The Future of Healthcare CITRIS Research Exchange September 13, 2006
Ravi Nemana Executive Director, Services: Science, Management & Engineering Center for Information Technology Research in the Interest of Society (CITRIS)
Ruzena Bajczsy, Shankar Sastry, Mike Eklund
Outline Î Brief Introduction Î Where are we headed? ►
Challenges & Trends in Healthcare ► Role of Information & Communications Technology (ICT) ► Role of Technology Innovation and Service Innovation
Î What can we do?
How CITRIS efforts come together in Healthcare ►
Ubiquitous, embedded sensing ► Elder care ► Security and Trust in health care systems ► Services: Science, Management, & Engineering
Î What does the future hold? ►
Services in Healthcare ► Healthcare ICT Services Innovation Center
Î Questions
September 13, 2006 2
Trend: Healthcare Demographics Age Distribution of the US Population Source: 2000 US Census
50,000,000
Age groups where care burden is greatest
45,000,000 40,000,000
Population
35,000,000
Population shift will increase care burden
30,000,000 25,000,000
2.5X
20,000,000
Current workforce shortages pose difficulty with care burden at this level
15,000,000 10,000,000 5,000,000 0 85 and over
75 to 84
65 to 74
55 to 64
45 to 54
35 to 44
25 to 34
15 to 24
5 to 14
under 5
Age (in deciles)
B. Lowensohn, Kaiser Research
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Trend: Healthcare Workforce
Total Medical School Matriculations -- 1994 to 2005 18,000
# S tudents / year
16,000
y = 56.35x + 16021
14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1994
1995
1996
1997
1998
1999
2000
Year
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2001
2002
2003
2004
2005
Sources: CDC, NCHS & AAMC
Trend: Worldwide age wave is coming 2002
2050
Percentage of Population over 60 years old Global Average = 10%
Percentage of Population over 60 years old Global Average = 21%
SOURCE: United Nations ▪ “Population Aging ▪ 2002”
Table compiled by the U.S. Administration on Aging based on data from the U.S. Census Bureau.
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Courtesy Mike Eklund
Trend: Elder care is returning home again Home “grandma”
Poor Houses / Almshouses “pauper”
Insane Asylum “inmate” Only way to save costs but increase quality is via home care (includes self care). Home care is fastest growing segment of health industry.
Productivity of Home Care services is poor.
of e l Ro ial soc tions! nec n o c
Home “grandma”
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Assisted Living “resident”
Nursing Home “senior citizen”
Hospital “patient”
Trend: Parent Support Ratio: 1950-2050
As the number of elderly needing care increases, the number of potential caregivers decreases. Today, 1 in 4 U.S. families care for an older adult.
30 25 20 15
No. +85
10
Persons 85+ per 100 people 50-64 years old
5 0
Source: U. S. Census
1950
1990
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By 2005, nearly 40% of U.S. workers will be more concerned caring for a parent than a child.
2010
2030
2050
Trend: End-Stage Care Evolves into Long Term Management Advances in Care… ►
Organ Assistance and Substitution Bioartificial kidney Closed loop artificial pancreas (Xeno) transplants Cardiac assists Genetic testing and tailored therapies Gene therapy-- cardiac and cancer Drug delivery systems: Stem cell therapy on the horizon ■ ■ ■ ■
► ► ► ►
... Lead to longer and better quality of life... … but higher costs ► Increased demand on delivery systems and clinical care personnel ► Increased role of technology Cardiac replacement with a total artificial heart as a bridge to transplantation. Copeland JG, et al. N Engl J Med. 2004 Aug 26;351(9):859-67.
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Trend: Cancer is Tamed but Not Conquered Î
New rules of engagement ► No longer a matter of winners and losers and at any cost (old paradigm of cytotoxic chemotherapy) ► Instead, opt for a negotiated truce by longterm treatment and lengthening quality survival ► Cancer “survivors”
Î
Cancer Æ chronic disease ► like diabetes, cardiac rhythm disorders, and osteoarthritis.
