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Title: Healthcare Tsunami! Tom Peters/ Planetree/ 10.11.2002


1
Healthcare Tsunami!Tom Peters/ Planetree/
10.11.2002
2
HealthCare2001Consumerism X Demographics X
IS/Internet X Info Consolidators X Genetics
Devices Revolution YIKES!
3
Golden Age of Patient-centric, Genetics-driven
Healthcare Looms! Current status 1.3T. 40M
uninsured. 90K killed and 2M injured p.a. in
hospitals. 85 treatments unproven. Cure depends
on locale in which treated. 50 prescriptions do
not work. 2X docs. 2X hospitals. IS primitive.
Accountability measurement nil. And
everybodys mad and feels powerless Docs,
patients, nurses, insurers, employers, pharma
device cos, hospital administrators and staff.
4
1. Consumerism (Patient-centric Healthcare)
5
Anne Busquet/ American ExpressNot Age of the
InternetIs Age of Customer Control
6
Amen!The Age of the Never Satisfied
CustomerRegis McKenna
7
The Web enables total transparency. People with
access to relevant information are beginning to
challenge any type of authority. The stupid,
loyal and humble customer, employee, patient or
citizen is dead.Kjell Nordstrom and Jonas
Ridderstrale, Funky Business
8
Online Medical Records Seen Empowering
PatientsSource Headline, Boston Globe,
07.31.2000, re 1K docs and 700K patients _at_
CareGroup
9
Parents, doctors, stockbrokers, even military
leaders are starting to lose the authority they
once had. There are all these roles premised on
access to privileged information. What we are
witnessing is a collapse of that advantage,
prestige and authority.Michael Lewis, next
10
Reuters (12.11.01) Teens and young adults are
flocking to the Web for health-related
information as much as they are downloading music
and playing games online and more often than
shopping online, according to a national survey
from the Kaiser Family Foundation.
11
A seismic shift is underway in healthcare. The
Internet is delivering vast knowledge and new
choices to consumersraising their expectations
and, in many cases, handing them the controls.
Healthcare consumers are driving radical,
fundamental change.Deloitte Research, Winning
the Loyalty of the eHealth Consumer
12
We expect consumers to move into a position of
dominance in the early years of the new
century.Dean Coddington, Elizabeth Fischer,
Keith Moore Richard Clarke, Beyond Managed Care
13
Todays Healthcare Consumer skeptical and
demandingSource Ian Morrison, Healthcare in
the New Millennium
14
Medical care has traditionally followed a
professional model, based on two assumptions
that patients are unable to become sufficiently
informed about their own care to allow them a
pivotal role, and that medical judgments are
based on science.Joseph Blumstein, Vanderbilt
Law School
15
He shook me up. He put his hand on my shoulder,
and simply said, Old friend, you have got to
take charge of your own medical care.
Hamilton Jordan, No Such Thing as a Bad Day
(on a conversation with a doctor pal, following
Jordans cancer diagnosis)
16
It may be the most far-reaching evolution of
them all the metamorphosis of passive patient
into consumer and well-informed, assertive
consumer at that. The defining axiom of
traditional medicine doctors orders is being
turned on its head. These days its the patients
who are armed, the doctors who must get wired to
keep nimble. E-health is the new house
call.Richard Firstman, Heal Thyself, On
Magazine (04.01)
17
The New MegaConsumerism HMO backlash (talent
demands plans with more choice). Alternative
Medicine, Wellness Prevention race to the top
of the charts. Info availability (disease,
health, docs, support groups, outcomes). Boomers
(Im in charge! Discretionary to spend
cosmetic surgery, vision improvement, fertility,
etc.). Self-care (chronic disease). High
expectations (genetics, etc.)
