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1 The Future of Healthcare Delivery Pamela C. Jenkins, MD, PhD Indo- Global Healthcare Summit 2014 June 22, 2014 Abstract. The future we want to achieve for healthcare delivery includes healthcare that is more convenient, more trustworthy, less costly, and more personalized than it is today. The future we want to avoid involves excellent access to care for some and little or no access to care for others, higher costs, and more mistakes or injury from healthcare. Health information is more accessible to the general public now than it has ever been, but the utility of that information is limited by a poor understanding of probabilities and risk. Overworked providers can find that implementing best practices for many conditions is difficult. Scientific advances tend to trickle down instead of being available to all in a timely fashion. We can move forward on all of these issues. With a focus on developments occurring now and in the near future, we will discuss how we can choose our future and take the next steps to achieve the future we want. Keywords: Healthcare Delivery Full Presentation No financial relationships to disclose. Commercial products will be discussed without endorsement. Goal of this Presentation To develop a consensus in the room on the future we want to achieve, and the next steps toward that future. Outline The future we want to achieve: Convenient Trustworthy Personalized The future we want to avoid: Disparity in access Increasing mistakes and injury from care Population health Technology applied to individuals Population Health The Goal is clear 7+ billion healthy and vibrant individuals

2 Usually Healthy Individuals Those with Chronic Treatable Disease Those with Chronic Debilitating Disease Those with Complex, Severe Illness The Usually Healthy Preventative care Unpredictable or single events, like accident or childbirth. Need convenient health care: walk- in clinics, nearby hospitals or triage systems Preventative health reminders Individualized health alerts This group is a moving away from physician delivery of health care toward individual tracking and response. Chronic Treatable Conditions diabetes, hypertension. Need a trustworthy on- going relationship with a health care system: medical homes, specialist care Generalist provider coordinates medical care Emphasis on disease control This group already uses individual tracking and response under the direction of a provider. Personal genomics may improve care

3 Chronic Debilitating Disease dementia, cerebral palsy, schizophrenia (3) Regional specialty care and multidisciplinary teams with pharmacy, palliative, and social support services anchored to tertiary care centers Specialist as the primary care provider Emphasis on quality of life and patient preferences Strong care coordination, palliative care The Severely Ill Complex and Severe Illness cancer, stroke Need for comprehensive care Centralized multidisciplinary centers anchored to research, with strong subspecialty care Reduce variation in treatment, using evidence- based standards A short video from UHC Research Institute about dividing the population according to health care needs. The Physician s Role If we are committed to the truth, we must acknowledge we have at times blocked excellent health care. Knowledge Experience and preconceptions Availability and social concerns Individual Health Patient as Consumer Even now, individuals with low- level computer skills can circumvent some of this system. Individual Has more detailed knowledge of symptoms than can be transmitted in visit Has more incentive to get information Has more invested in correct diagnosis Patient as Consumer Many tests are available without needing a doctor s approval. Soon consumer groups will be asking, if I think I need a test, why can t I have it? If a treatment is not addictive, why can t I have it?

4 Crowdsourcing Physicians can use crowdsourcing for better diagnosis and treatment. Patients with a diagnosis can ask for advice. Peer- to- peer healthcare has been happening on the web since well, the web. (2) Right and Wrong Track If Crowdsourcing of diagnosis becomes more popular than the nuanced, ambiguous and slow scientific information available, we will have difficulty regaining that ground. Find the Fallacy If you re sick and need a throat swab, you have few choices beyond seeing a health care professional at a clinic or hospital, creating an access bottleneck. A better system would equip ordinary people with mobile technology to make their own reliable health diagnoses anywhere, anytime. (1) Qualcomm Tricorder Xprize organizers Find the Fallacy If you re sick and need a throat swab, you have few choices beyond seeing a health care professional at a clinic or hospital, creating an access bottleneck. A better system would equip ordinary people with mobile technology to make their own reliable health diagnoses anywhere, anytime. (1) Fallacy #1 How to decide you need a throat swab? Prior Probability, Test characteristics Utility of the information Find the Fallacy If you re sick and need a throat swab, you have few choices beyond seeing a health care professional at a clinic or hospital, creating an access bottleneck. A better system would equip ordinary people with mobile technology to make their own reliable health diagnoses anywhere, anytime. (1) Fallacy #2 Mobile technology can make diagnoses? Really, mobile technology can perform tests A positive test result does not equal causation. A Diagnosis Website Input: Enter symptoms in detail Individual characteristics, history, exposures, locality Output: List of possible diagnoses with likelihood of each

5 Recommendations for testing Recommendations for diagnosis review Some Apps Exist New Sensors Information Transfer A Great Place for Technology A great deal of the healthcare encounter can be accomplished by technology faster, more smoothly and more accurately. Describe symptoms Work through a decision strategy Produce a treatment plan or provide the information the individual needs. Such a system would have current information about local communicable diseases and apply research more quickly than physicians do. The Center of the Issue What is currently not available on the internet is the relative likelihood of a diagnosis based on symptoms, an individual s risk factors, and relevant test results. There are two alternatives to a diagnosis website. One would be a Doc- On- The- Web type of service, where one could chat online about symptoms, get care reminders, or check in for local health information: an outbreak of gastroenteritis in your area, or an outbreak of dengue in the area you are traveling to. The other would be free or inexpensive local clinics that could fill the same roles. New Technology Internet access for all by 2020 New and more sensors, implants Local testing Robotics Nanotechnology Genomics It Could Happen Diagnostician and Therapian Voluntary Reporting to a National Registry Communicable diseases Sharing between nations Global Public Health National disease surveillance systems need faster information than Internet search engines to identify communicable disease outbreaks. A website could accept voluntary symptom reporting by region. Ideally the system needs to inform others in that area of an outbreak, preventative actions, or treatment.

6 Such a reporting system needs to be global no waiting for health authorities to release information on communicable disease outbreaks. It will vastly improve our understanding of disease transfer across the globe and allow us to better limit spread or anticipate threats. Conclusions Information on the Internet could reduce the need for healthcare visits. The future we want to achieve: The Internet makes information convenient If we can fill the gap of trustworthiness, healthcare can reduce costs, improve efficiency, and do good for more people References 1. Sabar, A. Inventing the real McCoy. Smithsonian, May 2014, p elwyn- et- al- crowdsourcing- health- care- hope- or- hype/ most- debilitating- diseases/ 4. Biography Dr. Pamela C. Jenkins is an Associate Professor of Pediatrics at the Geisel School of Medicine at Dartmouth College. She obtained her medical degree at the University of North Carolina at Chapel Hill, completed a residency in Pediatrics at Dartmouth Medical Center, and received a PhD in Outcomes Research from Dartmouth College. Past research involved multi- institutional studies of outcomes for a rare congenital heart disease. She trained in Quality Improvement techniques with Dr. Paul Batalden, a founder of the movement in healthcare, and applied these concepts clinically in her work as a Pediatric Hospitalist and as a long- standing member of her hospital s Sentinel Events Review Committee. She also developed and taught a 4- month course on Quality Improvement in Health Care during a Fulbright fellowship at St. John s Medical School in Bangalore, India, in 2008 and Current work involves medical device development and testing using technology appropriate for developing countries, as well as collaboration on medical app development for smartphones. She has won awards both for teaching and for clinical research. Address: 137 River Road Lyme, NH USA Pamela.C.Jenkins@dartmouth.edu