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.

www.healthtech.org415-537-6974

524 Second Street San Francisco, CA 94107

Translating Research Into Action An independent, non-profit research organization

• 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

• Anti-microbial Drugs

• Cardiovascular Drugs

• Remote Patient Mgmt

• Security Technologies

• Neuropharmaceuticals

• Gene Therapy

• Wireless Technologies

• Voice Recognition

• Clinical Trials

• Web Services

Technologies

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. CashDisposable household income of $55,000

(2004)

3. Connected by ComputersReady 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 OncologyGerontology GastroenterologyCardiology HematologyPulmonology Intensive CarePsychiatry UrologyNephrology RadiologyPediatric 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

• 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 Decision and Intervention

#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)

Shift to Earlier Intervention: the Tools #1

Endovascular Technologies (a disruptive technology)

• 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

Smarter, Smaller Surgical Devices-MIS #2

crimping the valvecrimping the valve

Percutaneous Mitral Annuloplasty

Congestive Heart Failure

A

L

P

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

AutomatedHand-sewn

Confidential

Mitral valve repair/replacement

CorCap only CABG

CorCap Surgical Applications

Cerebral AneurysmCerebral Aneurysm

Coiled Aneurysm

Tipping Point for Endovascular Treatment of Strokes & AneurysmsBarriers 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. coils3. Trained # neurovascular interventionalists.4. Technologic advances in image-guidance,

versatile detachable coils, and stents.

Radiosurgery

“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

#2

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)

# 3

“Bionic Man”

the Hattler Catheter

Organ Assistance and Substitution Devices

• Liver dialysis

• Artificial kidney

• Hattler intravenous membrane oxygenator

# 3

“Bionic Man”

Newer generations of VADs will diffuse more rapidly as they improve in function, size, and compatibility

# 3

“Bionic Man”

Micromed DeBakey Axial Flow Pump

#3

• Treatment strategy is changing:

No longer a matter of winners and losers at any cost (cytotoxic polychemotherapy)

Instead, opt for a negotiated truce by long-term treatment and lengthening quality survival

• Accept cancer as a chronic disease.

• Containment through vaccines, anti-angiogenesis, 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)

#4Cancer

• 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

#4Cancer

Surgical Procedures Move Out of 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

#5

• 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.

Access to Healthcare 24X7 #6

IT will Revolutionize Healthcare

• Reliance on genetic testing, proteomics pharacogenomics, and molecular specificity

• Identification of diagnostic and therapeutic targets for sub-groups of patients usingcancer 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)

Personalized Medicine #7

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.

• 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

# 8Use of IT in Healthcare: Expanding and Wireless

• 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

Supporting Technologies

Compensating for Workforce Shortages

#9

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

#10Inpatient Cardiac Services

• 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.

#10

Inpatient Cardiac Services Shrinking

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

# 10

Inpatient Cardiac Services

Domestic Robots in the Home

Intouch Health

www.intouch-health.com

Intouch Health

www.intouch-health.com

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

#10Inpatient Cardiac Services

#10

Inpatient Cardiac Services Shrinking

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

1. Increase in spending on health care

2. Growing proportion of new consumers

3. Credibility in public polls

4. Brand recognition

5. 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