18
Consumer ImperativesChoiceControl (Self-care,
Self-management)Shared Medical
Decision-makingCustomer ServiceInformationBrand
ingSource Institute for the Future
19
Savior for the Sickvs. Partner for Good
Health Source NPR/VPR 08.15.00
20
The curative model narrowly focuses on the
goal of cure. From many quarters comes evidence
that the view of health should be expanded to
encompass mental, social and spiritual
well-being. Institute for the Future
21
In many ways, the nursing profession is the most
qualified to respond to current changes in the
health system. Nurses training focuses more on
the behavioral and preventive aspects of health
care than does that of physicians. Institute
for the Future
22
Determinants of HealthAccess to care
10Genetics 20Environment 20Health
Behaviors 50Source Institute for the Future
23
2. Demographics The BOOMERS Reach 55!
24
NOT ACTING THEIR AGE As Baby Boomers Zoom into
Retirement, Will America Ever Be the
Same?USNWR Cover/06.01
25
507T wealth (70)/2T annual income50 all
discretionary spending79 own homes/40M credit
card users41 new cars/48 luxury610B
healthcare spending/74 prescription drugs5 of
advertising targetsKen Dychtwald, Age Power
How the 21st Century Will Be Ruled by the New Old
26
Boomer WorldFrom jogging to plastic surgery,
from vegetarian diets to Viagra, they are
fighting to preserve their youth and defy the
effects of gravity.M.W.C. Howgill, Healthcare
Consumerism, the Information Revolution and
Branding
27
Pick up any copy of Glamour or Mens Health, and
youll see pages of advertisements encouraging
readers to enlarge their breasts, retard
baldness, correct their vision, improve their
smile, or relieve stress through herbs, massage
therapy, acupunctureyou name it.Coddington,
Fischer, Moore Clarke, Beyond Managed Care
28
Message Boomer (1) There are l-o-t-s of us.
(2) We have the . (3) Were/Im in
charge! (4) Well take no guff from from
anyone. (5) We know the emperor has no
clothes.
29
3. The IS/Web REVOLUTION
30
InfoHealth RevolutionConsumerism (research,
consultation, B2C, etc.)Clinical Info Systems
(guidelines and outcome measurement, etc.)100
Web-based (internal) SystemsElectronic Medical
RecordsPatient-physician email-consultationTeleh
ealth-Remote Monitoring (biosensors, home
testing, etc.)Telemedicine (consultation,
invasive treatment, global medical village,
etc.)
31
Were in the Internet age, and the average
patient cant email their doctor.Donald
Berwick, Harvard Med School
32
In an era when terrorists use satellite phones
and encrypted email, US gatekeepers stand armed
against them with pencils and paperwork, and
archaic computer systems that dont talk to each
other.Boston Globe (09.30.2001)
33
Want email consultation 90 patients, 15
docs. Evidence Patients do not pester docs.
Time is saved. No one has sued (shows care
connectionthe absence of which is the major
cause of suits).Source New York Times/06.06.02
34
Telemedicine Reduces days/1000 patients and
physician visits for the chronically
illDecreases costs of managing chronic
diseaseExpands service areas for
providersReduces travel costs to and from
medical ed seminarsDouglas Goldstein,
e-Healthcare
35
Without being disrespectful, I consider the U.S.
healthcare delivery system the largest cottage
industry in the world. There are virtually no
performance measurements and no standards. Trying
to measure performance is the next revolution
in healthcare.Richard Huber, former CEO, Aetna
36
A healthcare delivery system characterized by
idiosyncratic and often ill-informed judgments
must be restructured according to evidence-based
medical practice.Demanding Medical Excellence
Doctors and Accountability in the Information
Age, Michael Millenson
37
As unsettling as the prevalence of inappropriate
care is the enormous amount of what can only be
called ignorant care. A surprising 85 of
everyday medical treatments have never been
scientifically validated. For instance, when
family practitioners in Washington were queried
about treating a simple urinary tract infection,
82 physicians came up with an extraordinary 137
strategies.Demanding Medical Excellence
Doctors and Accountability in the Information
Age, Michael Millenson
38
Quality of care is the problem, not managed
care.Institute of Medicine (from Michael
Millenson, Demanding Medical Excellence)
39
CDC 1998 90,000 killed and 2,000,000 injured
from nosocomial hospital-caused drug errors
infections
40
1,000,000 serious medication errors per year
illegible handwriting, misplaced decimal points,
and missed drug interactions and
allergies.Source Wall Street Journal/
Institute of Medicine
41
Various studies 1 in 3, 1 in 5, 1 in 7, 1 in 20
patients harmed by treatment Demanding
Medical Excellence Doctors and Accountability
in the Information Age, Michael Millenson
42
In a disturbing 1991 study, 110 nurses of
varying experience levels took a written test of
their ability to calculate medication doses.
Eight out of 10 made calculation mistakes at
least 10 of the time, while four out of 10 made
mistakes 30 of the time.Demanding Medical
Excellence Doctors and Accountability in the
Information Age, Michael Millenson
43
RAND (1998) 50, appropriate preventive care.
60, recommended treatment, per medical studies,
for chronic conditions. 20, chronic care
treatment that is wrong. 30 acute care treatment
that is wrong.
