to entry relatively low. In time, however, the US and the UK might be able to benefit from some of Narayana’s best practices so that an increasing percentage Americans may have access to high quality affordable healthcare and NHS England maybe reformed to ensure its survival.

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9 years, 3 months ago

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Is patient engagement the new blockbuster drug?

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Is patient engagement the new blockbuster drug?

Patient engagement improves outcomes
The future is not a continuation of population based medicine
Personalized medicine requires effective patient engagement
Doctors are the main obstacle to enhanced patient engagement

If patient engagement were a drug, it would be front-page news, and malpractice for doctors not to use it. A significant and growing body of opinion believes that an effective way to scale care, and enhance outcomes is to develop patient engagement, but this requires a cultural and behavioral change on the part of doctors, which is not happening fast enough.

Low patient engagement means poor outcomes

Each year payers spend billions on treating avoidable chronic lifetime diseases, yet the incidence of such diseases continue to escalate inflicting devastating personal, and social hardships on people and communities. Some wealthy regions of the world, such as the United Arab Emirates, where diabetes is spiraling out of control, have invested in “cathedrals” of diabetes healthcare staffed by experts, but still do not have the costly burden of diabetes under control. See, Diabetes threatens the future stability of the UAE

Tackling causes

In other regions of the world, the treatment costs alone for avoidable chronic lifetime diseases are expected to bankrupt healthcare systems in the near future. The reason for this is simple. Despite eye watering investments in state-of-the-art treatment strategies, and despite some doctors’ initiatives to engage patients, no healthcare system yet has effectively engaged large proportions of patients living with lifetime chronic diseases, and successfully nudged them towards changing their diets and lifestyles, which are the root causes of a substantial proportion of such conditions.

Dr Seth Rankin Managing Partner of a London based NHS primary care clinic, describes his efforts to engage patients living with diabetes in order to improve outcomes:

(click on the image to play the video)

Behavioral techniques

Rankin’s endeavors to engage patients benefit from behavioral techniques, which explain how people behave, and encourages them to reduce unhelpful influences on their health, and change the way they think and act about important health related issues such as diets, lifestyles, screenings and medication management. See: Behavioral Science provides the key to reducing diabetes

“Our new pathway of care borrows from the behavioral sciences and engages patients living with diabetes. It’s based on very simple technology, which can provide huge reach at low cost. We are keen to extend our pathway to other NHS Clinical Commissioning Groups, and would welcome support from well capitalized diabetes agencies,” says Rankin.

Doctors’ support critical

Rankin insists that, “Only when patients are meaningfully engaged in their own health will they continuously learn how to improve care for themselves”. Effective patient engagement enhances the connectivity between doctors and patients, and is a sound foundation for behavioral change. However, for patient engagement to be scalable and effective, it has to be supported by appropriate IT, and patient-generated healthcare information.

Doctors control patient engagement

Patients gather healthcare information from the Internet, and this encourages and supports self-management, and enhanced understanding of prevention and risk. However, the quality of online healthcare information is patchy, and patients have difficulty differentiating between legitimate and bogus information. This is resolved when doctors’ engage with patients to help them with the interpretation. Some doctors welcome this opportunity, while others object. This gives doctors the upper hand. Even if the situation is improved by enhancing patients’ access to premium and reliable medical information, doctors still decide whether such information is introduced into patient care pathways.

Improved healthcare

Objections from doctors suggest that online health information results in longer and fraught doctor-patient relationships, which are a costly waste of time. But this is not necessarily so. Evidence, such as that published in 2008 in Telemedicine and eHealth, suggests the opposite: that patient-generated healthcare information, and effective patient engagement can lead to better understanding of specific conditions and treatment options, enhanced medication management, reduced complications, reduced face-time with doctors, and reduced visits to A&E. Specifically, the 2008 paper’s findings report that online healthcare information resulted in: (i) 19.74% reduction in hospital admissions, (ii) 25.31% reduction in bed days of care, and (iii) 20 to 57% reduction in the onset of complications.

Takeaways

Despite evidence to suggest that patient engagement enhances outcomes and reduces costs, it is not happening at a rate and quantum to render it effective. The main obstacle is the attitudes of doctors who fear an erosion of their status. Only a significant cultural and behavioral shift on the part of doctors will change this, and open the door to the many other professional disciplines, such as behavioral economists, software designers, community leaders, data scientists and risk managers, who are well positioned to help healthcare and medicine deliver better outcomes for patients.

The future of healthcare is not a continuation of population-based medicine with its one-size-fits-all therapies mediated by general practitioners. The future of healthcare is personalized medicine, which recognizes that patients and medicines are complex and adaptive, which require smart and adaptive systems. This includes greater patient engagement.

