Transcript Document

Top Ten Technology-Driven
Trends in Health Care
2004-2014
Annual Meeting of the University of
California Academic Business
Officers Group
Century City
April 27, 2004
Possible Reasons for Interest in
my Presentation
• Work in an AMC (AHC.)
• Work in a unit that’s part of a campus with
an AMC.
• Have an interest in the future of health.
because it has academic interest.
• Currently a patient.
• Consumer who will some day become a
patient.
Institute for the Future
Forecasting
Creating plausible, internally consistent,
and possible future scenarios in order
to make better decisions today: an
invaluable and irreplaceable context
for strategic planning.
Translating Research Into Action
An independent, non-profit research organization
www.healthtech.org
415-537-6974
524 Second Street
San Francisco, CA 94107
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Minimally Invasive Surgery
Drug Delivery Devices
Sensors for Monitoring
Organ Assistance and
Substitution
Stem Cells
Genetic Testing
Imaging
Tissue and Fluid
Bioengineering
PACS and CAD
Point of Care: Mobile
Computing
Networking
Cancer Pharmaceuticals and
Biologics
Technologies
• Anti-microbial Drugs
• Cardiovascular Drugs
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Remote Patient Mgmt
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Security Technologies
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Neuropharmaceuticals
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Gene Therapy
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Wireless Technologies
• Voice Recognition
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Clinical Trials
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Web Services
Framing Issues: 2004-2014
1. New Consumers: changing health care and
its providers.
2. Rising expenditures for HC driven by new
technologies and consumer demand.
3. Increasing specialization: a byproduct of
advances in medical technology, diffusion
of IT, and accessible information on
outcomes.
4. Workforce shortages.
1. One-half of America’s Adults
Qualify as New Consumers
1. College (1 year)
Analytical sophistication and
confident in making decisions
2. Cash
Disposable household income of
$55,000 (2004)
3. Connected by Computers
Ready access to the Internet.
2. Expenditures for Health Care as
% GDP
• $1.7b rising in 2003 to 15.3% of GDP
• Highest among industrialized nations (av. 7.5% for
the other 28.)
• Arbitrary cap of 15% considered “sustainable”?
• But, forecasts for 2011 are:
CBO and CMS-17% of GDP
Others-20% of GDP
3. Greater Specialization
• Specialty units and “centers of excellence”
within many hospitals.
• Free-standing specialty hospitals and
ambulatory centers defined by organ
system, disease or specialty.
• More sharply defined specialization within
departments, single specialty groups, and
hospital systems.
• Regionalization by default
4. Projected Shortages: Physicians
Anesthesiology Oncology
Gerontology
Gastroenterology
Cardiology
Hematology
Pulmonology
Intensive Care
Psychiatry
Urology
Nephrology
Radiology
Pediatric Specialties (an exception to serving
a rapidly expanding older population.)
And Also,
Nurses
Technicians
Bioengineers
Biomedical computer scientists
Pharmacists
Non-physician clinicians
Impact of New Technolgies on
the Workforce
1. Endovascular technologies create new
fields
2. Stents replace angioplasty, add to volume.
3. DESs replace bare stents: negative impact
on cardiac surgeons but expands
indications.
4. New neuropharmaceuticals and devices
for stroke create more volume
5. Computer-controlled magnetic-guided
catheters lower the bar for training
Shift to Earlier Decision #1
and Intervention
• Earlier diagnosis and management
• Test selection by sensitivity and specificity
to minimize time delay (R/O & R/I)
• Efficient: reduces anxiety and return visits
• More expensive tests may have lower total
“cost” (MRI vs. CT, PET/CT vs. MRI)
• Panel or a combination of tests may be
preferable (gene micro-array for diagnosis,
PET/CT over MRI for staging)
Shift to Earlier
Intervention: the Tools
#1
• Faster, smaller imaging devices
• Point-of-care diagnostic devices
• RPM (remote patient monitoring)
technologies
• Attached and implanted sensors,
physiologic and biochemical, that are
“smart” and self-reporting and wireless
• Molecular imaging (PET)
Smarter, Smaller Surgical
#2
Devices-MIS
Endovascular Technologies
(a disruptive technology)
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Stents, grafts, coils, balloons, debris baskets
Infusion of chemotherapeutic agents
Implantation of radioactive seeds
Delivery of growth factors, genes, stem cells
and antiangiogenic molecules
• Portal for chronic drug delivery
Percutaneous Mitral Annuloplasty
A
L
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Congestive Heart Failure
crimping the valve
Annular Ring Implant
Explant at 28 days
PVT Percutaneous Heart Valve
3D CT Angiography
Triple Play
1.Carotid stent placed to open carotid
artery
2.Concentric (MERCI) retriever used to
extract most of the clot
3.Intra-arterial tPA used to clear smaller
arterial branches
None of these is an approved therapy.
