Technology Outlook 2020 Healthcare
Healthcare is facing serious challenges in many countries as it needs to improve and demonstrate quality and safety while being faced with ever increasing expectations of the general public in a climate where investment is limited. We firmly believe that technology is a key part of the solution to meet many of the challenges and believe that the best way to be prepared for the future is to have a broad view over which technologies may be available.
ReseaRch & InnovatIon technology outlook 2020 HEALTHCARE www.dnv.com/foresight technologies that will make a difference Who wouldn't want to know which technologies will be in play towards the end of this decade? With today's speed of innovation and introduction of new technologies, anticipating the future is no easy task. DNV's Research and Innovation unit has a long tradition of publishing Technology Outlook, where we try to look into the crystal ball for selected sectors. Earlier this year we shared our views on how technology may develop in the areas of shipping, fossil energy, renewables and nuclear energy and in this publication we have done the same for healthcare. We have no doubt that some of our predictions will turn out to be incorrect and there are certainly many technologies that will have an impact in 2020 but where we have not had space to cover, but we nevertheless hope to achieve our objective of stimulating discussion. The views and analyses have been formed by the Research and Innovation unit and might not be shared by all parts of the DNV organisation. We don't claim to have all the answers, but we have based our opinions on our expertise and competence in a broad range of areas. We start by summarising the most important global trends independent of industry sector. We then paint four different pictures of how the healthcare sector might develop using a scenario approach that draws on many of the uncertain drivers that may impact differently on this sector over the next decade. This is followed by the technology uptake chapter describing selected healthcare technologies and we complete the outlook with a visualisation of how safe healthcare may be provided in 2020. Healthcare is facing serious challenges in many countries as it needs to improve and demonstrate quality and safety while being faced with ever increasing expectations of the general public in a climate where investment is limited. We firmly believe that technology is a key part of the solution to meet many of the challenges and believe that the best way to be prepared for the future is to have a broad view over which technologies may be available I hope you will use this publication to engage in a discussion about the future with us. Enjoy the read! Elisabeth Harstad Managing Director, Research & Innovation this is dnv DNV is a global provider of services for managing risk. Established in 1864, DNV is an independent foundation with the purpose of safeguarding life, property and the environment. DNV comprises 300 offices in 100 countries with more than 9000 employees. research and innovation in dnv The objective of our strategic research is to enable long term innovation and business growth through new knowledge and services in support of the overall strategy of DNV. Such research is carried out in selected areas that are believed to be of particular significance for DNV in the future. contents Global MEGaTrENDS Population Health and wellness Economy Governance Information technology Natural resources Climate change 06 08 10 12 14 16 18 20 FroM TrENDS To ScENarioS Scenarios for the Healthcare sector 22 24 HEalTHcarE TEcHNoloGy UpTakE Information Technology The Internet changes healthcare Remote care Point-of-Care Personalized medicine Next generation imaging Novel medical treatment 26 28 30 32 34 36 38 40 THE SaFE HoSpiTal The Safe Hospital 42 44 Global MeGaTrends Global meGatrends The adoption of future healthcare technologies is heavily dependent on how the world will develop. Predicting the future is always difficult but there are a number of important trends where uncertainty is low and impact is global � so called megatrends. Here we identify and summarise six megatrends that are based on our interpretation of a wide variety of material from sources outside DNV. In our view, these six megatrends will influence the development and uptake of technologies within the healthcare sector. INDEx Population Health and wellness Economy Governance Information technology Natural resources Climate change 8 10 12 14 16 18 20 8 Global MEGaTrENDS POPUlATION most populations out of balance THE WorlD popUlaTioN continues to grow fast and will pass 7.5 billion people by 2020. Whilst populations in the West, China, and Japan are greying, the Middle East is becoming younger; in most developed countries a smaller declining working-age force will have to support more elderly, and a growing and younger population will aggregate in urban areas. The pressures on natural resources, urbanization of exposed areas, natural disasters, and conflicts will be motivating factors for migrations � both domestic and international. FundaMental changes Four demographic changes will intensify and fundamentally alter the world's population in the decades to come: � the demographic weight will shift from developed regions towards developing regions, � labour forces in developed countries will age and decline - potentially constraining economic growth, � the world's population growth will be mainly concentrated in today's poorest, youngest, and least developed countries, � the majority of the world's population will live in cities. Migration to a better liFe - or not? The lure of prosperity, hopes for a better life, resource shortages, violence, and natural disasters are the main driving forces behind migration. In 2008, there were more than 200 million migrants, 2.5 times more than in 1965; by 2020, this number is likely to have increased to 260 million. In the long-term, climate change could add another 150-200 million refugees, as people try to escape from severe weather events, flooding, droughts, or agricultural disruptions. A larger workforce in a developing country could provide new opportunities for economic growth, but if people remain unemployed and this may also lead to rising poverty levels, social unrest, or the rise of extremism. A lack of labour forces in Western Europe will act as a magnet, attracting several million workers over the next 10 years. Only if migration is maintained at its current level, will the working-age population in most OECD countries not have declined by 2020. This will challenge the immigration policies of many countries, e.g. EU. On the other hand, brain drain, which results from the migration of skilled workers from developing countries to developed ones, will assist in cementing the economic differences. Traditional migrant-sending countries are likely to become migrant-receiving countries, leading to a shift from a South-North to a South-South migration pattern. More people � More elderly Every year over the next 10 years, about 57 million people (i.e. approximately equal to today's population of Italy) will be added to the world population. The current global fertility rate of 3.11 children per woman will gradually fall to 2.5 by 2020, adding 500 million people to the world's population, and resulting in 7.5 billion. This growth will mainly occur in today's developing countries, and by 2020 approximately 19 % of the world's population (or 1.4 billion people) will live in China. In contrast, the proportion of elderly people (older than 65 years) in most industrialized countries will rise, increasing in Europe, for example, from the current level of 14.7 % to about 22 % by 2020. The US, however, will be an exception, due to high net migration and higher fertility levels. The unfunded nationwide Chinese pension system combined with the one-child policy may result in a special situation, as nearly 400 million Chinese will be over 65 years by 2020. A greying population will put more strains on national economies through increased number of pensions, healthcare expenditure, social insurance, and labour shortages. By 2020, around 40 regions will experience a 10 % decline in the workforce, whereas countries such as Bulgaria and Poland may even have to cope with reductions exceeding 25 %. Not all effects of a greying population are negative. For example, the wealth accumulated by the elderly (goods, savings) may be gradually released into the national economy. Also, the currently high unemployment of 10-20 % in many developed countries may automatically drop. THE GENEraTioN DiViDE Global MiGraNTS population in millions. source: us census bureau there will be an estimated 260 million global migrants worldwide, or about 3.5% of the world's population. source: pstalker.com Page 9 9 aSia aloNE will account for 56% of the global population by 2020 Source: CIA China 19 % 19 China India 17 % % 17 IndiaAsia Rest of 20 % % 20 Rest of Asia Africa 16 % % Africa USA 4% % 16 USA Amerikas Rest of 9 %4 % Rest and Russia 12 %9 % Europe of Amerikas Europe and Russia3 % % Middle East 12 Middle East 3% urban jungle � the bitter-sweet liFe Currently more than 50 % of the world's population live in cities and this number will further increase by 5 %, or 715 million people, by 2020. In 1900, there were 11 cities with more than 1 million residents, in 1950 there were 80, in 1990 there were 276, and this had climbed to about 400 by year 2000. In 2020 there will probably be more than 600, but most of the urbanisation will occur in smaller cities, and in the world's poorest countries. These cities may not have the resources needed to cope with the influx. Currently, more than 50 % of the urban population in South Asia and 40 % in Sub-Saharan Africa lack access to sanitation services, highlighting the need for adequate health care, and basic infrastructures. Cities are already responsible for 70 % of all global greenhouse gas (GHG) emissions and 70 % of the world's energy consumption. One billion people live in slums, and 66 % of the world's population live within 100 km of the ocean; the urbanization rate is much faster in the more prosperous coastal regions. For city development to be sustainable, focus will need to increase on environmental consequences (habitat destruction, poor air quality, sewage, waste), as well as on more typical urban problems (traffic congestion, housing, crime). The congregating of people from the countryside in urban areas will continue to weaken traditional family ties and values. This, together with Indiaof Asia 17% greater exposure 20% Rest to the egocentric Western way of Africa definition, 16% self Americas 9% suggest that a further growth in demand of consumer USA 4% goods should be expected. East Europe and Russia 7% West Europe 5% Middle East 3% China 19% the religious glue Over the next 10 years, religion and new ageism are likely to play more prominent roles in how people define themselves. The reasons for this can be found in greater uncertainty, higher mobility, and growing diversity of hostile groups, enabled by the use of modern IT, especially the Internet. In 2020, some of the largest Christian communities will be found in China and Nigeria, which may transform the traditionally Western-based Christian institutions towards a more African or Asian style. In most regions with youth bulges, the number of religious "activists" with a rather black-white worldview is likely to rise. By 2020, radical religious groups might be expected to be making a significant global impact through the creation of transnational organisations. Every year over the next 10 years, about 57 million people (i.e. approximately the current Italian population) will be added to the world's population. organized criMe Crime, particularly organized crime, will thrive in resource-rich states that have either a weak government or that are being destabilised by significant political and economic transformations. Weak governmental control is likely to lead to increased corruption. Organized crime will become more closely involved in the international economy, with growing demands for illicit transportation of people, drugs, and smuggled goods, and greater profits to be made. UrbaN popUlaTioN UNcErTaiNTiES aND DiSrUpTorS World Africa Asia Lat.America/ Carib. More dev. regions 55% of the world population will live in urban areas in 2020. source: un (2009) � Effect of religion on politics will be larger in some regions � Urban sustainability will become a pressing issue � Natural disasters will gain a larger effect � With increasing world population the likelihood for a pandemic increases but its effect will be uncertain � long lasting severe draught may seriously hamper local economy and agriculture � Conflicts or natural disasters can result in large numbers of out-of country refugees 10 Global MEGaTrENDS HEAlTH AND WEllNESS global health coNTaiNMENT oF HEalTHcarE coSTS is viewed as a key national priority in many/most developed countries. The aging of the population and the pandemic of obesity among adults and children will become an additional burden while at the same time the expectations of healthcare "consumers" to receive high quality, safe and timely care will continue to increase. Thus the need to limit healthcare costs while providing more care will drive change in the ways we manage healthcare. growing healthcare expenditure In many developed countries, healthcare spending has risen more rapidly than GDP over the last decade, and the challenge of bringing soaring healthcare costs under control is expected to increase. Various trends, such as aging populations with chronic diseases, advances in diagnosing and testing diseases, lack of clean air and water, and the explosive growth of densely crowded cities, will add to the complexity. Improvements in infrastructure, access, affordability, equity, safety, quality, and efficiency of care will all play important roles in facing the challenges of higher costs in the future. Organizations that develop biomedical innovations often assert that their products reduce costs by detecting or treating diseases more effectively than previously existing interventions. However, many health economists believe that biomedical innovations typically increase healthcare expenditure. Depending on the technology, both perspectives can be correct, and this has led to a growing use of healthcare technology assessment methodology by payers and healthcare authorities. rise oF obesity and chronic diseases The pandemic of