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9 years, 3 months ago

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The end of doctors

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The end of doctors

A second technology revolution threatens the future of healthcare
Healthcare systems that ignore evolving technologies will collapse
Most healthcare systems are trapped by three basic failures
Doctors are the interpreters and not the processors of medical knowledge
Will a computer decide to turn off a life support machine?
Who owns the medical information on the Internet?

The role of doctors is about to change more than it has in the past two centuries, as the technology revolution enters a new era.

Radical change

This is the conclusion of Richard and Daniel Susskind in their book, The Future of Professions, published on 22^nd October 2015 by Oxford University Press. They argue that, over the next 20 years, “the second future”, dominated by artificial intelligence (AI) and the Internet, will drive radical changes in healthcare systems, which will involve the transformation of how medical knowledge is made available.

Today, computer systems can delve into vast amounts of patient data, identify trends and make more accurate predictions than doctors. Machines such as IBM’s Watson, which can attain high levels of intelligent behavior is already being used in medicine. In parallel, the Internet provides people with new and effective ways to build communities and share healthcare information.

Never too big to collapse

Some doctors argue that their activity will never change because it depends on deep expertise, creativity and strong interpersonal skills; none of which can be replaced by computer systems. Earlier, managers of global companies that dominated world markets made similar claims before there enterprises grew obsolete and collapsed.

Twenty years ago, the failure of global companies to meet transformational challenges resulted in 74% of them leaving the Fortune 500 as new technologies and innovations opened the way for agile start-ups and entrepreneurs. The list is long, but here are a few examples. Digital Equipment and Wang Laboratories, once leading computer firms, disappeared completely. Even resurgent giants such as Apple and IBM stared into the abyss of irrelevance, and made painful changes before clawing their way back to the top.

In the 1980s the advent of digital photography, software, file sharing, and third-party apps ended Eastman Kodak’s world market domination, during which time Kodak made breakthrough technologies, which included the Brownie camera in 1900, Kodachrome colour film, the handheld movie camera, and the easy-load Instamatic camera. Motorola, another global giant, that developed and built the world's first mobile phone, and dominated that market until 2003, failed to focus on smartphones that could handle email and other data; and as a consequence, rapidly lost share to newcomers such as Apple, LG, and Samsung.

Dr Devi Shetty, world-renowned heart surgeon, founder, philanthropist, and chairman of Narayana Health, India’s largest hospital group is viewed as the person who will have the biggest influence on 21^st healthcare. Here he describes how information technology is set to radically change healthcare:

(click on the image to play the video)

Healthcare systems not immune

The Susskind’s agree with Shetty, and believe that healthcare systems, predicated upon antiquated patient-doctor technologies, face a similar demise to that of large companies that failed to adapt and change. The more successful healthcare systems will be those, that copy large companies who survived by collaborating with smaller, agile firms either as suppliers or partners. Rigid bureaucratic healthcare systems that find it more difficult to innovate will fail.

Three reasons for failure

Failure to address three major challenges accounts for the failure of most healthcare systems. The first is the continued investments in failing antiquated systems, and the consequent failure to pursue fresher, more relevant ones. The second is psychological: healthcare systems and doctors fixate on what made them successful in the past, and fail to notice when something new is replacing it. The third challenge is strategic: healthcare systems that only focus on today, and fail to anticipate the future will fail.

Previous HealthPad Commentaries have illustrated these three failures by the billions spent on failing diabetes education programs over the past decade, while the incidence of the condition escalated. This is because diabetes education and awareness programs fixate on antiquated systems, and fail to embrace, smarter and more effective ones. See: Behavioral Science provides the key to reducing diabetes

The concentration of medical expertise

A doctor’s raison d'être is to provide solutions to problems that people do not have sufficient specialist knowledge themselves to solve. Previously doctors were the ‘processors’ of medical knowledge, but with medical information becoming ubiquitous, increasingly doctors are becoming the ‘interpreters’ of medical knowledge. Doctors are gateways to specialist medical information.

In most healthcare systems, doctors are a huge and increasing expense, a large proportion of them use antiquated methods, and the expertise of the best doctors is only enjoyed by a few. This is changing by technological innovators finding ways to make medical expertise more widely available. Also, technology is enabling clinical expertise to be broken down into smaller tasks, which can be better achieved with a machine; telemedicine is just one example.

Who owns medical knowledge?

Online healthcare information empowers patients and threatens doctors by providing people with medical knowledge that previously resided in the minds of doctors. Such knowledge, which can help to diagnose illnesses, is free, increasingly common, and controlled by users. An important unresolved question is, who owns this medical knowledge?