Î
Advances: drug delivery, imaging, genetic testing, pharmaceuticals, IT, MIS, nanotechnology
Î
Earlier, more accurate diagnoses; better staging; improved outcomes
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Trend: Shift to Earlier Intervention Drive Delivery System Reconfiguration The Tools: Î Faster, smaller imaging devices Î Biomedical sensors Î Point-of-care diagnosis Î Genetic testing, profiling Î PACS and CAD Î Remote health services Î Data capture, transmission and response
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Trend: Blockbuster Drugs Wilt as Customized Therapies Blossom Factors Driving Customized Therapies: Î
Loss of patent protection for portfolios
Î
Genetic testing
Î
Diagnostic and therapeutic targets
Î
Increased role of imaging
Î
Fragmented and smaller target populations
Î
Higher risk, lower yield for developers
Î
Genotype tailored therapy for many conditions
Î
Targeted gene therapy
Î
In conjunction with implantable sensors
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Trend: Smarter, Smaller Surgical Devices Drive Volume to MIS Where is the growth occurring?
Surgeons no longer need to directly see nor touch the tissues on which they work. MIS moving toward using natural body guides and orifices for access. Open Areas: - Dexterity improvement - Networked OR - Micro-robotics - Auto and remote navigation for diagnosis and treatment - Energy-based surgery
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MIS Procedures: Î
Pain, discomfort, disability, or other morbidity more often results from the trauma involved in gaining access than the actual surgical procedure itself.
Î
Hospitalization is more often to recover from the trauma caused by accessing the surgical site than the actual procedure itself.
Î
Tremendous productivity and cost gains result from MIS, for both physicians and hospitals Æ Adoption
Mack, M. J. JAMA 2001;285:568-572.
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Trend: Patients Accept “Bionic Man” Model o
n
p q
q
r n o r u tr u vr w u
r v t
r
s u
September 13, 2006 14
s p
w
Trend: Convergence of Sensors and Jewelry
Language Xlator (CMU)
Body Gateway (NASA)
Pulse oximetry Blood Press. (MIT) Cell Phone as gateway Fashion addresses the stigmata of care Patients: bearing greater costs of care– for self and for family members Self care is a real possibility September 13, 2006quality, productivity, Approaches that address 15 efficiency and timeliness are needed.
Courtesy Paul Wright
Trend: Liquidity of Information Changes Dynamics of Care Factors Driving Access to Care: Î For Clinicians: New modes of operation ► ► ► ► ► ►
Orders, medical record, results, images Evidence Bases Æ Payment ripples Patient communications (RPM) Billing and payment information Æ Spy v. Spy with Payors Language Interpreting New Risks of medical practice
Î For patients: Revolutionary change ► ► ► ► ► ► ► ►
Web-enabled access to the physician Access to their medical record Financial settlement Communication & Research ability Early intervention to prevent acute episodes Second opinions / review evidence-based studies Increased participation in decision making 24/7 access to care and services
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Sehda, Inc
Trends: ICT central to Health Care Nearly all medical technologies will transmit something…. ► an image ► a report ► a point of data … and IT will capture, process, sort, send and store these streams. Decouples diagnosis & treatment Separates “brainpower” from “manpower” Integration into daily life, new sites of care The Future: IT will consult, broker, predict, suggest, and act on your behalf ►
E.g. IT as “traffic cop”
The Challenge: integrate these into the service processes of healthcare September 13, 2006 17
Trend: IT and Pharmacy / Lab Robots Robots that carry out simple, repetitive tasks with precision and accuracyÆ Automation
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Trend: Service Innovations– Out-tasking Task-specific robots that function to help automate the care delivery processÆ Labor Arbitrage
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Trend: Service Innovations– Robots Robots that aid surgeons and rehabilitative therapists in the delivery of care to the patientÆ Productivity & Outcomes Improvements
MIT Stroke Rehabilitation Robot
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UCB/UCSF Laparoscopic Telesurgical Workstation
Domestic Robots Robots used for the delivery of healthcare in the home or assisted living facilitiesÆ Unclear
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Other Service Innovations: Remote Presence Î Expansion of eICU concept Î Robotics + Remote Presence
Æ New models of care Î Ancillary services
The Challenge: Navigation
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Trend: Workforce Shortages Only Soothed by Technology Deployment An increasingly instrumented world… Î
Sensors for monitoring embedded in patient beds
Î
Point-of-care testing
Î
Monitors with direct download to medical record
Î
Slow release implantable drugs
Î
Inhalable opioids
Î
Closed loop implantable devices
Î
Smart systems for provider alerts
… increases the Noise-to-Signal ratio!