obesity among adults and children is a major public health concern. Obesity is a known risk factor for numerous chronic health problems, including diabetes, cardiovascular diseases, respiratory problems (asthma), musculoskeletal diseases (arthritis), and some types of cancers, resulting in premature death (8-10 years sooner) and increased healthcare expenditure. The rate of obesity is increasing in many countries and in several OECD countries at least 50 % of the adult population is now defined as being either overweight (body mass index > 25 kg/m2) or obese. However, there is great variation in prevalence, with the problem increasingly common in low- and midincome countries. Obesity-related chronic illnesses will impose a burden of significant costs on healthcare systems in the future. burden oF disease � predictions towards 2020 Globally fewer children younger than 5 years of age will die, and the number of people dying from non-communicable diseases will increase, with a concomitant decrease in infectious diseases. In lowincome countries, infections of the lower respiratory tract, diarrhoeal diseases, HIV/ AIDS, and malaria are still the leading contributors to high DAlY* values, while the prevalence of cardiovascular diseases is increasing. In high-income countries, the burden of disease is dominated by unipolar depression, adult onset hearing loss, and alcohol abuse disorders, for which direct mortality is low. Globally, the prevalence of cardiovascular diseases (i.e. heart attack and stroke) will continue to grow, together with road traffic accidents. *DALY (disability-adjusted life year) represents years of life lost due both to premature death and to time lived in states of disability or less than full health. A high DALY indicates poor health status of the population. The global DALY is expected to decrease in the future, mainly due to prolonged life expectancy and fewer years of life lost. If nothing is done to reduce the risk of chronic diseases, heavy losses in terms of human life and economic production can be expected. WHO 2007 boDy MaSS iNDEx lEaDiNG caUSES oF bUrDEN oF DiSEaSE Globally 100 % 80 % Injuries 60 % 40 % 20 % Noncommunicable conditions Communicable diseases, maternal and perinatal conditions and nutritional deficiencies 2008 2015 2030 source: who health statistics and informatics body mass index is currently used to detect obesity. source: wikipedia.org Page 11 11 20 ToTal ExpENDiTUrE on health, % of Gross Domestic Product (GDP). Source: OECD Health Data 2010, National Health Expenditure Projections 2009-2019 (USA), WHO national health accounts. 15 10 United States OECD EU BRIC countries 1960 1970 1980 1990 2000 2010 2020 5 0 shortage oF healthcare workers Healthcare workers represent the very foundation of a functioning healthcare system, but the ability to attract, train, retain, and distribute healthcare workers poses a serious challenge to both developed and developing countries worldwide. Although there are approximately 100 million healthcare workers worldwide, a shortage of more than 4 million workers has been estimated. The gap in supply of human resources in EU healthcare has been estimated by the European Commission to reach approximately 1,000,000 health workers by 2020. This means that almost 15 % of the healthcare requirements of the EU population will not be covered. The lack of healthcare workers contributes to growing geographic and socioeconomic disparities in access to safe and effective healthcare, and will have a negative impact on mortality. pandeMics A pandemic is an epidemic occurring over a wide area, crossing international boundaries, and usually affecting a large number of people. Most recent pandemics include influenza H1N1, HIV, and multidrug-resistant tuberculosis. Prediction modeling of pandemics faces several obstacles and focuses mainly on influenza. Probabilistic methods allow testing prediction models, however, with insufficient accuracy of morbidity and mortality prediction. Worst case scenarios have proven to be misleading in the recent A/H1N1 pandemic, confirming wide variability in the severity of pandemic potential and unpredictability of emerging infectious diseases. Emerging pathogens (e.g. HIV) add to the complexity and uncertainty of predictions with a great variation in at risk groups. Migrating populations and increasing air transport may add to the increasing speed of global spread, making any new local pathogen a potential global threat. In the future, more baseline and realtime data will be obtained together with influenza surveillance among pigs and birds to enable early warning. Pandemic preparedness plans will improve, however; the accuracy of predictive models is not likely to increase due to complex interaction between an emerging pathogen and the ecosystem. Predictions of when and where the next human influenza pandemic will occur or how severe it will be have a great deal of uncertainty. Some mathematical models suggest an increasing hazard of another epidemic after about 25 years. Based on current surveillance systems data, we are likely to see pandemics of resistant bacteria in the nearest future due to increasing antibiotic resistance, unmet by generation of new drugs. Many bacterial infections will thus become untreatable in a few years' time with a global potential of spreading. patients on the Move The number of patients travelling across national borders in order to obtain healthcare services has risen steadily over the last decade, and is expected to increase further. In the US alone, it is estimated that 750 000 patients travel to access healthcare services, and this number is expected to grow by 35 % annually. In Europe more patients are expected to seek medical treatment across national borders as EU member states implement the requirements of the EU cross border healthcare directive in 2013. Drivers for rising patient mobility include long waiting lists, high healthcare costs in the home country, and improvements in technology and standards of care in many countries of the world. Popular medical travel destinations include India, Cuba, Singapore, Mexico, Costa Rica, and Thailand. The cost of healthcare poses a burden to the developed countries that could spark immense financial crises if not contained. IMF, April 2011 HEalTH proFESSioNalS aND oTHEr HEalTH WorkErS coSTS oF kEy HEalTHcarE procEDUrES iN USD US Cardiac surgery Bone marrow transplant liver transplant Orthopaedic surgery 50,000 62,500 500,000 16,000 Thailand 14,250 62,500 75,000 6,900 India 4000 Physicians 30,000 45,000 4,500 Dentists, pharmacists, physiotherapists Nurses total source: dg sanco, 2010 ESTIMATED SHORTFAll BY 2020 230,000 150,000 590,000 970,000 ESTIMATED PERCENTAGE OF CARE NOT COVERED 13.5 % 13.5 % 14 % 13.8 % source: india brand Foundation report, ibeF research 12 Global MEGaTrENDS ECONOMY from $, to � and THE iNDUSTrial rEVolUTioN shifted the economic centre of the world from Asia to the West, but this is now being reversed. Favourable demographic transition periods imply that relatively more of the economic outputs will occur outside the currently developed economies. This is likely to result in larger social changes and generate new business opportunities, but at the same time will impose further pressures on the environment. By 2020, it is possible that the size of the global middleclass will have doubled, with Asia accounting for 50%. an ongoing transForMation The world is in a period of massive shifts in economic power and influence, and these are likely to result in a significant future transformation in the structure of world production, global consumption, and financial power. Since the end of the Cold War, a large proportion of global production has moved to Asia, particularly China, while the share of global economic output from developed economies has simultaneously decreased from 70 % to 53 % today. These shifts in global economic gravity that have occurred over the last decades have brought with them changes in the various institutions of the world economy. Demand for commodities has surged, largely due to strong growth from China. Indeed, in 2008, a milestone was reached when nonOECD energy consumption exceeded that of OECD countries for the first time, largely due to developments in Asia. Development in capital markets has also flourished. Brazil, Russia, India, and China's (BRICs) share of global capital markets has increased tenfold over the last ten years, and in 2009 these countries attracted more investments than America and Europe combined. The reasons for high capital influx include the opening up of markets in Asia; they are already large in terms of volume (e.g. car sales, mobile phones sales), and they are predicted to grow strongly in the years ahead. Patterns of global trade and international relations are also changing. During recent decades there has been a growing tendency for developing countries to cooperate directly with each other. So-called "SouthSouth" trade, i.e. trade exclusively between developing countries, has expanded faster than world trade, driven by an increasing demand for food, energy, and semi-finished products. In this context, regional/bilateral trade agree-ments have grown rapidly. Although many of the trade agreements are registered through the World Trade Organisation, there is a tendency for direct bilateral engagements, beyond the domain of international organisations, particularly with respect to the relationships between China and parts of Africa. This may suggest a general trend for a higher degree of political autonomy being exerted, as particular developing countries increase their relative global economic power. Thus, factors concerning international relations might grow in importance towards 2020, as new economic powers become more visible on the world stage. These factors include shifts in military power, increased prominence of politically controlled corporations, economic protectionism, and the push for transparency and accountability in international resource trade agreements and infrastructure developments. shiFt FroM west to east and the south Fundamental changes are likely to continue towards 2020, as fast-growing economies are in a favourable demographic period that fosters continuous economic growth. largely due to aging populations and risks such as large existing debt levels, most OECD countries are likely to experience lower levels of economic growth in the future, and those shifts in economic gravity that are already evident are likely only to intensify. According to estimates by Goldman Sachs, the combined economic outputs of the BRIC countries may constitute 50 % of G7 by 2020, conservatively representing a doubling of economic outputs from China and India. Countries such as Vietnam, Turkey, South Korea, Mexico, Indonesia, and South Africa may also become more prominent on the global economic stage. To varying extents, high economic growth rates are likely to continue to boost infrastructure development as the populations in these economies expand, urbanise, and enjoy increases in their disposable income. By 2020, the investments of the fastest growing economies in infrastructure may be worth US$ 4.35 trillion, of which 60 % may be spent in China. Indeed, according to some estimates, by 2020, Asia may very well produce half of the biggest Western multinational sales and profits, about a doubling from today's levels. It is therefore not only likely that Asia and other fast developing economies will constitute future battleground for business, but it is possible that Asian multinationals will become increasingly significant players in the developed world. NEW EcoNoMic SUpErpoWErS DoUbliNG iN MiDDlEclaSS SpENDiNG 60 000 50 000 40 000 30 000 20 000 0 Middle East and North Africa Sub-Saharan Africa Asia Pacific Central and South America Europe North America 2009 2020 2030 year when china and india`s gdp`s will exceed todays rich countries. source: goldman sachs annual spending in usd by the global middleclass 2009-2030. source: oecd, (2010) Page 13 13 cENTrE of global economic gravity shifts eastwards Source: OECD, 2010 the global Middleclass set to double Towards 2020, the investment of the fastest growing economies in infrastructure may be worth US$ 4.35 trillion, of which 60% may be spent in China. Whereas shifts in centres of global production are well documented, strong economic growth over the last two decades has fuelled a vast increase in what may be termed "the global middleclass", defined as those with daily expenditures ranging between US$10 and US$100 per person. Towards 2020, this group may nearly double in size, rising from current levels of 1.8 billion people to 3.2 billion people, and representing an increase comparable to that of the combined populations of India and USA. The vast bulk of new entrants are likely to be from China, India, and other Asian countries, and Asia's current 25 % share in the global middleclass may double by 2020. The possible growth of the global middleclass is anticipated while many of the potential new entrants are currently living close to the lower poverty line, and high economic growth rates may lift these people over this defined threshold. However, it should be noted that although more people from the developing world will enter the ranks of the middleclass, absolute income levels will remain well below those of the very richest countries. In this respect, it is important to view the global middleclass as more than a consumer segment. With higher incomes, increasingly diversified spending is likely to emerge, that spreads beyond the essential spending related to maintaining basic human needs such as water, food, and shelter. In China and India, for example, current penetration of non-essential goods, such as broadband, personal computers, and automobiles, remains very low in comparison with Europe and USA, signifying that the possible "catch-up" potential is huge. Social services may be increasingly in demand domestically, pushing for infrastructure development in areas such as transport, healthcare, and communication. Hence, infrastructure markets, as well as the markets for non-essential goods, may experience rapid growth. This will further intensify the pressure and competition for those resources required to develop products and services demanded from the growing middleclass. A challenge which, in itself, may pose a constraint on the expansion of the middleclass. EcoNoMic oUTpUT SHiFTS To EaST UNcErTaiNTiES aND DiSrUpTorS 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 Others Others EU EU United