44
YE GADS! New England Journal of Medicine/
Harvard Medical Practice Study 4 error rate (1
of 4 negligence). Subsequent investigations
around the country have confirmed the ubiquity of
error. In one small study of how clinicians
perform when patients have a sudden cardiac
arrest, 27 of 30 clinicians made an error in
using the defibrillator. Mistakes in
administering drugs (1995 study) average once
every hospital admission. Lucian Leape,
medicines leading expert on error, points out
that many other industrieswhether the task is
manufacturing semiconductors or serving customers
at the Ritz Carltonsimply wouldnt countenance
error rates like those in hospitals.Complication
s, Atul Gawande
45
In health care, geography is destiny.Dartmouth
Medical School 1996 report, from Demanding
Medical Excellence Doctors and Accountability in
the Information Age, Michael Millenson
46
Geography Is DestinyE.g. Ft. Myers 4X
Manhattanback surgery. Newark 2X New
Havenprostatectomy. Rapid City SD 34X Elyria
OHbreast-conserving surgery. VT, ME, IA 3X
differences in hysterectomy by age 70 8X
tonsillectomy 4X prostatectomy. Breast cancer
screening 4X NE, FL, MI vs. SE, SW. (Source
various)
47
Geography Is DestinyOften all one must do to
acquire a disease is to enter a country where a
disease is recognizedleaving the country will
either cure the malady or turn it into something
else. Blood pressure considered treatably high
in the United States might be considered normal
in England and the low blood pressure treated
with 85 drugs as well as hydrotherapy and spa
treatments in Germany would entitle its sufferer
to lower life insurance rates in the United
States. Lynn Payer, Medicine Culture
48
Practice variation is not caused by bad or
ignorant doctors. Rather, it is a natural
consequence of a system that systematically
tracks neither its processes nor its outcomes,
preferring to presume that good facilities, good
intentions and good training lead automatically
to good results. Providers remain more
comfortable with the habits of a guild, where
each craftsman trusts his fellows, than with the
demands of the information age.Michael
Millenson, Demanding Medical Excellence
49
PARADOX Many, many formal case reviews failure
to systematically/ systemically/ statistically
look at and act on evidence.Complications, Atul
Gawande
50
Deep Blue Redux 2,240 EKGs 1,120 heart
attacks. Hans Ohlin (50 yr old chief of coronary
care, Univ of Lund/SW) 620. Lars Edenbrandts
software 738.Only this time it matters!
51
Probable parole violations Simple model (age,
of previous offenses, type of crime) beats M.D.
shrinks. 100 studies Statistical formulas gt
Human judgment. In virtually all cases,
statistical thinking equaled or surpassed human
judgment.Atul Gawande, Complications
52
Most physicians believe that diagnosis cant be
reduced to a set of generalizationsto a
cookbook. How often does my intuition lead me
astray? The radical implication of the Swedish
study is that the individualized, intuitive
approach that lies at the center of modern
medicine is flawedit causes more mistakes than
it prevents. Atul Gawande, Complications
53
Leapfrog Group/med errors Not since Jackson
Hole Group guru Paul Ellwood, Jr., M.D., coined
the term HMO in 1970 has one idea so fully
captured the imagination of the healthcare
industry.HealthLeaders/06.2002
54
Leapfrog Group
CPOE/Computerized Physician Order
EntryICU staffing by trained
intensivistsEHR/Evidence-based Hospital
ReferralDuh I Welcome to the computer
age.Duh II How about using experts?Duh
III If you do stuff a lotta times, you tend to
get/be better.
Source HealthLeaders/06.2002
55
Computerized Physician Order Entry/CPOE 5 of
U.S. hospitalssource HealthLeaders/06.02
56
Empire Blue Cross and Blue Shield 4 quarterly
bonus for hospitals that meet Leapfrogs CPOE and
ICU-staffing standards.Source
HealthLeaders/06.2002
57
The VHA gets it! E.g. Laptop at bedside calls
up patient e-records from one of 1,300 hospitals.