Takeaways

Doctors exist to provide solutions to medical problems. If technology provides better more reliable solutions, the need for doctors dissolves. However, the most convincing objection for the displacement of doctors is an ethical one. Is it morally wrong to leave the decision to turn off a life support machine to another machine?

The debate is just beginning.

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9 years, 3 months ago

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The convenient quality healthcare revolution

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The convenient quality healthcare revolution

Demand for primary care services outstrips supply
People want affordable convenient, quality healthcare
The retailization of healthcare is large and growing fast
US Minute Clinics in CVS retail outlets expect 6 million visits in 2015
Traditional health providers can’t stop the convenience healthcare revolution, but they can encourage it

“It” is larger, and growing faster than most people think. “It” is driven by the combined burdens of heightened patient expectations, disproportionate growing and ageing populations, and finite resources. “It” will significantly impact healthcare systems throughout the world. “It” . . . . is the ‘retailization of healthcare’, which uses pharmacists, and nurse practitioners to provide a range of healthcare services in diverse retail locations.

A convenience revolution

In 2010, Rite Aid, the US retail pharmacist, partnered with American Well, a company providing online access to doctors 24-7; 365 days a year, to test a service, which allows consumers to interact directly with Rite Aid pharmacies for medication advice, and results in an electronic record, which is shared with primary care doctors.

Larry Merlo, the CEO of CVS, the second largest drugstore chain in the US, which has 100 million customers each year, is leading the charge to create more healthcare services in CVS stores. Already, CVS has 960 walk-in Minute Clinics staffed by pharmacists and nurse practitioners. The clinics are open on nights and weekends with no appointments. Prices are between 40% to 60% lower than traditional US doctors, and a fraction of the cost of A&E. This year, Minute Clinics expect some six million visits, and CVS plans to open a further 500 such clinics by 2017. In 2014, at CVS stores, more than 700 million prescriptions and five million flu injections were administered.

Walgreens, the largest drug chain in the US with 8,217 stores in 50 states, has also set-up healthcare clinics, and similar initiatives, are afoot in the UK. These, together with other retail initiatives, constitute a convenience revolution in healthcare.

“US and UK healthcare systems will go bankrupt if they don’t change their current healthcare delivery models,” says Devi Shetty, world renowned heart surgeon, founder and chairman of Narayana Health, India, which provides affordable quality healthcare.

(click on the image to play the video)

Adherence to medication

People like the fact that pharmacists are accessible friendly health professionals, and over time grow trusting, personal and valued healthcare relationships with them, which enhance adherence to medications. Non adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300 billion, and results in 125,000 deaths every year.

Rajiv Dhir a senior prescribing pharmacist working for NHS England describes the importance of patients being able to discuss their drug regimens with pharmacists:

(click on the image to play the video)

Primary care environment

In the UK and elsewhere the demand for rapid and convenient primary care, outstrips it's supply. For instance, the UK is experiencing an exodus of GPs. In just five years, 40% have left to work abroad, and around 22,400 GPs – more than half of England’s 40,200 family doctors – want to retire before the usual age of 60. Younger doctors are not filling the gaps, with up to one in eight GP training posts unfilled. They are instead either choosing careers as hospital specialists or going to work abroad. Today, some 1,063 GPs are needed in England just to return to the patient-doctor ratio of 2009.

Coordination between primary and secondary healthcare

Walk-in retail clinics can provide a valuable link between primary and secondary care. CVS has partnered with over 50 secondary health providers including the Cleveland Clinic, which offer their Minute Clinics follow-up services, and answer questions a nurse practitioner might have over the telephone. Such relationships are well positioned to be enhanced by increased electronic sharing of patient data.

Takeaway

Traditional health providers can’t stop the convenience healthcare revolution, but they can encourage it.

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9 years, 3 months ago

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Expanding the role of community pharmacists

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Expanding the role of community pharmacists

As efforts to integrate community healthcare falter, access to primary care becomes more difficult, and A&E departments become over-burdened with minor aliments, increasing attention is being paid to innovative ways to mine the vast, and easily accessible clinical expertise of pharmacists in order to increase the quality of healthcare and reduce costs.

An untapped reservoir of clinical excellence
Various reports describe how patients are increasingly tapping into the professional expertise of community retail pharmacists. However, the vast reservoir of pharmacists’ clinical knowhow and expertise is not optimally utilized in the provision of healthcare, and is not fully appreciated by the general public and healthcare providers.