States Japan United States 40% Japan Other Asia India Other Asia China India China of the world economy will occur in Asia in 2020 2000 2010 2020 � The nature and extent of future global GDP growth � Ability of China to switch from export led to consumption led economy � How the world will manage shifting relative economic power to Asia � Geo-political conflicts between slow growing and fast growing economies leading to restrictions on economic cooperation and potentially also conflicts � Social unrest which could disrupt economic production and may eventually lead to larger economic systemic changes 2000 share in % of2010 global middleclass. source: oecd, (2010) 2020 14 Global MEGaTrENDS GOVERNANCE old structures struggling with new challenges cUrrENT GoVErNaNcE STrUcTUrES were mainly created in a post World War II setting, and designed for concerns of an ealier and different time. Phenomena such as the EU, BRIC countries, Wikileaks and Facebook did not exist then, but are now shaping agendas worldwide. Handling the "goods and bads" of globalisation is a major challenge, and governance structures for collective action have yet to be developed. The modern challenges for effective and inclusive governance on global issues, such as financial stability, trade, climate change, water, and security, may be a source of increasing risks towards 2020. challenges and governance gaps Globalisation, population boom, and economic growth have created a world with high interdependency and complexity, leading to global challenges and systemic risks. Technological progress has integrated markets and created economic structures with global reach. The meltdown of the global economy in 2008 revealed a series of vulnerabilities in our governmental systems. An integrated global economy has also generated challenging systemic risks, such as pandemics, security crises, and threats from global terrorism. Additional risks are overpopulation, poverty, social-environmental and economic consequences of resource shortage, pollution, and climate change; governance structures are struggling to address all of these challenges. Global integration and free market ideology continue to reduce national governments' role in direct management of the economy. Regulators are mainly national, and global institutions, where they exist, have failed to respond. Political agendas and interest constellations of today are not those of the post-world war and cold war era. Thus outdated governance structures not adapted to the new world order are ill-equipped to address global challenges. The lack of agreement on collective actions magnifies the risks even further. Multiple actors and new arenas Many governance frameworks, global, regional, and functional, will continue to exist in parallel. Global governance will continue to be a mix of governmental and non-governmental activities that shape political and economic life. In the current global deregulated economy, business is at the heart of decision-making, and political involvement from business will continue in fora such as the World Economic Forum in Davos and the World Business Council for Sustainable Development. Meanwhile, civil society will attempt to act as a force that counterbalances corporate power. Civil society organisations, promoting values and purposes, will push agendas and have an important role in research and information exchange. New forms of global media, such as Whyweprotest, Changents, Facebook, Wikileaks, and various blogs, will continue to put pressure on governments to adopt sound policies. Social media may advance democracy and participation by promoting accountability in the political arena. On the flip side, social media democracy is shaped by ad hoc mobilisation and rapid shifts in attention. It is likely to promote a short-term and reactive mode of governance, at the expense of long-term strategies and political commitment. Thus, in combination with short-term electoral cycles, politicians may be pushed into a `symptom cure' mode of action, rather than being forced to address underlying root causes. National focus: By the middle of 2010, Global Trade Alert had identified 300 new protectionist measures among G20-members, pointing to crisis-era protectionism. NEW GoVErNaNcE STrUcTUrE? FacEbook popUlaTioN coMparED To coUNTriES are not the same as the post-world war and cold war agenda of aligned and non-aligned nations. The governance structure from that era cannot manage the new world order and is ill-equipped to face current global challenges. Political agendas 600 mill (2011) facebook Facebook 300 mill (2009) 308 mill 141 mill 0 (2004) 127 mill 81 mill 61 mill UK USA Russia Japan Germany only india and china have larger populations than Facebook source: clickymedia.co.uk / wikipedia (2011) Page 15 15 Social MEDia is playing an increasingly important role on the political scene. Source: Obama's Social Media Advantage, ReadWriteWeb, Nov. 5, 2008. towards a Future with higher risks Advances in technology and the flow of capital will continue to integrate markets, which will create interdependent global economic structures. How will the global world be governed by 2020 and what will be the consequences of failure? Governance innovations will have to manage interrelated problems. International Health Regulation (WHO) on health security is one area where global collaboration has been achieved and created winwin situations. For initiatives concerned with energy and climate change, however, consensus will be less viable, as the economic impacts of regulation are tied to existing industry structures, economic interests, and resource use. A major challenge will be to develop frameworks for handling burden-sharing and for distribution of costs and benefits. Without global agreements, national and regional governments will remain centralised towards 2020. There will be no automatic transition to global governance, and any fragile commitment to global cooperation will continuously be threatened by protectionism and nationalist sentiments. A key concern for regulation and governance will be obtaining sufficient anchoring in public support and legitimacy at the local and individual level. legitimacy must be built into the system. The world is changing faster than our global governance structures can adjust. The lack of effective and inclusive governance on global issues, such as economic crises, climate change, water, and security, will be a source of increasing risk towards 2020. governance directions towards 2020 International institutions will have to be reformed, reflecting power changes. Countries with the power to make a difference will be not likely be Western, will have fewer common interests, and will be more ideologically and culturally diverse. The contours of three possible developments are emerging. G20 power: G20 could expand its role in monitoring, regulating, and intervening in industrial and economic activities that pose risks to economic stability, and also address global volatility from effects of poverty, environmental security issues, and climate change. This would require the creation of new institutions, possibly inspired by the EU, with a commission to initiate common policy and with executive capacity. The G20 arena would gather economic heavyweights and delegate decision-making to smaller groups towards 2020. Success would depend on willingness to give up national sovereignty to a supranational authority. The current UN logic of `one country, one vote' would be abandoned, probably resulting in tension among countries without access. However, this may encourage participation in regional organisations in order to obtain representation in the G20 arena. Economic nationalism: With uncertain economic recovery, public interest is likely to concentrate on national conditions, pressurising politicians to `do something at home'. Political priorities would be focused on domestic innovation and renewal of industry structures to create employment. By the middle of 2010, Global Trade Alert had already identified 300 new protectionist measures among G20 members, pointing to "crisis-era protectionism". Trade barriers against countries that have not implemented measures to reduce greenhouse gas emissions, less stringent state-aid rules to fund investments, Research & Development, `buy national' provisions, and stimulus packages - all indicate the rise of economic nationalism. With these developments, public and political attention on global cooperation and on slowly evolving global crises is likely to dwindle. regional cooperation: Regional cooperative structures could become central for handling security issues and resolving territorial and bilateral disputes. As competition for energy, water, food, and mineral resources continues to grow, security of supply will become a primary concern and create territorial hotspots. Regional cooperative structures would govern access to critical resources and territory. Emerging regional cooperations would reflect the shift in power balances, trade patterns, resource locations, and geographical hotspots. larGE caScaDiNG FailUrES UNcErTaiNTiES aND DiSrUpTorS refer to breakdowns in an entire system, and are evidenced by co-movements amongst most or all of the parts. Concepts that describe systemic risks are: macro-shocks that are triggered when relatively modest tipping points hit their threshold and produce large, cascading failures on most or all of the system. Source: Goldin, Ian. et al 2010. Systemic risks � Droughts resulting in food scarcity and rationing of supply to the Western world � A climate induced major disaster in China, Europe, or USA � The financial drain from the "war on terrorism" forces global commitment to collective action � A major accident at a nuclear power plant � A technology breakthrough, resulting in low cost renewable energy � Breakdown of the internet over prolonged periods 16 Global MEGaTrENDS INFORMATION TECHNOlOGY moore's law still valid in 2020 iNForMaTioN TEcHNoloGy (IT), has had an enormous impact on personal life, business, and society at large. Easy production and sharing of information results in an exponential growth in data, and thus lead to challenges related to retrieval and security. The proliferation of cheaper, smaller, more powerful computers, combined with increased wireless connectivity, will not only result in greater automation and ubiquitous computing, but also in challenges for safety and (cyber)security issues associated with integrated software-intensive systems. inForMation explosion Information quantity is growing exponentially, and almost all of it is in digital form. In 2006, roughly 161 billion GB of new data were stored, and this will have increased by six-fold by 2010. The major drivers are cost reduction and replacement of analogue/ paper-based practices with digital processes. Miniaturization and embedding software in `Things', together with social media arenas, will further accelerate this trend. IT is being increasingly applied to new areas, both private (recreational, gaming, personal relationships) and industrial (healthcare, tourism, simulation), and by 2020 it is expected that 200 times more data will be generated annually than in 2008. With an expected price of less than US$ 100 for sequencing your own genome, several GB are likely to be added to your medical record. Advances in storage technology (10fold increase in storage capacity roughly every 4 years) will lead to storage costs of 0.5$/TB by 2020. The need for automated data management will become increasingly apparent, as will advanced search capabilities and knowledge discovery. The limited support-time for storage hardware, of generally 3 years, is likely to emerge as a significant problem. connect(h)ing "Connectivity" encompasses Internet access, mobile telephony, and all kinds of gadgets with wireless connections. In 2000, the total Internet traffic was just over 1 exabyte, and in 2010 will be about 256 exabytes, corresponding to an annual growth rate of 70 % over ten years. Although this rate of growth will reduce somewhat, it will reach more than 1 zettabyte well before 2020. In 2008, China surpassed the US in number of Internet subscribers. As only 30 % of China's population currently have Internet access (in contrast with 74 % of the population of USA), a further increase in Chinese Internet users is expected. This will result in Chinese becoming the dominant Internet language before 2014. An increasing proportion of information (news, books, real-time data, TV, entertainment) will be accessed via various handheld devices, and these will form ad hoc wireless networks with other autonomous gadgets in the vicinity. Thus, wherever a user goes, they will leave behind him/her a trail of digital traces. In developing countries, the focus will be on telephony and messaging rather than Internet access, leapfrogging beyond industrialized countries in the use of mobile phones by simply dropping wired telephone infrastructures. Urban 4G mobile phone telephony networks will be increasingly deployed, supporting between 100 Mbits/s and 1 Gbit/s for high mobility. powering up Today's mobile phones have the processing power of desktop computers 10 years ago. In 2020, mobile phones will have the power of today's PCs. Cheap, small distributed sensors will have the abilities of today's mobile phones. Moore's law from the 1960s, with the doubling of numbers of transistors every two years, will hold true until 2020. Further shrinkage is prohibited by quantum effects, but a continuation of the exponential growth in processor performance will be achieved beyond 2020 by stacking, multicore and multithreaded central processing units (CPU), grid and cloud computing, virtualisation, and use of memristors in integrated circuits. The raw processing power will impact data collection, and will allow intelligent monitoring and control. local, real-time data processing will highlight the need for new data formats and process models. Power computing will give rise to new requirements for programs and programming languages. The first quantum computers will probably be commercially available by 2020. SToraGE cHiNESE caTcHiNG Up WiTH ENGliSH storage capacity will cost 1000 times less in 2020 than in 2011 1 giga byte (gb) 1 tera byte (tb) 1 peta byte (pb) 1 exa byte (eb) 1 zetta byte (zb) 1 yotta byte (yb) = 1024 Mb = 1024 gb = 1024 tb = 1024 pb = 1024 eb = 1024 zb � movie on a dvd 50,000 trees made into printed paper 50% of all u.s. academic research libraries 20% of all printed material volume of digital information created & duplicated in 2010 1.3 yotta spits required to fill all the oceans 536.6 mill. 536.6 mill. English 27 % 444.9 mill.ChineseChinese 23 % 444.9 mill. 23 % 153.3 mill. 8% 153.3 mill.SpanishSpanish 99.1 mill. Japanese 5 % English 27 % 8% 99.1 mill.GermanJapanese 5 % 75.2 mill. 4% 657.4 mill. 33 % 75.2 mill.Rest German 4% 657.4 mill. Rest 33 % top internet languages (2009) source: internet world stats (2010) Page 17 17 a MEMriSTor is basically a resistor with memory. Their advantage lies in smaller size, less energy usage, faster operation and cheaper production. Source: HP soFtware everywhere High product flexibility, adaptivity, and robustness, at reduced cost and time-to-market, result in an ever increasing number of products containing embedded software. Mechanical control is replaced by digital control systems, and these are found everywhere, e.g. in washing machines, cars, telephones, even fitness accessories. In 2000, a car may have contained software with one million code lines, by 2010 this number increased a 100-fold, and by 2020 an equivalent car will probably contain 10 billion lines. Software engineering will face higher demands regarding effectiveness and cost-efficiency. Goal-based software synthesis and model-driven frameworks will increasingly replace prescriptive models, and multicore processors will try to utilize parallel processor capabilities. The need for scalable product version management, release control, verification, and validation will rise enormously. More autonomous, decentralized software applications (i.e. inhabitant software), combined with high processor power, will make central control increasingly difficult. Ensuring security, identity, and resource management will be of growing concern as users will put more trust in them. Electronic gadgets containing inhabitant software will become a part of, and utilize, cloud computing and grid networking. Judgement will be more momentary, resulting in higher demands for product quality assessment methods. the dark side oF cyberspace New technology, in combination with a double digit growth rate in inexperienced users, will attract criminals. Cyber threats range from fraud, ID theft, and credit card misuse, to money laundering, industrial espionage, and terrorism. Cybercrime attacks rose by 800 % between 2002 and 2008. Most cybercrimes are still economically motivated, but an increasing proportion target infrastructures such as power production and distribution, even hospitals. The number of potential security breaches increases disproportionally with greater system complexity. New social media, such as Facebook or Twitter, offer new ways of exploitation. With increasing reliance on software, greater decentralization, and higher connectivity, our modern societies are becoming extremely vulnerable. Small software faults or security flaws might have the potential to propagate automatically towards huge disturbances or exploitable weak points. Remote monitoring and control, or integration of industrial process software with enterprise software will generally result in more complexity, more instability, and more vulnerability. Integrated operations, in which, for example, the control of multiple oil production platforms is operated from onshore site(s), will thus have a higher security risk. Moore's Law from the 1960s, with the doubling of numbers of transistors every two years, will hold true until 2020 SEcUriTy aTTack DiFFicUlTy UNcErTaiNTiES aND DiSrUpTorS None 10 % High 17 % criminals Moderate 17 % still have easy access to corporate information systems... Low 17 % � Paralysation of Internet due to national or criminal attack � Major incident caused by software fault � Documentation of health hazards from use of wireless technology � IT usage for serving a greying society � Degree of spread of IT into new areas barriers for security attack on corporate information systems 18 Global MEGaTrENDS NATURAl RESOURCES natural resources under increasing stress THE oVEr-ExploiTaTioN of resources is one of the most important challenges facing us. Water will come under stress and alternative technologies may be hampered by scarcity of rare earth elements. Increased urban population will introduce new challenges, but also opportunities for recycling and better utilisation of waste. Addressing these resource issues is an immense, but not insurmountable, task. overexploitation oF the planet If humanity's demands on the planet continue at the same rate as today, by the 2020s the equivalent of two planets will be needed in order to maintain our lifestyles. Key building blocks for civilisation, arable land and water, will come under increasing pressure as the global population and standards of living continue to increase towards 2020. With emerging countries adopting the same consumption patterns as their industrialised neighbours, population growth is likely to exacerbate resource disparity further and impose additional pressures on already distressed ecosystems. Many resources are falling victim to overconsumption, with potentially dramatic consequences for society and environment. Climate change factors will further stress the biological capacity of the planet. Biodiversity loss, currently running at about 1,000 times the "natural" species extinction rate, will result in resources being lost forever. The economics of biodiversity suggest that deforestation alone costs the global economy US$ 2-5 trillion each year. Food For thought The proportion of people worldwide that are undernourished has decreased from 24 % in 1970 to 14 % in 2010. However, more than a billion people still do not have enough to eat. The UN Food and Agricultural Organization (FAO) reports that current world food production should be able to sustain twice the world's population, but one of the major challenges is efficient food distribution. In areas where food is abundant, enormous quantities of food are discarded at all steps of the food supply chain and also from households, and wasted food also means wasted water. In the US alone, as much as 30 % of food is thrown away. This corresponds to about 40 trillion litres of direct water usage in agriculture and processing operations, corresponding to the household needs of 500 million people. The economic crisis pushed millions of people into starvation; while the global demand for food, feed and fibre is expected to grow rapidly. Annual cereal and meat production will need to grow by 20 and 5 million tons, respectively, at a time when production is disrupted by increasingly frequent and severe extreme weather events. Industrialized food production is completely dependent on the use of manufactured fertilizers. Biofuel production has increased the pressure on fertilizers, in particular the macronutrients nitrogen, phosphorus, and potassium. Nitrogen is readily available, but the production of ammonia for fertilizer is a large consumer of fossil fuels, using 2% of the worlds energy production. Mining of phosphorous and potassium rapidly consumes these minerals; current known resources of phosphorous are likely to >> uneven global water challenges The water challenge isWater Use of supply, water use today is for agriculture (70 %), Average a question Per Person Per Day demand, and uneven distribution. The while industrial activities use 17 %, and US Australia Italy current rate of construction of new water domestic requirements and municipalities Japan Mexica infrastructure will result in a significant use 13 %. The demands of the two last Spain Norway supply deficit. Northern China, southern categories quadrupled in the second half of France Austria Denmark central India, southern Australia, the the 20th century. Financially, it is 3-4 times and Germany Brazil South West United States and the Middle more effective to create better demand Peru Philippines East will be the regions that are most solutions then to focus on the supply side. UK India China affected by water shortages. Bangladesh Kenya Towards 2020, the importance of water for Ghana Nigeria Towards 2020, new, more cost-effective power generation will also come into focus. Burkina Paso Niger Angola and energy-efficient desalination plants In 2007- 2008, power plants in USA were Cambodia Ethiopia have to be developed, as well as more will within days of being forced to shut down Haiti Rwanda efficient distribution networks. Currently, due to a lack of water for cooling. The Uganda Mozambique between 30 % to 50 % of225 distributed water frequency525 this600 of type of event is expected 0 75 150 300 375 450 is lost due to leakages, requiring Litres clearly to increase towards 2020. Moreover, most United Nations Development Program - Human Devopment Report 2006 large-scale investment in new infrastructure of the alternative energy and climate towards 2020. Regardless of improvements change technologies require considerable on the supply side, more efforts are needed amount of water. to reduce demand. Globally, the greatest WaTEr USEaGE rarE EarTH ElEMENTS US Mexico Norway Germany UK China Cambodia Uganda Mozambique 0 75 150 225 300 375 450 525 600 Litres average daily water use per person. source: undp 2006. Page 19 19 cHaNGiNG Global ForEST coVEr: Deforestation, estimated at above 13 millions hectares a year, or an area roughly equivalent to the size of Greece. Source: UNEP/GRID-Arendal rare Materials rarer >> be depleted within between 50 and 100 years, and "peak phosphorous" has been suggested to occur by 2030. Phosphorous reserves are controlled by five countries including China, USA, and Morocco (also controlling West Sahara's reserves). While phosphate rock costs are increasing, the quality is decreasing. One alternative source of phosphorous is recovery from municipal sewage, resulting in an added benefit of reducing the overall pollution load on lakes, waterways and coastal waters (eutrophication). The overall maximum potential from wild capture fisheries in the oceans has been reached or exceeded, and aquaculture production is expected to continue to increase in order to cover the world's need for marine protein, and will contribute at least 50 % of the fish consumed by humans. Aquaculture production is currently the fastest growing food sector (9 % annually), and is expected to continue to expand towards 2020, although at a slightly slower rate. Aquaculture is a large consumer of wild fish (typically fish not used directly in human consumption), so there will be a much more intense focus on sustainable practices in the seafood industry. An integral part of many alternative energy solutions is the use of permanent magnets in electric generators and motors. The production of these requires relatively large quantities of exotic and semi-exotic materials often referred to as Rare Earth Elements (REE). Neodymium, dysprosium, and samarium are used in permanent magnet motors, yttrium is used in lEDs, lanthanum is used as the anode in nickel metal-hydride (NiMH) batteries, cerium used in catalytic converters, and other REE are used as alloying elements, semiconductor dopants, and in welding applications. The global annual production of REE is concentrated in China, whose mines account for 97 % of global supplies (see table), at an all-time historical high. Until new mines are opened to satisfy the exponentially growing demand the production of hybrid cars and electric vehicles as well as new generation wind turbines may be constrained by limited production of permanent magnets. The photovoltaic industry is changing rapidly as solar cells are no longer just exclusively sawed wafers of pure silicon. Although thin film technologies are cheaper, they rely on tellurium, cadmium, selenium, and indium, elements that could become a limiting factor. None of the rare materials will be depleted by 2020, but the realisation that access to these resources will not last forever may generate an innovation pressure. urban Mining The waste stream represents a risk to the environment, public health and safety. However, the waste stream can also be considered as a resource stream. The largest challenge with the waste stream is separating the vast range components, compounds and elements that are otherwise comingled. landfills contain chemical, biological, biodegradable, non-biodegradable, electronic, wastes in liquid or solid form, some of which are hazardous or toxic. For most of these materials, present recycling rates are low, but high demand combined with limited resources is likely to encourage recycling. Theoretically, many streams, such as aluminium, steel, glass and some plastics, could be recycled indefinitely. Recycling these materials could result in significant energy savings; as much as 75 % less GHG emissions can be realized for recycled steel. Managing materials' wastes is directly linked to the recycling stream, but waste management is cumbersome. Most municipal recycling programmes rely on selective sorting by consumers and industries, which requires education, legislation, and suitable infrastructure. Currently 33 % of municipal waste in USA is recycled (up from 10 % in 1980), and many countries in Europe recycle 50 % of their waste but globally, only 10 % of aluminium foil is recycled. Towards 2020, goods will be increasingly designed to be reused and recycled in an automated way, and "urban mining" will become a growing focus area. coNSUMpTioN UNcErTaiNTiES aND DiSrUpTorS Two planets will be needed in order to support humanity's lifestyles in 2020. � Trade wars on rare materials � Severe water shortages in developed countries pushing the agenda towards more sustainable solutions � More cost and energy efficient desalination technologies � Breakthrough or fatigue with respect to recycling and energy efficiency � The discovery of harmful effects for certain substances � like it happened for asbestos � could lead to their ban and impact producing regions � Hybrid technologies will eventually lead to a shift toward new energy systems requiring different resources 20 Global MEGaTrENDS ClIMATE CHANGE a climate for change alTHoUGH, liMiTED cHaNGES to the global climate will occur over the next 10 years, climate scientists have concluded that in the next 30-50 years significant and disturbing effects will be unavoidable. Some changes are already clearly visible. If we assume "business as usual", global Green House Gas (GHG) emissions are expected to rise by up to 20 % by 2020. The next 10 years are considered to be crucial. Both for obtaining lasting emission reductions at a reasonable cost, but also to prevent a tipping point for an irreversible development. cliMate