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Bottom Line Health care is a service … ► ►
Heavily knowledge and information dependent Highly customized, co-produced delivery
… and full of services problems ► ► ► ► ► ► ► ► ►
Labor force productivity Service supply chains Appropriate automation, outsourcing / out-tasking Coordination of services Service levels & quality provision Service engineering Service innovation and scaling services Information processing, engineering, and visualization Demand Management
NAE + IOM: “Building a Better Delivery System”
… for which science, engineering, and management offer possible solutions Î Technology Innovation AND Services Innovation ► ►
New tools to care for patients and New ways to increase capacity in the health care system
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Trends: An Historical Context
Energy
+
Affordable Transportation
+
Standard Parts
Goods
The industrial / technological revolution helped us to perfect the art of making things of value.
Computing Power
+
Internet
+
Assets
Services *
Is there a “services revolution� underway to help us perfect the art of doing things of value? What does this mean for health care? With the help of Jean Paul Jacob
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What is SSME @ CITRIS? Î Services: Science, Management, and Engineering (SSME) is a new
academic curriculum and research area Î Aims to improve the performance of services by applying scientific,
engineering and management disciplines to the configurations of people, technology and business. Î Improves the predictability, productivity and quality of services Î Provides Berkeley graduates new skills and tools to contribute to,
participate in, and thrive in a services world. Î Is this a new science?
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SSME @ CITRIS / Berkeley Academic Advisory Board: Henry Chesbrough Robert Glushko Rhonda Righter Shankar Sastry AnnaLee Saxenian Paul Wright
Research
Curriculum
PROPOSED: HEALTHCARE ICT SERVICES INNOVATION CENTER September 13, 2006 27
Role of Services: Science, Engineering and Management ENGINEERING SCIENCE
Data & Information
MANAGEMENT
Knowledge
Value
Health care areas where SSME can help: ► ► ► ► ► ►
Information Security Services Decomposition, distribution, coordination, design, deployment Services Infrastructures and architectures Embedded Sensors & Telemedicine Information Processing, software, visualization Modeling and Simulation
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Example: Modeling and Simulation Î Problem: New services can’t be tried in a laboratory;
poor planning tools ► Result: trial and error, high labor cost, high inertia, poor scaling from pilots Î Approach: use modeling and simulation as a virtual
laboratory for health services and service lines ► Potential to reduce trial and error, adverse outcomes, and improve profitability Î Specific areas: ► Reynolds
number for modeling patient flows, health system disaster response (Recrit) ► Architectural Planning – virtual reality
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Example: Sensing the Environment
Fire Response
Vineyards Great Duck Island
Building Comfort, Smart Alarms
Elder care
Redwoods
Elder Care Factories
30
September 13, 2006 Wind Response Of Golden Gate Bridge
Soil monitoring
Example: The ITALH System Records continuous sensor data Fall Detection algorithms Radio communication (Bluetooth) Triggered Reporting
Nokia 6680, 6630, 9500
ts n e rim in e p an Ex ay c i w r r e e und sh- Am etting i s Finn r Care CA e , d a l E September 13, 2006 om n o 31 in S
Wearable Fall Detector
Fixed Sensors
Berkeley Telos Motes with sensors embedded in living environment
Security: TRUST Portfolio Integrative Research Project Themes ► ► ► Community Support Friends
Extended Family
Legally Authorized Reps
Immediate Family
Primary care Specialists
Patient Provider
Business Consultants
September 13, 2006
External accreditation orgs
Ancillaries
Claims Payer Fraud Processors Detection Subcontractor s Clearinghous Medical es Insurers Information Bureau
32
Internal QA
Clinical Trials Sponsor s
Admin. Staff
► ► ►