An underutilized clinical knowledge bank
Pharmacy is the third largest health profession in the UK, with universally available and accessible community services. In England about 6,000 pharmacists work in hospitals, some 3,000 are employed in the pharmaceutical industry, and about 32,000 work in 13,000 community retail pharmacies. All are highly trained graduates, who have undergone competency training, and a registration examination, which enables them to practice.

Access
In contrast to GPs, pharmacists have a significant high street presence, and long opening hours. They are also open at weekends, and no appointment is required for their services. According to a 2014 Royal Pharmaceutical Society report, 99% of the UK population can reach a pharmacy within 20 minutes by car, and 96% by walking or using public transport. Community retail pharmacists help people stay well, and use their medicines effectively. Each year, the NHS spends some £12bn on medicines; £100m of which is wasted on their ineffective use.

A 2014 Care Quality Commission review of 8,000 GP surgeries in England, uncovered overly long wait-times for appointments, and poor care of the elderly. Forty per cent of GPs questioned in England by the magazine PULSE, said that they expected two-week wait-times for non-urgent appointments in 2015.

Expanded role of pharmacists
Pharmacies are extending their services to patients’ homes, residential care, hospices, and primary care offices. This provides a significant opportunity for healthcare systems.

Pharmacists can play an expanded role in out-of-hours primary and urgent healthcare, and are well positioned to raise disease awareness, deliver educational information at multiple points of contact, and offer sexual health services. In 2013, more than 16,000 free Chlamydia tests were carried out in pharmacies. In 2010 NICE recommended that pharmacists should offer a full range of contraceptive services to tackle the exceptionally high under 18 conception rate in England.

However, the core business for 21^st century healthcare systems is to meet the large and growing needs of people with life-long chronic conditions, such as diabetes, cancer, heart disease, and respiratory conditions. Community retail pharmacists are well positioned to monitor and manage such conditions to alleviate their symptoms, and reduce the need for invasive, costly and disruptive interventions. This role would be significantly enhanced if pharmacists had access to patient records.

Takeaways
There is an urgent need for community retail pharmacists to expand their range of clinical services. Working with other health professionals, pharmacists have an expanding role in optimizing the use of medicines, providing a national minor ailment service, and playing a larger role in the on-going management of patients with long-term chronic conditions.

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10 years, 3 months ago

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Healthcare trends in 2015

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In 2015 expect increasing healthcare challenges from (i) aging populations and rising chronic illnesses, (ii) escalating costs and patchy quality, (iii) access, (iv) changing technologies, and (v) security.

Aging populations and chronic illness
Aging populations and the escalating prevalence of chronic lifelong diseases, will drive demand for healthcare in 2015, and impose significant burdens on healthcare systems.

Europe has the world's highest proportion of people over 60. By 2017, 20% of Europeans will be over 65. By 2050 about 40% will be over 60. The US has similar trends. This aging and the increasing prevalence of chronic lifestyle diseases will continue to drive healthcare expansion, and pressure to reduce healthcare costs.

Escalating costs and patchy quality
According to the World Healthcare Outlook of the Economist Intelligence Unit 2014, total global health spending is expected to grow at over 5% in 2015.

In Europe rising government debts, constraints on tax revenues, and aging populations will force health providers to make difficult choices about the provision of healthcare. Rising demand, and continued cost pressures will increase pressure on traditional healthcare business models and operating processes to change.

Despite the expected annual productivity and efficiency savings of some 4%, UK healthcare expenditure in 2015 is estimated to be about 10.3% of GDP. In the absence of changes to the delivery model, the UK's NHS funding gap is likely to increase significantly in 2015.

In their struggle to manage the escalating healthcare costs, health providers will accelerate their transition from volume to value. This will mean a greater emphasis on improving outcomes while lowering costs. This will drive payers to seek out global best practices of delivering affordable quality healthcare such as Narayana Health.

Access
Improving access to healthcare will be one of the most pressing policy issues in 2015. Shortages of health professionals represent significant challenges in healthcare access, and healthcare systems will be pressed to recruit, and retain health professionals.The US is addressing this. US employment in healthcare increased from 8.7% of the civilian population in 1998 to 10.5% in 2008, and is projected to rise to 11.9% (nearly 20 million people) by 2018.

The UK is not in such a good position. In 2012 the UK had a shortage of 40,00 nurses, which it hasn't resolved. This is compounded by shortages GPs. Europe has an estimated shortage of some 230,00 doctors.

Increasingly, developed countries recruit health professionals from developing economies. The morality of this will be further questioned in 2015 as the policy significantly erodes the number and quality of healthcare professionals in emerging countries.

Changing technologies
The development of healthcare technologies has been rapid, and in some cases disruptive. Technologies such as telemedicine, electronic health records, mHealth, e-prescriptions, and predictive analytics have changed the way health providers, payers and patients interact, and contributed to improved quality of care, lower costs and improved outcomes. In 2015 expect the spend on healthcare technologies to slow.