change indicators will be clearer than ever As individuals, we experience local weather and seasons, but we cannot directly sense global climate and how it changes. This can only be understood through monitoring systemic parameters across the entire globe over a long period. These parameters include air temperature throughout all levels of the atmosphere, ice thickness, extent and mass over continental scales, water temperatures across oceans at depths of hundreds of meters, changes in forests and groundcover that can be monitored by satellite imaging, gas, aerosol, and particle composition for the entire atmosphere, and more. Data accrued from these measurements over the next decade will show that most of the main indicators of climate change are following a more worrying trend than the worst case IPCC forecast published in 2007. The primary examples (already confirmed) are loss of polar sea ice cover and net melting of the Greenland and Antarctic land ice. These trends will continue to accelerate. Satellite data will show new, globallyaveraged high temperature records. New local high temperature records will be registered at many places across the globe, outnumbering by a clear margin new local record low temperatures. One of the most disturbing observations will be that the rise in atmospheric CO2 concentration will probably exceed the 2010 rate of increase of 3 ppm/year, after a decade of increasing by about 2 ppm/ year. Positive feedback processes will be confirmed to be operating, as indicated by a clear increase in atmospheric methane concentration, in addition to increases in CO2. By 2020, the extent of summer ice over the Arctic sea may be less than 10 % of that which has been considered as normal for the last 800 thousand years, further enhancing warming of Arctic surface waters. Dramatic climate change will appear to be unavoidable in the 30-100 year time-frame and the only remaining uncertainty will be how fast and how negative the global consequences will be. A climate change "tipping point", after which warming continues despite complete elimination of anthropogenic GHG emissions, may be confirmed to be unavoidable. The mechanisms and processes responsible for long-term climate change are relatively well understood, but current climate models do not include all the relevant 1st and 2nd order effects and therefore are not yet fully predictive. However, as simulation methodology improves and computing power increases, climate models will become much more reliable and will be able to provide relevant guidance for long-term planning. Such models may even provide new insights into how responses to climate change can be managed in more effective ways than are currently being considered. Before this, real-world risk management decisions will need to be made in order to start the long process of mitigating and adapting to inevitable changes. cliMate change and health Climate change is the biggest global health threat of the 21st century. Changes in the earth's surface temperature, sea level, precipitation and extreme weather events will put the lives and wellbeing of billions of people at increased risk. While the temperature rise is likely to be the greatest in higher latitudes (i.e. Greenland, Canada, Siberia), the profound health effects will occur among those with the least access to the world's resources, who have contributed the least to the climate change. Heat waves will cause increased mortality from respiratory causes among populations at risk. The changes in global temperature will also affect health through altered spread and transmission rates of vector-borne and rodent-borne diseases. Pathogen maturation and replication within the mosquitoes, the spread of insects to new geographical areas, and the likelihood of being infected are all affected by temperature rise; thus, malaria, tick-borne diseases and dengue fever will become increasingly widespread. The biggest impact of climate change, however, is believed to come from indirect effects on water, food security and extreme climatic events. More than one billion people rely on water from the Himalayas and are at risk of losing potable water following the melting of glaciers. In some African countries, yields from rain-fed agriculture will halve by 2020. Efforts to mitigate climate change are likely to have immediate positive health effects that may offset mitigation cost. life style changes following the reduction in CO2 emissions, i.e. increased physical activity, will have large beneficial effects on chronic diseases such as obesity, heart disease, diabetes and cancer. aTMoSpHEric co2 coNcENTraTioN PARTS PER MILLION 395 1.0 0.8 TEMpEraTUrE DiFFErENcES 390 0.6 0.4 385 0.2 0.0 380 -0.2 -0.4 375 2006 2007 2008 2009 2010 2011 -0.6 1860 1880 1900 1920 1940 1960 1980 2000 Years Monthly mean co2 concentration in hawaii. annual fluctuation in green. source: noaa global average near-surface temperature differences in �c between 1850 - 2009 zero = average teperature in year 1900. source: Met office SOURCE: Met Office Page 21 21 THE arcTic SEa icE melts considerably faster than predicted. The average summer ice volume in 2009 was 55% less compared to the 1979-2000 average. First-year ice is now the dominant ice type which is less resistant to waves resulting in a further increasing decay. The Arctic may indeed be free of summer ice already by 2020. Source: DNV, Natl. Snow and Data Center cliMate change Mitigation In the absence of strong international agreements, unilateral, regional, and bilateral commitments to emission reduction (e.g. EU) will become more important in the period up to 2014. It is also possible that the lack of political action may be balanced by strong shifts in consumer and corporate attitudes, resulting in a privatisation of climate change mitigation through voluntary shifts in consumption. In all cases, peaking of society's GHG emissions (either before or after 2020) will require fundamental changes in the way humans produce and use energy and organise their activities, especially in the electric utility, transport, and building sectors. By 2020, it will become clear which technological solutions and strategies are most cost-effective, and which technologies can be scaled-up. In parallel, a range of low-hanging fruit will be picked to reduce emissions, primarily energy efficiency improvements in the transport and building sectors. For each year that peaking of global emissions is delayed increases the acceleration of climate change due to positive feedback, and thereby ever more stringent measures will be required to reverse the climate change trends. By 2020, the level of anticipated damage in the next 25-50 years due to unavoidable climate change may become high enough to motivate in-depth evaluation of a range of geo-engineering concepts and solutions. Technological innovations will steadily reduce the cost of several key climate change mitigation strategies. Publicly supported research will be essential for achieving the required innovations, but it will also be necessary to adjust market signals through pricing of GHG emissions. the case For adaptation planning For the world to have a fair chance of keeping the average temperature increase below 2 �C over the next 100 years, global GHG emissions need to peak before 2020. Current strategies for permanently reducing GHG emissions are progressing too slowly. The EU-funded study PlANETS concluded that the best likely CO2 concentration obtainable is 530 ppm, with an expected temperature increase of 2.5 �C. It is therefore expected that in the next decade, negative consequences from climate change will impact the most highly exposed regions. Even if all anthropogenic emissions totally ceased from today, global average temperatures would continue to rise for centuries, due to the inherent inertia in the climate system and the long residence time of CO2 in the atmosphere. The shipping and offshore industries as well as other industries with infrastructure along coastal areas will need to expand their adaptation measures in order to resist higher environmental loads and floods. Coastal cities with hundreds of millions of inhabitants will probably be overwhelmed in the next 50 years, unless they take serious measures. Such upgrading and enhancement of flood protection systems are typically 10-30 year projects, so in order that they are effective in time for unavoidable climate changes, then they must be initiated within the next decade. A range of agricultural practices will be exposed to drier and hotter summers, less predictable rainfall in the spring, and reduced access to irrigation as competition for fresh water resources increases. Radical regional-scale changes in agricultural production will be unavoidable, requiring considerable planned and coordinated responses on both the national and international levels. By 2020, yields from rain-fed agriculture (the dominant method) in some African countries, could be reduced by 50 % from already inadequate levels. Global Warming UNcErTaiNTiES aND DiSrUpTorS is inevitable due to the thermal inertia of the oceans. Source: Science, Wigley SEa lEVEl riSE: obSErVaTioNS aND MoDEl Satellite Observations IPPC projections (2009) 6 3 0 -3 1970 Tide Gauges Measurements 1980 1990 2000 2010 � large quanities of methane and CO2 are released from thawing of Siberian peat bogs � The melt water of Greenland permanently disrupts ocean currents, e.g. Gulf stream or the deep water conveyor belt � Major vulcanic erruption that (temporarily) reverses or halts global warming � There is still uncertainty about the strength and effect of different feedbacks in the climate system that could result in tipping points where unforseeable cascading effects can occur. � A warmer ocean could also lead to the emission of methane from clathrate hydrates in ocean sediments. Sea Level Change in cm the measured sea level rise is on the upper extreme of ippc's projections. source: ippc (2009) From megatrends to SCENARIOS IntroductIon Global megatrends will influence the development and uptake of future technologies, both directly and indirectly. However, other important issues associated with significant uncertainty from a 2020 perspective, might also have a considerable impact on healthcare and associated technology uptake. We have therefore used a scenario approach in which we explore combinations of drivers with a high impact and a high degree of uncertainty for the healthcare sector. Developing useful scenarios for a sector which is largely national in nature is challenging but the intention here is to illustrate that the future may develop in different ways depending on a multitude of factors rather than predict the future. Economic growth (robust/fragile) and the move towards either curative or preventative care (preventative/curative medicine) were selected as the two main drivers. Together, they form four possible alternative futures. 23 How to read tHe scenarIo cHart: Our two main drivers divide the future into four scenario quadrants. These four scenarios will be referred to in the following section, when analysing to what extent technologies will be used by 2020. The three circles in the scenario chart symbolize varying degrees of technology uptake. The inner, smallest circle denotes low uptake, the outer circle high uptake, and medium uptake is the middle circle. This illustrates how the uptake of a particular technology will vary according to our position on the scenario scales. lOW MEDIUM HIGH vertIcal axIs move towards preventive medicine vs. move towards curative medicine This axis represents whether there will be any shift between the resources spent on treatment and therapies provided to a patient with an intent to improve symptoms and cure the patient's medical problem versus those interventions designed to avert illness or injury. PREVENTIVE MEDICINE M NE ICI ED WE AL TH Y TH AL HE FRAGILE ECONOMIC GROWTH TOU GH ROBUST ECONOMIC GROWTH Fragile economic growth vs. robust economic growth This axis represents whether the world economy has recovered from the financial crises in 2008 and 2009 and thereafter returned to robust economical growth or if we have a world that stills struggles financially. There will be local discrepancies regardless of scenario, but it seems likely that, independent of funding mechanisms, the availability of funding for healthcare will be linked economic growth. LL Y IL L CURATIVE MEDICINE EX P NS E VE I CU HorIzontal axIs RE CR ITI CA 24 ScENario scenarios for the healthcare sectors TOU GH M NE ICI ED CR ITI TOUGH MEDICINE ImPacts Standards in clinical practice rise, driven by centrally developed and imposed healthcare quality metrics. There are stricter requirements for medicine to be evidence-based and more cost-effective than alternative interventions. Medical innovations focus more on low cost, or targeted solutions, often directed at monitoring health indicators. Expensive drugs and interventions that cannot pass the rigorous cost-benefit requirements of health authorities are increasingly only available to the wealthy. Focus on environmentally sustainable lifestyles advocated through social media. Decisions around prioritisation of healthcare are distanced from political control and largely influenced by the work of health economists. IndIcators The proportion of GDP spent on healthcare is stable. life expectancy remains stable, with no significant change from that in 2010. There is a slight decline in the number of preventable chronic diseases compared with 2010. Taxation on unhealthy foods and other mechanisms introduced. Dedicated centres for preventative medicine are established, although as scarce resources restrict them their impact is limited. CRITICAllY Ill ImPacts Many United Nations' Millennium Development Goals are still not achieved, including ending poverty, universal education, gender equality, child and maternal health targets, combating HIV/AIDS, ensuring environmental sustainability, and establishing global partnerships. Pandemic preparedness is low. The resource rich continue to have access to good quality healthcare, either at home or abroad, while, on a global basis, more and more people struggle to find even basic healthcare of reasonable quality. Hospital-acquired infections and other patient safety metrics remain at an unacceptable level. Hospitals are falling behind in technology investments. Hospitals are judged on the number of patients treated and how well they stay within budget. More patients are readmitted to hospitals following a demand for efficiency with early