PAS•Port for Vessel Anastomosis
Confidential
PAS•Port: Acute Results
Hand-sewn
Confidential
Automated
CorCap Surgical Applications
CorCap only
Mitral valve repair/
replacement
CABG
Cerebral Aneurysm
Coiled Aneurysm
Tipping Point for Endovascular
Treatment of Strokes & Aneurysms
Barriers to diffusion were referral pattern (vs.
coronary angioplasty) and poor early
outcomes for balloon aneurysm occlusion
Drivers at the tipping point:
1. Evolution of Neurovascular Stroke Units.
2. Comparative information on published
outcomes and ISAT on surgery vs. coils
3. Trained # neurovascular interventionalists.
4. Technologic advances in image-guidance,
versatile detachable coils, and stents.
Radiosurgery
#2
“Radiosurgery for trigeminal neuralgia,
epilepsy, vascular malformations, acoustic
neuromas, multiple metastases and other
benign and malignant brain tumors is drawing
patients away from neurosurgery. In less than
10 years, the number of acoustic neuromas
treated by radiosurgery will exceed the
number removed surgically.”
CW, 2003
“Bionic Man”
#3
Implants and Transplants:
Joints
• Hip, now evolutionary (MIS)
• Knee (disruptive)
• Others (shoulder, digits, wrist,
intervertebral disc)
Stimulators
• Cardiac
• Nervous system (brain, spinal
cord and peripheral nerves)
“Bionic
Man”
#3
Pumps
Cardiac (LVADs, mechanical heart)
Drug delivery (insulin, chemotherapy)
Nervous system (morphine, spasmolytics,
GFs)
Grafts, Stents and Coils
• Cardiac (coronary artery, valves, other)
• Intracranial (stroke, aneurysms, other )
• Peripheral (gut, biliary, vascular)
“Bionic Man”
#3
Organ Assistance and
Substitution Devices
• Liver dialysis
• Artificial kidney
• Hattler intravenous
membrane oxygenator
the Hattler
Catheter
“Bionic Man”
#3
Newer generations of VADs will diffuse more rapidly
as they improve in function, size, and compatibility
Micromed DeBakey Axial Flow
Pump
#3
Cancer
• Treatment strategy is changing: #4
No longer a matter of winners and losers at
any cost (cytotoxic polychemotherapy)
Instead, opt for a negotiated truce by longterm treatment and lengthening quality
survival
• Accept cancer as a chronic disease.
• Containment through vaccines, antiangiogenesis, serial therapy, and new
multimodality approaches
Cancer
#4
Forecast of Important Technologies
• Conjugated monoclonal antibodies
• Molecular re-classification of cancer
• Molecular treatment based on rational drug
design and development
• Vaccines: preventive (ID) and therapeutic
based on molecular/genetic specificity, e.g.,
Provenge (Dendreon) for prostate cancer
(Jan. 12, 2004)
Molecular imaging (cell death)
Cancer
• Gene therapy: most act through immune
mechanisms and by use of RNAi
• Anti-angiogenesis and blockers of
metastasis as long-term strategies
• More effective delivery of radiation therapy
with IMRT (radiosurgery)
• Improved drug delivery, e.g., lipsomes,,
focused US, polymers, nanoparticles
• Palliative use of directed energy, e.g., RFA,
US, cryosurgery, radiosurgery
#4
Surgical Procedures Move Out of
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Hospital
• General Hospital : what’s left? serious trauma,
complex surgical operations (CA, NS, Ortho,..)
• Surgical Hospital-cardiac, spine, total joint
• Ambulatory Surgical Center– short term stay:
laparoscopic, spine, oncology, cath lab
• Ambulatory Surgical Center—same day: hand,
some spine, ENT, arthroscopy, oncology,
cosmetic, hip (?)
• Clinic/Office: urology, ophthalmology, oral
surgery, cosmetic, G.I., dermatology, oncology
Access to Healthcare 24X7
• Driven by demands for improved patient
safety, efficacy of care and communication
• Finally gaining agreement on standards for
data sets, medical record vocabulary and
format, record storage, and retrieval.
• Development of regional information
systems that can be accessed from secure
Web portals,pulling in information from
disparate sources, and displaying images.