Security
Reportedly, there is a growing and lucrative black-market for personally identifiable information, and personal healthcare information. Many healthcare organizations already have low security budgets, and only about 50% employ adequate encryption technologies to secure their endpoint data. Compared with other industries, healthcare experiences significant losses of endpoint healthcare data. Security challenges for the healthcare sector will accelerate in 2015.

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10 years, 5 months ago

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Lessons from an axed telehealth project

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Was the UK Department of Health (DH) right to axe its telehealth project?

Telehealth
Telehealth is a combination of medical devices and communication technology used to monitor diseases and symptoms, and support health and social care remotely. It represents a solution to the challenges of rising healthcare costs, an aging population, and the increasing prevalence of chronic diseases.

The Whole Systems Demonstrator Project
The DH's Whole Systems Demonstrator (WSD) project was an ill-conceived top-down endeavour doomed to fail. It cost £31m, and was the world's largest randomised control trial of telehealth involving 7,000 patients, 240 primary care practices across three UK sites.

3millionpeople
In 2011 an interim evaluation concluded that the WSD project could achieve a 45% reduction in mortality rates, a 15% drop in A&E visits, a 14% reduction in bed-days, and an 8% reduction in tariff costs.

These estimates are in line with international findings. Based on a review of some 2,000 studies, GlobalMed concludes that telehealth has reduced hospital re-admissions by 83%, decreased home nursing visits by 66%, and lowered overall costs by more than 30%. Nothing else has worked to reduce such costs.

It was projected that by 2017 three million people in England with long term conditions would be recording their medical data and vital signs remotely, and sending them, via email and text, directly to GPs. This could save the NHS £1.2 billion a year, and significantly enhance the quality of patient care.

GP's wrath should have been expected
Despite its projected success, the DH's telehealth project was quietly axed, following a London School of Economics (LSE) study, which concluded that the project, "does not seem to be a cost-effective addition to standard support and treatment", and GPs complaining of a "tsunami" of data.

Too much importance was given to the LSE study, and not enough to GPs. The DH failed to understand how to change a large healthcare system. As a consequence the UK telehealth project was a bolt on to a poorly integrated care system not adapted to telehealth, and was sure to incur the wrath of GPs.

Despite endeavours to train more GPs and expand community nurses, there is abundant evidence to suggest that GPs struggle under large and growing workloads, and reports of stress and burnout are common. Not a group you would impose change upon from the top.

A human system which uses technology
The DH wrongly viewed telehealth as a technology system, and healthcare as a machine with processes and activities that delivers services to patients. Telehealth is a human system, which uses technology.

Health professionals, patients and their carers are the essential tools of telehealth. As they become more experienced in collecting, analysing and acting upon the information they receive from telehealth devices, so they become more integrated, and patients benefit and cost effectiveness increases.

Lessons for the DH

Healthcare is an organic system comprised of people operating in a context
Change is non-linear
GPs are not commodities on which to impose change from the top, but sources of power, which can bring about change
Seeds of change should have been planted with GPs who perceive change as an opportunity for personal development and growth.

Takeaway
The DH was right to axe its badly conceived telehealth project, but would be wrong to withdraw its support for telehealth.

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10 years, 6 months ago

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Healthcare Unplugged: Curing the Problems of General Practice

Gordon Moore

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Gordon Moore
Professor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand. In the UK, spotty shortages exist now, but will become widespread over the next decade.

The causes of rising clinical demand are well known:

Continued growth of the things medicine can do
Surge of lifestyle diseases
Burgeoning patient devices that collect data and require monitoring by clinicians
Increased public expectations for access to GPs
Aging of the population
Emergence of multiple, complex chronic illness
Diversion of GPs to management activities such as commissioning

Little analysis of root causes
Less is known about the underlying causes of the shortfall of supply in GPs.   The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers.   The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better. In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns
I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”. First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style.   Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.

Lifestyle challenges
There is little evidence that medical students will select GP careers if they earned more. In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice. In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care.   At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference.

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else. Without fixing this, throwing more money at the problem is unlikely to reverse the trend.   Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.

Multi-purpose teams failing
The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver. Recent studies (see: Friedberg M.W., 26^th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower.   Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer
As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”. No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model.

Adopt best practice
What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients? Surely, we can draw lessons from other industries. Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support.

The role of technology
Digital infrastructure for general practice has failed to keep up with the rest of the world. The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do.

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying.   It is time to invest in true infrastructure innovation in the NHS. It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.