discharge. IndIcators The cost of healthcare is rising and takes up a greater proportion of GDP. Only 2 % of health expenditure is spent on prevention and public health programmes in developed countries. A growing population is without healthcare insurance. The increase in life expectancy reaches a plateau due to higher mortality among patients with chronic diseases. There is a 50% increase in the incidence of adverse events in hospitals compared to 2010. Hospital acquired infections and other patient safety indicators remain high. CA LL Y IL L storYlIne - touGH medIcIne Funding for healthcare, measured as a fraction of gdp, has remained stable for several years, despite the fragile world economy. a social movement of "responsible citizens", led by younger generations and promoted through social media, has become influential. they are driven by the belief that we cannot live how we please, but must promote lifestyles that are healthier for the planet and for ourselves. recognition of the financial and human burdens of increasing chronic disease, fuelled to a large extent by obesity, has led to greater investments in public health. healthcare decisions are increasingly evidencebased and rely on cost-effectiveness. policies have been developed that facilitate government, industry, communities, families, and "society as a whole" working together to change behaviours and create healthy environments. several countries are close to the goal of being "smoke free", and recruitment of new smokers has virtually stopped. likewise, unhealthy eating and unhealthy lifestyles are becoming less socially acceptable. public health funding comes at the cost of limiting the resources available for secondary care. this is managed by continued focus on quality, evidence, and efficiency, as well as by tough prioritisation of resources. storYlIne - crItIcallY Ill several years of a stagnating world economy have put severe pressure on healthcare spending. rising healthcare costs are unsustainable, and are taken as a clear indicator of the need for fundamental healthcare reforms in many countries. nevertheless, very few governments have the political will to push through unpopular changes that threaten the access of the general public to expensive drugs and technologies. cuts that are implemented usually target public health campaigns, and infrastructures are desperately needed to control ever-increasing obesity and to promote a healthier lifestyle. due to the lack of necessary investment in the wider changes needed in society to promote a healthier lifestyle, the burden caused by chronic diseases continues to increase. lack of adequate resources and a series of restructurings designed to cut costs have resulted in serious wage cuts in the healthcare sector, leaving staff generally demoralised, and making this career option less attractive for young people. recruiting the necessary new resources into the healthcare sector is proving very difficult and healthcare personnel are migrating within and between countries. in order to cover critical needs and to speed up processes, regulations for healthcare education certification in developed countries have become less strict, leading to potential safety and health hazards for patients. work in hospitals is focused on efficiency (number of patients treated and meeting the budget), with great variation in quality and safety. investments in research, monitoring of adverse events, and risk management are scarce. Page 25 25 WE AL TH Y TH AL HE WEAlTHY HEAlTH ImPacts Costs associated with chronic diseases are still high, although there are some initial signs that investments in wellness are starting to pay off; for example, levels of type II diabetes have stabilised globally, and are starting to fall in some countries. Wellness programmes are an essential part of any healthcare strategy or plan. The attractive profits within the healthcare sector drive innovation of new services, technologies, interventions, and drugs. As patients require transparency, accountability, and choice, quality indicators are developed that include patient safety metrics and results are published online. IndIcators There is a growth in healthcare spending, both in real terms and as a percentage of GDP. life expectancy at birth continues to increase. Rates of smoking-related cancers and cerebrovascular disease decline. Road traffic deaths decrease by a further 10 % in high-income countries. Preventative healthcare spending increases and is provided in new arenas. New services, such as healthcare "coaches", help individuals to navigate through healthcare institutions and extract maximum benefit. Home health services prosper, driven by advances in telemedicine and remote patient-monitoring technologies. Alternative care delivery models emerge as more care is provided beyond the walls of the doctor's office or hospitals. The cost of genome decoding plummets, and the market in developed countries for this service explodes. Hospitals start to reorganize and rebrand themselves as health and wellness centres. ExPENSIVE CURE EXP EN ImPacts Increasing specialisation in hospitals enables them to provide "production line" services, characterised by high quality and efficiency, although errors are less easily identified, due to complacency and over-reliance on technology. Patient safety metrics are published by many hospitals, often as part of their marketing activities. Medical tourism continues to expand and becomes the norm for several conditions and diagnoses. IndIcators The proportion of GDP spent on healthcare increases due to costly technological advances. life expectancy remains stable or decreases slightly compared with 2010. The incidence of obesity and chronic diseases continues to rise. More than 30 % of the populations in developed countries are obese. There is a steady increase in the building of new high-technology hospitals. Road traffic deaths increase substantially in low and middle-income countries. storYlIne - wealtHY HealtH Most national economies have enjoyed steady growth after the financial crisis of 2008/2009. this has led to continued improvements in living and working conditions, as well as progress in medical care. the aging population has resulted in the "silver economy" of the 2020s, in which the older population remains engaged in, and contributes to, society. there is greater confidence among consumers, with "health and wellbeing" becoming one of the most profitable sectors in the economy. globally, healthcare remains fragmented, with markets generally national in nature. Modern healthcare responds to the demands of the new patients, and welcomes patients as valuable partners who contribute actively in their own health decisions. the philosophy of patient-centred care becomes the norm, and includes many aspects of preventative medicine, often supported by emerging sensor, genomic, and it-based technologies. people turn to the internet for healthcare and wellness information. social media and online communities now form an important channel for both healthcare and self-help providers. the shortage of qualified healthcare workers has never been higher, as colleges and universities struggle to respond to the challenge to educate more. storYlIne - exPensIve cure biotechnology has started to deliver major breakthroughs in treatment of chronic diseases, but as these technologies reach the clinics, costs continue to rise. however, the continued buoyant international economy has enabled elevations in healthcare costs, and politicians avoid making unpopular decisions regarding the need to prioritise healthcare resources. people enjoy the security and material benefits brought about by the wealth derived from years of sustained growth. the effects of public awareness campaigns on tobacco, alcohol, and processed food consumption that were promoted a decade ago are substantially diminished. advertising campaigns run by commercial interests have made it socially acceptable to be obese, smoke, or misuse alcohol. people choose to enjoy the "here and now", and only seek medical advice when they think that they have a problem to be fixed. through initiatives driven largely through the private sector, international quality metrics and standards for secondary care have been developed and are increasingly adopted in both the private and public healthcare sector. these, in turn, facilitate the movement of patients, healthcare staff, and technologies across borders. VE SI CU RE Technology upTake: HealtHcare The central section of Healthcare Technology outlook discusses a selection of technologies that we consider to become pertinent by 2020. Many of the technologies described are not revolutionary. Many may have been around for some years, but have had little impact to date while others may progress more rapidly from development or discovery to impacting on patient care. Depending on how the future develops (and which scenarios emerge and dominate) certain technologies might become recognised as important innovations towards 2020, while other promising technologies may play a less important role. The extent to which a particular technology will be used in the various scenarios is qualitatively indicated as "low", "medium", or "high". our description is by no means a ranking of the most important future technologies. it is a selection of those technologies that we consider to have great innovation potential when applied at the right time. CONTENTS information Technology The adoption of information technology lags behind in healthcare. How may information technology solve the challenges of healthcare in 2020? 32 The internet changes healthcare The Internet is an integrated part of many industries. How will the Internet change the delivery of healthcare? 34 remote care Healthcare is facing challenges in growing expenditure and increased demand for services. Will remote care enable healthcare services in meeting these challenges? point-of-care Contextually and conceptually new technology will become available at point-of-care. How may new technology applied at the point-of-care improve healthcare delivery? personalized medicine The cost of DNA sequencing will plummet towards 2020. How will the availability of the technology influence the management of disease? 36 38 40 Next generation imaging Personalized medicine is an emerging trend. What imaging technologies will be adopted during this decade to support the trend in diagnosing disease and monitoring of treatment? Novel medical treatment Research and innovation ensure continuous medical advances. Which technologies will benefit management of disease? 42 44 28 TEcHNoloGy UpTakE HEAlTHCARE information technology � handling healthcare data ImPlementatIon oF InFormatIon tecHnoloGY is considered one of the major challenges for healthcare during this decade. Internationally recognized interoperability standards will emerge, which, in turn, will promote the adoption of integrated electronic health records. Traceability systems document the activities along the patient pathway. As the volume of information per patient escalates, decision support software will assist clinicians in adhering to best practices. INTRODUCTION Healthcare Information Technology (HIT) should improve the quality, safety, and efficiency of healthcare. This may be achieved by structuring workflow, detecting errors, and providing evidencebased decision support at point-of-care. However, in comparison with other technology and information intensive industries, healthcare lags behind in terms of IT adoption. Modern intensive care units and operating rooms can contain from 50 to over 100 pieces of electronic equipment, many which are unable to communicate with each other or work efficiently together. This lack of communication and standardization may pose a hazard to patient safety and also hinder new technologies from improving productivity and reducing costs in healthcare. Initiatives that support interoperability and standardization of equipment, such as the development of integrated electronic health records, will facilitate the uptake of IT into healthcare systems. The huge amount of information generated per patient while keeping pace with continued medical advances, may present an obstacle to healthcare professionals and become a hazard, rather than an advantage, to the patient. Development of computerized clinical decision support systems will enable clinicians to provide care that is in adherence with guidelines, thereby improving patient safety and the quality of care. standards � enabling sharing oF healthcare data Appropriate standards for healthcare information and systems provide the backbone for achieving a healthy healthcare infrastructure. The lack of integrated systems for handling healthcare information can result in diagnostic errors, failure to identify deteriorating patients, communication errors, and inefficient workflow. Industries such as financial services successfully deployed interoperability standards long ago, as a means to improve productivity. Healthcare lags behind other industries in implementing interoperability standards, partly because appropriate standards do not exist, but also because too many exist and because they are inconsistent. Standard Development Organizations, Special Interest Groups, and other initiatives have been established to address the issue of standards in health IT. International Standard Organizations and consortia supply the framework upon which interoperability will develop. The task of driving interoperability standards in healthcare is complex, but successful development of such standards for the healthcare industry will facilitate integration of disparate data streams and clinical workflows into a single smart system, as already occurs in other industries. For healthcare, the ultimate result will be improvements in patient safety and greater efficiency in healthcare delivery. Hospitals with automated notes and records, order entry, and clinical decision support have fewer complications, lower mortality rates, and lower costs. Arch Internal Medicine CHAllEnGES, SolUTIonS And oUTCoME Challenges Medication errors Fragmented healthcare delivery Rising cost of healthcare Increasing labour shortage HIT solutions Electronic prescription SAvInGS FRoM HIT Outcome Better access to information Integration of agencies Improved efficiency Integrated electronic health records PACS, EMS, telehealth Workflow management solution Staff retention source: rand health (www.rand.org) the potential of healthcare information technology to improve healthcare delivery. 