#6
IT will Revolutionize Healthcare
Personalized Medicine
#7
• Reliance on genetic testing, proteomics
pharacogenomics, and molecular specificity
• Identification of diagnostic and therapeutic
targets for sub-groups of patients using
cancer markers (genomic and proteomic).
• Defining homogeneous but much smaller target
populations (Gleevec and EGFR’s)
• For Pharma, a new business model: greater risk
and higher margins, but with better outcomes
for patients (Genasense—untreated advanced
melanoma : antisense)
Theranostics
Theranostic applications fall into three general
categories:
1. Genetic predisposition diagnostics.
2. Theranostics that aid physicians in
selecting the proper drug and dosing of
that drug.
3. Clinical trials diagnostics.
Use of IT in Healthcare: # 8
Expanding and Wireless
• Wireless technologies enable information
access and data entry at any site
• Clinical data entry by voice, tablet,
keyboard or some combination widens
acceptance among physicians
• End to lost wheel chairs, infusion pumps
and patients (RFID)
• provides rapid access to clinicians and staff
Compensating for
Workforce Shortages
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Supporting Technologies
Wireless and networked systems
Integrated medical records
Web-based systems
Access anywhere, anytime
Sensor-based devices for home care
External sensors, e.g., vest, pouch, wrist
Algorithm-based chronic and post-acute
care monitoring
Inpatient Cardiac Services
#10
Causes of lower operating margins for
inpatient cardiac procedures
1. Payor push-back: employers and CMS hold
down costs
2. Image of hospital and physician/patient
expectations require painful choices to use
technologies with negative margins
(DESs, LVADs)
3. Rising salaries of nurses and techs
Inpatient Cardiac Services
Shrinking
#10
• Competition from ambulatory cath labs,
short-stay heart hospitals, and full-service
heart hospitals
• POC screening and imaging of patients with
acute cardiac events in the ED avoids
admission to observation or inpatient units
• Improved cardiovascular pharmaceuticals
• Catheter-based procedures replacing open
operations for CAD, valves, ablations, etc.
Inpatient Cardiac Services
# 10
Patients kept out of hospital by:
• Implanted devices that avoid hospital
admission: pacemakers, implanted
cardioverter defibrillators (ICDs), LVADs,
• New approaches to prevention: better
treatment of diabetes, genetic predisposition
testing, employer-based prevention and
public education, premium discount
• Effective disease management programs
enabled by RPM, wireless transmission of
information, personal robots, smart homes
Domestic Robots in the
Home
Intouch Health
www.intouch-health.com
Inpatient Cardiac Services
#10
Patients no longer admitted because of:
• Non-implanted devices that allow
treatment outside of hospital settings:
extracorporeal ultrafiltration for CHF
• Technologies to eliminate or modify
unhealthy behavior: gastric banding,
nicotine vaccines, liposuction
• 30% of current CABG caseloads will
migrate to PCI with drug-eluting stents and
90% of PTCAs stents will be drug-eluting
Inpatient Cardiac Services
Shrinking
#10
Incidence of Heart Disease ?
Recent advances and trends:
• BNP as treatment of CHF
• Importance of inflammation, e.g. statins
(Lipitor won this head-to-head study)
• Potential of ApoA-1 Milano (now Pfizer’s
for $2b) mimics function of HDL, dissolves
plaque
• Emphasis on pharmacogenomics
• Greater use of generic drugs
• Combination pills (Pfizer): Novasc/Lipitor,
Lipitor/CTEP
Greater Interest in Clinical Trials
1. Increasing numbers of surviving patients
with cancer and cardiovascular disease
2. Population expanding and more elderly
3. Media and pharma hyping powerful new
drugs (before and after FDA approval)
4. Information about clinical trials has
become readily accessible
5. Growing numbers of informed patients
Implications of this Forecast
1. Scenarios for several technology trends in
the coming decade seem clear.
2. Healthcare will grow faster than other
industries worldwide, and its % of GDP
will continue to rise, certainly in the U.S.
3. Forecasts are not predictions: expect to
make course corrections along the way.
4. Your choice today: either to be at the head
of the curve or to play catch-up.
For AMCs, the Next Ten Years
Look Good, Very Good
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Increase in spending on health care
Growing proportion of new consumers
Credibility in public polls
Brand recognition
Shift to specialty care: physicians, clinics,
COEs and hospitals within hospitals
6. Increasing interest in clinical trials
Attributions
• Bobby Robbins, Stanford
• Marilyn Rymer, Mid America Brain and
Stroke Institute, St. Luke’s Hospital
• Colleagues at the Health Technology
Center, San Francisco, and the Institute for
the Future Menlo Park, CA