Bar-coded wristband confirms meds. National
Center for Patient Safety in Ann Arbor. Docs
and researchers discuss optimal treatment
regimensresearch center in Durham NC. Doc
measures guidelines e.g., pneumonia
vaccinations from 50 to 84. Blame-free
system, modeled after airlines. Whats needed
in the U.S. is nothing short of a medical
revolution and the VHA has gone further than most
any other organization to revamp its culture and
systems.Rand/SourceWSJ 12.10.2001
58
The Benefits of FOCUSED EXCELLENCE
Shouldice/Hernia Repair 30-45 min, 1
recurrence. Avg 90 min, 10-15
recurrence.Source Complications, Atul Gawande
59
4. The Consolidators Fat or Thin?
60
Virtual health care webs force providers to
focus on their areas of excellence and to invest
in areas where they can generate a sustainable
competitive advantage.Healthcare.comRx for
Reform, David Friend, Watson Wyatt Worldwide
61
WebMD (or heirs and assigns)
62
The future of hospitals is murky. A combination
of technological advances, managed care, and
changes in Medicare reimbursement policy means
that the underlying demand for inpatient services
will continue to fall.Institute for the Future
63
5. Genetics, Devices, the Future of Big Pharma
64
Recognizing that a single misspelled gene means
the difference between being poisoned and being
cured was the first victory for the new science
of pharmacogenetics.Newsweek (06.25.01)
65
Genetic data 2X every 6 months.Source FT,
11.27.2001
66
Pharmacogenomics could fundamentally change the
nature of drug discovery and marketing, rendering
obsolete the pharmaceutical industrys practice
of spending vast amounts of time and money to
craft a single medicine with mass-market
appeal.The Industry Standard (05.28.01)
67
E.g., Genentechs Herceptin, useful in 25 of
advanced breast cancer cases. Would probably have
been uneconomic if subjected to 9X patients in
phase III clinical trials.Source FT (11.27.01)
68
Pharmacogenomics End of Blockbusters by
End-of-Decade (Reuters/5-22)Barrie James,
Pharma Strategy Consulting Were moving from a
blunderbuss approach to laser-guided munitions,
and it marks a sea change for the industry. The
implications for existing business models are
devastating. Allen Roses, SVP Genetic
Research, GlaxoSmithKline minibuster. Rob
Arnold, Euro head of life sciences, PWC Once
you start dealing with minority treatments, small
biotechs who are more nimble and dont need
500-million-a-year drugs to make money could be
at a real advantage.
69
BIG DRUG MAKERS TRY TO POSTPONE CUSTOM REGIMENS.
Most drugs dont work well for about half the
patients for whom they are prescribed, and
experts believe genetic differences are part of
the reason. The technology for genetic testing is
now in use. But the technique threatens to be so
disruptive to the business of big drug companies
it could limit the market for some of their
blockbuster products that many of them are
resisting its widespread use.The Wall Street
Journal (06.18.2001)
70
Forbes100 from 1917 to 1987 39 members of the
Class of 17 were alive in 87 18 are in 87
F100 the 18 F100 survivors underperformed the
market by 20 just 2 (2), GE Kodak,
outperformed the market from 1917 to
1987.Source Dick Foster Sarah Kaplan,
Creative Destruction Why Companies That Are
Built to Last Underperform the Market
71
Imagine the day that your surgeon performs your
heart bypass sitting at a computer thousands of
miles from the operating table. That day may come
sooner than you think.Newsweek (06.25.01)
72
There is no question in my mind that the future
of heart surgery is in robotics.Dr. Robert
Michler, OSU Med Center, upon the FDAs approval
of robotic partial-bypass surgery
73
6. Conclusion.
74
Golden Age of Patient-centric, Genetics-driven
Healthcare Looms! Current status 1.3T. 40M
uninsured. 90K killed and 2M injured p.a. in
hospitals. 85 treatments unproven. Cure depends
on locale in which treated. 50 prescriptions do
not work. 2X docs. 2X hospitals. IS primitive.
Accountability measurement nil. And
everybodys mad and feels powerless Docs,
patients, nurses, insurers, employers, pharma
device cos, hospital administrators and staff.
75
HealthCare21Tom Peters/03.26.2002
76
HealthCare21 21 Ideas for Century211.
Hospitals kill people. (And those they dont
kill, they wound.) (And they deny it.)
(ERRORS RULE!)2. Hustling ambulances kill
pedestriansand dont save patients.3. Doctors
are spoiled bratswho dont like measurements.
Or any form of interference. Docs are also
cover-up artists par excellence (the REAL
Hippocratic Oath DONT RAT ON A FELLOW
DOC). 4. Most prescriptions dont work for
the PARTICULAR individual in question.5.
THERE IS LITTLE SCIENCE IN MEDICINE. (See
state to state variations, country to
country variations, the general lack of
agreed upon treatments.)6. You could save
thousands of livesif you just outlawed
handwritten prescriptions.7. Detailers will
disappear when GenX docs arrive.
77
HealthCare21
(Cont.)8. IS/IT in hospitals is sub-primitive
(despite enormous expenditures).9. ELECTRONIC
MEDICAL RECORDS PERIOD. (PLEASE.)10. Systemic
IS/IT is horridlinks between docs, insurers,
providers, patients.11. The Web WILL
Liberate. (Info Power.) (BELIEVE IT.) 12.
80M BOOMERS RULE. (. Desire for
c-o-m-p-l-e-t-e CONTROL. NOW.
LEADERSHIP OF AGING PROCESS.)13. Drug
Discovery processes at Big Pharma are
hopelessly over-complicated. (??? Bye
Bye Big Pharma.)14. 90 of the fix HARVEST
THE LOW-HANGING FRUIT. They are NOT
the Enemy. Damn it.15. Insured consumers
are spoiled brats who act as if H.C. is a
Free Good. (MAKE THE BASTIDS PAY at least a
little more than a little.)
78
HealthCare21 (Cont.)16.
Genetic engineering biotech change
EVERYTHING. (Within 10 years.)17. New
Medical Devices change EVERYTHING. (Within 20
years.)18. IS/IT changes EVERYTHING.
(Within 10-15 years.)19. New Docs change
EVERYTHING. (Within 10-15 years.)20. New
Patients change EVERYTHING. (Within 5
years.)


79
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