29 HIGH MEDIUM lOW RD S RE CO RA TE D RD IlI CE AB DA ST AN TE G CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO integrated electronic health records Data about an individual patient, such as medical history, radiology images, laboratory test results, and recordings of vital signs monitoring, are often stored in separate systems that are unable to communicate with each other. An integrated electronic health record (EHR) is a systematic collection of all electronic information relevant to any individual patient. An EHR has the ability to generate a complete record of any single patient-healthcare encounter, including medical history, medications and allergies, radiology images, laboratory test results, immunization records, monitoring of vital signs, patient tracing information, evidencebased decision support, quality management, outcome reporting, and much more. The success and implementation of the integrated EHR depends largely on agreement of standards for interoperability. Integrated EHR has the potential to contribute to improved patient safety and efficient healthcare delivery. >> management. Traceable items may be tangible (patient, device) or less tangible (processes). Continuous standardization and harmonization of identification regimes and technologies will facilitate information exchange platforms that enable electronic traceability of all activities and items in an institution and between institutions with different global locations. The flexibility and scalability of novel traceability solutions will enable real time patient safety management and promote operational excellence. clinical decision support systeM � providing a second opinion A computerized decision support system has the potential to improve guideline adherence. Clinical decision support systems (CDSS) are software systems designed to assist physicians in interpreting clinical signs and reaching a definitive diagnosis and appropriate treatment plan. The software matches individual patient characteristics to a computerized knowledgebase, generating patient-specific recommendations. The systems are based on artificial intelligence techniques, such as neural and Bayesian networks, that have the ability to incorporate new data. Such systems are especially valuable in high complexity situations where the amount of available information is so great that it hinders an intuitive interpretation or diagnosis by healthcare professional. The provision of CDSS to provide "just in time, just for me" support at the point-of-care is one of the greatest challenges for healthcare in the 21st century. The deployment and future development of CDSS has the potential to improve patient safety through improved adherence to guidelines. traceability Healthcare service providers represent complex nodes of supply and value chains with complex tracking and tracing requirements. The systematic and structured capturing and exchange of specific data in an electronic traceability system is a powerful tool that enables providers to manage and improve the delivery of healthcare services. Information carriers and labelling technologies, such as barcodes, 2D matrices and Radio Frequency Identification (RFID) are being refined and tailored to the specific needs of the health care sector. Further development of readers and scanners will enable traceability of items of miniscule proportions parallel to enabling product lifecycle support and patient safety >> TRACEABIlITy InFoRMATIon ovERloAd Food Facts per Decision Personnel 1000 Medical devices Proteomics and other effector molecules 100 Functional Genetics: Gene expression profiles Lab tests Pa$ent Manage- ment 10 5 0 1990 2000 2010 2020 Human Cognitive Capacity Pa$ent- provider interac$ons Recycled assets The patient represents athe of many traceable services. hub patient represents a hub of many traceable services. source: learning healthcare system concepts v. 2008. annual report. ioM roundtable on evidence based medicine. DE CI TR A TOUGH MEDICINE IN Structural Genetics: e.g. SNPs, haplotypes Decisions by Clinical Phenotype SI O N SU PP O S TY RT 30 TEcHNoloGy UpTakE HEAlTHCARE the internet changes healthcare � empowered patients take control IndustrIes across different sectors globally depend on the Internet for communication. Healthcare providers, however, lag behind in the implementation of internet solutions. online social networking is gaining rapid popularity globally and is an important arena for information sharing. While virtual reality is associated with computer games and simulation in aviation it may also benefit healthcare systems. Advances in web technology will provide powerful tools for online information retrieval. Finally, internet technology will enable the patients to access their own healthcare information and to contribute to their own health records. INTRODUCTION After the introduction of the Internet two decades ago, the number of users has increased steadily and by 2020 it is expected that 5 billion people or approximately 66% of the global population will use the Internet. The internet has redefined the traditional communication media such as telephone, television, music, and film. News media and other printed media, retail, financial services have all adapted to web technology and provide online products and services. Advances in web technology enable new ways of human interaction through social networking. Many healthcare systems, however, have been slow in adopting web technology into their services. Patients will lead the way towards changes in how healthcare services are delivered. An increasing number of patients go online to search for information and knowledge that was previously only available to professionals. Patients use social networks to share personal information about their health with family, friends, and support groups created by other patients with similar conditions. The adoption of new technology enables a shift from paternalistic to conversational medicine. Patients become partners in managing their own condition and seek professional advice from a physician before they make their own decisions regarding their own treatment plans. social networking and support groups Social networking plays an increasingly prominent role in healthcare. Social networks such as Facebook and Twitter transmit user-generated media such as text, video and audio among a group of people with common interests (friends, family, profession etc.). Social networks may be used to share healthcare information between consumers, between patients, and between patients and healthcare professionals. For instance, health information such as blood pressure, ECG, body weight, results from home testing, and drug compliance, may be shared online with whom the patient decides, e.g. designated healthcare professionals. The application of social networking in healthcare enables a two-way sharing of health information between patients (peer-to-peer) and may improve communication between patient and healthcare professional with potential cost saving effects. virtual reality A skilled and knowledgeable workforce is essential for a safe healthcare environment. Advancement in game technology facilitates new approaches to continuous education and training in modern healthcare systems through the Internet. Virtual reality (VR) refers to computer-simulated environments that simulate physical presence in the real world. The sensory input is usually visual either on a computer screen or through stereoscopic displays and auditory through speakers or headsets. Developers may create virtual hospital environments with patients and healthcare professional avatars for simulation of clinical skills and team work to improve work force skills. Disseminating health information in the virtual reality via the Internet provides effective health communication and produce reallife health results at low cost and with high impact. SoCIAl nETWoRkInG And SUPPoRT GRoUPS InTERnET BloGS source: www.patientslikeme.com source: www.mayoclinic.com 31 HIGH MEDIUM lOW S AN OC D IAl SU N PP ETW O O RT R G KIN RO G UP S VI RT UA l RE Al IT Y TI C CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO seMantic web The average online health search is redundant, piecemeal, and highly keyword sensitive. Semantic Web (Web 3.0) is a system for connecting web information based on the meaning and context of the information, depending on common formats for integration and combination of data drawn from diverse sources. The development is a collaborate effort led by the World Wide Web Consortium (W3C) to provide a common framework that allows data to be shared and reused across application, enterprise and community boundaries. The technology, in concert with social networking and other applications, will become a powerful tool for sharing knowledge across communities. It will enable healthcare professionals and patients to make well-informed decisions based on context sensitive searches within different areas such as drugs, patients, diseases, proteins, cells, and molecular pathways. personal health records Traditionally healthcare professionals are responsible for recording and storing patient records, the owners of the information, however, are typically the patients. Currently available online services such as Microsoft HealthVaultTM enable patients to record, store and transfer their healthcare information between a variety of health-related applications, devices, services, and clinical systems, and will increasingly be used by patients. Patients will be able to author and comment on their own healthcare information online, as "wikirecords". Recordings of blood pressure, blood glucose, body weight, physical exercise, and drug compliance will be uploaded and assist patients with chronic conditions in managing their health. The information may then be shared with other healthcare providers, family, friends and special interest groups. Enabling and allowing the patient to record their own health data, access their own lab results and to share the data with whom they decide is going to change the way healthcare services are delivered. "The ability to log on to my medical records online has changed my relationship with the doctor: it has become a discussion when I see him, rather than him saying Do this, do that'. 60 year old patient from the UK vIRTUAl REAlITy GloBAl PEnETRATIon oF THE InTERnET In 2011 Internet Penetration Rate, 2011 North America Oceania/Australia Europe Latin America Middle East World Average Asia Africa 0 10 20 30 40 50 60 70 80 90 source: www.secondlife.com source: www.internetworldstat.com SE M TOUGH MEDICINE P RE ERS CO ON RD Al S AN HE Al TH W EB 32 TEcHNoloGy UpTakE HEAlTHCARE remote care � connecting patients and healthcare workers through telecommunication advances In tecHnoloGY will continue to move healthcare delivery setting away from highcost hospitals and into alternative and low-cost arenas. In developed countries, telemedicine will enable patients to receive healthcare at home. Small, wireless biomedical sensors and ultra-wideband radar technology will enable monitoring of patients in different, non-medical settings through wireless networks. Smartphone applications will continue to be developed and those aimed at healthcare will provide new ways for patients to communicate with their healthcare providers. INTRODUCTION The growing demand for healthcare services, together with a shortage of healthcare professionals, will require a shift in focus from addressing established disease states towards proactive management of wellness, and in particular, prevention and early detection of disease. Home-based monitoring systems such as mobile, low-cost, light weight, intelligent biomedical sensors, and wireless communication provide an innovative and pragmatic approach to early detection of significant clinical signs that may require intervention in the chronically ill patient. This enables acutely and chronically ill patients to stay in their own home, reducing the burden of hospital admissions. Worldwide, approximately 40 % of the population live in rural areas without health services, as do more than 80 % of the populations of developing countries. Remote care may overcome geographical barriers in less populated areas with limited access to healthcare services, mainly by linking providers based at health centres, referral hospitals and tertiary centres. teleMedicine The growing aging population and the need to reduce healthcare spending in developed countries impose new ways to provide healthcare. Concomitantly, large populations in developing countries lack access to timely quality healthcare. Telemedicine is the delivery of healthcare where geographical distance is a key factor. It includes the use of ICT such as computers, video camera, the Internet, and mobile phones to improve patient outcome by increasing access to care and medical information. In developed countries, telemedicine enables patients with acute and chronic diseases to receive care at home, avoiding hospitalization. In developing countries telemedicine is typically used to overcome geographical barriers linking providers at health centres, referral hospitals, and tertiary centres. Telemedicine continues to move healthcare delivery from the hospital into the home in developed countries. The wide range of applications of telemedicine has transformed it from a technological augmentation of medical care to a novel system of health care, reducing healthcare spending and providing healthcare to populations in developing countries who lack good quality healthcare. bioMedical sensor and wireless Monitoring technology Advances in novel medical sensors facilitate continuous monitoring of patients in their own homes and in situations outside the traditional setting of a hospital or intensive care unit. Biomedical sensor networks may span an individual's body and home, measuring a wide range of characteristics. Such networks typically rely on tiny wireless sensors, either incorporated into items that can be worn (e.g. shirts, caps, gloves) or inserted into the body. Examples of sensors include electrodes for sensing and recording of an electrocardiogram (ECG), >> TElEMEdICInE AT HoME dIGESTIBlE CoMPUTER InTEGRATEd In MEdICInE telemedicine to follow up on patients in their homes. source: proteusbiomed.com 33 HIGH MEDIUM lOW Y RA G DA R NO EB A NE TE CH CI SE NS O TE lE M CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO sMartphone applications >> haemodynamic sensors that are surgically positioned for blood pressure monitoring. Signals