Secure Network Embedded Systems (Wicker, Mulligan leads) Identity Theft, Phishing, Spyware and Related Issues (Mitchell, Tygar leads) Electronic Medical Records (Sztipanovits, Bajcsy, Eklund leads) Trustworthy Systems (Wagner, Aiken, Reiter leads) Network Security (Joseph, Birman leads) Seedling Topics
Public Health
Society
State Licensure Law Enforcement
Boards
Bioterrorism Detection
Empower patients: National Security
Access to own medical records ► Control the information ► Monitor access to medical data ► Increase “liquidity of information” ►
From: Dan Masys: “The nature of biomedical data”
Trends and the Role of IT & SSME Shift to point of care (POC)
POC can be ANY location Capturing data, identification, location
New Devices
New data streams, real-time evaluation Security issues Language services
Info explosion & liquidity
New Approaches to care
Image / ICT dependent Data fusion required Productivity innovation ÆRPM
New Reimbursement
Patient safety & quality Evidence-Based Systems Report Cards
Workforce & Retention
Remote Access and Productivity Patient Experience Trust Retention
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New data presentation mechanisms Context-sensitive information Security & Safety issues Personal health records New Market Dynamics
Services Infrastructure Layer 3
Layer 2
Layer 1
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HEALTHCARE ICT SERVICES & INNOVATION CENTER • EHR and PHR sharing • Clinical Data acquisition • Evidenced based care / mgt. • Virtual service laboratories • Security and trust architectures • Policy languages • Social models of care • Aggregation of embedded sensing streams • Integration of new layer 1 tools • “Population care” tools • Imaging modalities •…
Major Healthcare Trends
█
Shift to Earlier Interventions Drives Delivery System Reconfiguration
█
Smarter, Smaller Surgical Devices Drive Minimally Invasive Surgery
█
Patients Embrace the "Bionic Man" Model
█
Cancer is Tamed but Not Conquered
█
Demographics, Disease incidence, and Workforce pressure costs
█
Elder care moves back home
September 13, 2006 35
█
End-Stage Care Transforms to LongTerm Disease Management
█
Liquidity & growth of information changes dynamics of care
█
Blockbuster Drugs Wilt as Customized Therapies Blossom
█
IT Takes Center Stage
█
Workforce Shortages Only Soothed by Technology Deployment
█
Sensors & Communications Infiltrate All Aspects of Daily Life
Services and Healthcare @ CITRIS Layer 3
Layer 2
Layer 1
September 13, 2006 36
HEALTHCARE ICT SERVICES & INNOVATION CENTER
The Bottom Line Î
Much of the technology on the horizon helps optimize existing capacity
Î
Re-engineering required for new capacity in the health system
Î
Central role for innovative Methods, Technologies and Tools ► ► ► ► ► ►
Î
Self Care Remote Patient Management Social Care models Consumer Devices and incentives Gaming & Entertainment Security
New Science: Services Science, Management, Engineering (SSME) at UC Berkeley ► Initiate
a new approach to jump start service innovation ► Promote multi-disciplinary talents, tools, methods, and skills in the workforce ► Expertise in reconfiguring healthcare components
September 13, 2006 37
Conclusions Î
Broad trends lead us to interesting combinations of technology and service innovation approaches ► ► ► ► ►
Î
Healthcare and Services are new major areas of focus within CITRIS ► ► ►
Î
Coordinating existing projects Supporting new projects HEALTHCARE ICT SERVICES & INNOVATION CENTER
Many cooperative efforts ► ►
Î
Services architectures Services decomposition and engineering Embedded sensors, imaging, information & communications technology Re-engineering the capacity of the health system Promote adoption through productivity gains
Within CITRIS and other Academic Centers With international research partners and corporations
Corporate and governmental partners and collaborators will be essential for large scale deployments and ongoing research and development
September 13, 2006 38
The Future of Healthcare
Ravi Nemana, MBA Executive Director, Services Science Center for Information Technology Research in the Interest of Society (CITRIS) University of California, Berkeley RNEMANA@citris-uc.org RNEMANA@eecs.berkeley.edu 510-642-1083
http://www.citris-uc.org/services http://ssme.berkeley.edu
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