from the sensors can be collected and processed for analysis, either locally or at an external location. The healthcare provider uses the results to tailor the management of the patient as appropriate. Sensor technology opens up for a wide range of ambient monitoring that may avert serious diseases such as a heart attack or a stroke, keeping patients out of the hospital with a healthcare cost saving effect. Smartphones are handheld computers with powerful computing capabilities that are rapidly gaining market share. The open operating systems encourage development of applications that may also be used in healthcare. The technology for smartphone applications is based on the most frequently used platforms, including Android, Apple iOS, RIM BlackBerry, Symbian, and Windows. In hospitals, the smartphone applications are already being used for workflow activities, such as receiving lab results, scheduling, providing information lookups, and improving information dissemination, and is only likely to increase in the coming years. Smartphone applications may also enable patients themselves to access healthcare information, actively participate in their own care, and maintain contact with the healthcare provider. The applications have potential for improving patient care and safety through better communication between staff, and between healthcare providers and patients. ultra-wideband radar Continuous monitoring of a patient's vital signs is traditionally conducted in specific settings, such as intensive care units. This is partly because continuous monitoring drains resources and partly because continuous monitoring reduces access to the patient and limits patient mobility. Ultra-wideband radars emit narrow electromagnetic pulses, and analyse the reflection signals received for characteristic indicators of material boundaries and movements. The signals penetrate biological tissue, are non-contact, and non-ionizing, and the device is portable, cheap, and has low power requirements. The highly intense pulses enable remote monitoring and measuring of motion over short distances. The potential clinical use of UWR includes monitoring of the patient either through a device installed in the hospital bed or mounted to the ceiling at a distance from the patient. This technology may be used for remote monitoring of vital body functions, such as breathing, electrical activity of heart (ECG), oxygen saturation of a patient's blood, and may be suitable for longterm, continuous monitoring, both out-of-hospital and in-hospital. PoTEnTIAl USE FoR UlTRA-WIdEBAnd RAdAR SMARTPHonE APPlICATIonS potential clinical use of uwr. source: akvelon SM AR TOUGH MEDICINE Ul TR A TP HO ED I -W R ID NE AP PS lO ND 34 TEcHNoloGy UpTakE HEAlTHCARE point-of-care � moving technology from the laboratory to the bedside PoInt-oF-care refers to moving the technology to the patient rather than moving the patient or samples to the technology. It has the potential of improving healthcare accessibility and delivery through shortening of the timeline between testing and availability of results, thus facilitating early diagnosis and reduction in healthcare cost. As technology become more robust and compact, traditional laboratory tests and technologies such as ultrasound, nucleic acid identification and nuclear magnetic resonance become portable. INTRODUCTION Point-of-care means bringing diagnostic tools right to the site of patient care. Point-of-care technology allows diagnoses to be conducted in a physician's office, in an ambulance, at home, in the field, or in hospital. Examples of traditional point-of-care diagnostic tests include: home pregnancy testing kits and bedside monitoring of arterial blood gasses in the intensive care unit. Advances in technology are improving the portability of diagnostic devices and will enable introduction of new diagnostic tests for use at the point-of-care, thus facilitating timely treatment. Novel point-of-care technologies may include well-known technologies, such as diagnostic ultrasound, being applied in a new context and also conceptually new technologies, such as lab-on-a-chip for biochemical and antibody-based assays, micronuclear magnetic resonance for antibody-based identification of bacteria and tumour cells, and nucleic acid testing for infectious diseases. Point-of-care technologies are rapidly expanding and are expected to contribute substantially to improvements in treatment quality. Challenges to overcome include issues concerning sensitivity and specificity, and limiting the technology to those applications for which time to intervention or treatment may be usefully reduced. portable ultrasound Real-time dynamic imaging of body organs provides guidance for invasive procedures and diagnostic assessment, but the size of traditional equipment has limited its availability and use. Ultrasound imaging uses highfrequency (1-18 MHz) sound waves for dynamic assessment of soft tissue and internal organs. As the technology advances, the image quality produced by portable ultrasound systems will improve. Cost reductions will accelerate transfer of the technology to new areas of point-of-care. In-hospital ultrasound imaging will become a standard bedside procedure for rapid assessment of disease status and for visual guidance during various procedures performed by physicians and other healthcare professionals. In developing countries, the technology has the potential to meet a large proportion of all imaging needs. Dissemination of the technology will contribute to improve availability in most fields of clinical practice, facilitating early and accurate diagnoses in healthcare worldwide. As this technology becomes more widespread, there will be an urgent need to ensure appropriate training for all operators so that inappropriate use or erroneous results are minimised. lab-on-chip The time lag between ordering a laboratory test and receiving the results, causes decision-making to be delayed, and can thereby increase the risk of miscommunication. lab-on-a-chip technologies downscale the techniques that are used in large laboratories on to small chips of only millimetres to a few square centimetres. The technology has the potential to perform multiple tests in real-time at the point-ofcare. A variety of technologies are under development, mostly based on chips that integrate electrical, optical, and physical measurements and combine these with fluid >> PoRTABlE UlTRASoUnd source: courtesy of general electric 35 HIGH MEDIUM lOW D CA TI O N EN TI FI UN Ul TR A ID IP NCH AD BO PO CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO Micro-nuclear Magnetic resonance >> handling. The system provides spatial localization that is relevant to observing the function of a single active enzyme, the activity of a single active receptor on a cell surface, or the release of molecules in an immune system cell. The technology will reduce the risks of miscommunication that currently exist between clinicians and laboratories, but issues concerning sensitivity and specificity need to be addressed in order for these technologies to reach their full potential. Improved microbiological point-of-care devices could significantly assist antibiotic stewardship, reducing the amount of inappropriate and unnecessary antibiotics prescribed prior to laboratory results. Cancer cells contain critical and time sensitive information for tumour classification, stratification of patients for molecular targeted therapies and for monitoring of treatment efficacy. Advances in technology facilitate rapid identification and real-time analysis of tumour cells at the point-of-care. The miniature nuclear magnetic resonance (NMR) machine is a portable device that is able to detect cells rapidly, cheaply, and with high sensitivity. For example, fine-needle aspirate of the patients' tumour is incubated with antibodies covered with magnetic nanoparticles that are specific for the proteins of interest. The sample containing tagged tumour cells is inserted into the portable device where magnets will align the atoms in the sample, and a radio frequency signal will cause them to vibrate. The NMR signal decays faster in samples containing the magnetic nanoparticles than samples without nanoparticles, and the duration of the signal indicates the number of tagged cells. The portable micro-NMR device improves the speed and accuracy of cancer diagnosis, leading to earlier and more effective treatments for cancer patients. nucleic adic identiFication Optimal control and treatment of infectious diseases require early detection and identification of the aetiological agent. Where traditional laboratories may take days to process samples, nucleic acid testing for pathogens at the point-of-care provides rapid identification of pathogens. Nucleic acid testing involves sample preparation whereby the integrity of the pathogens is destroyed to expose the nucleic acid, isothermal amplification of the nucleic acid, followed by real time detection (by for e.g. fl uorescence). For point-of-care nucleic acid testing, lAB-on-A-CHIP this whole process is integrated into an inexpensive, automated, miniaturized, closed system. The use of this technology at the point-of-care may reduce the risk of spread of disease by early diagnosis and surveillance of various infectious diseases such as tuberculosis and methicillin-resistant staphylococcus aureus (MRSA) and for detection and monitoring of HIV viral load. MICRo-nUClEAR MAGnETIC RESonAnCE source: courtesy of dr ivan dimov the micro-nMr probe detects cells that are covered by antibodies labelled with nanoparticles. courtesy of dr weissleder. lA NU Cl TOUGH MEDICINE M DE AG VI NE CE T IC lE RT AB EI C RE SO IC NA SO NC E 36 TEcHNoloGy UpTakE HEAlTHCARE personalised medicine � genomics move into the clinic dna sequencInG of the patient�s genome facilitates the switch from "one size fits all" to "tailor made" management of disease. The cost of sequencing technology will plummet and by 2020 genome sequencing technology will provide diagnosis to conditions that were previously not available. Pharmacogenetics will provide information on the individual's responds to drugs and almost eliminates adverse drug reactions. Cancer genomics will facilitate early detection of cancer through identification of dnA mutations. INTRODUCTION Ten years on from the first draft of the human genome being published, there has been tremendous progress towards understanding the structure and function of the genome, and the genetic contributions towards health and disease. The price of sequencing will continue to plummet as we approach 2020 and the wide-scale availability of sequence data will drive further discoveries. The genetic basis for most monogenic disease will have been identified and significant insights into many polygenic diseases will have been made within a decade. Hospitals will need to consider carefully how to organise clinical genetics as it becomes relevant to most, if not all, other clinical specialities. As the field of genomics matures, it will move increasingly from enabling researchers to have a better understanding of biology, to advancing medicine and, ultimately, to improving the efficacy of modern healthcare. sequencing technology The impact of DNA sequence technology in clinical use has been relatively limited, partly because sequence information has been expensive to generate and partly because sequence analysis requires specialised competence and software. In the space of just a few years, research has advanced from simple gene analysis to whole genome scans. Sanger capillary-based sequencing, which has a typical run output of 100 kilo base pairs, has given way to second generation sequencing technologies, with typical run outputs of peta (1015) base pairs and beyond. Fierce competition between different sequencing technologies will continue to drive innovation, and by 2020 the cost of sequencing a complete (>98 %) human genome will be well below the $1000 target set by US National Institute of Health (NIH), and have an accuracy of less than one error per 100000 base pairs. Novel sequence technologies will continue to develop, such as those exploiting nanopore technologies that are able to identify individual DNA molecules. Other technologies and methods will evolve, enabling epigenomic, transcriptomic, and microbiomic analyses within the next 10 years, although their initial clinical use will be limited. Major challenges in the coming decade will be how best to store, process, analyse, and visualise the huge complex data sets, rather than data generation. CHRoMoSoME dnA SEqUEnCInG Single molecule? Chromosome 1.000.000.000 Kilobases per day per machine MASSIVELY PARARELL SEQUENCING Short-read sequencers 100.000.000 10.000.000 1.000.000 100.000 10.000 1.000 100 10 0 Manual slab gel GEL-BASED SYSTEMS Automated slab gel CAPILLARY SEQUENCING Microwell pyrosequencer DNA Secound-generation capillary sequencer First-generation capillary 1980 1985 1990 1995 2000 2005 2010 Future increasing capability for dna sequencing over time. Year based on: nature 2009 37 HIGH MEDIUM lOW EN ET IC S G DI EN AG OM NO E ST BA IC SE S D S TE EqU CH E NO NC lO ING G Y O AC PH A CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO genoMe-based diagnostics Using DNA sequence information to support the specific diagnosis or treatment of an individual patient has traditionally been limited to those patients referred to a specialised medical genetics department. As sequencing costs fall and the clinical utility associated with genomic information increases, clinicians in departments other than medical genetics will increasingly wish to use this technology. In some countries, genomic sequencing of children may have become the norm and Direct-to-Consumer companies will be offering complete genome sequencing and analysis services, independent of their customers' location. Many thousands of genomic variants associated with disease risks and treatment responses will have been discovered and new models for capturing and displaying these variants and their phenotypic consequences will have been developed. Robust software will have been designed that will provide secure access to the information for the patients and their healthcare providers, so that the data can be interpreted and reinterpreted as knowledge evolves. Complete genomic diagnostic panels could be used as routinely in some countries as blood chemistry panels are today. >> more than 50 %, as well as enable optimisation of drug regimens and the identification of responders and non-responders. Current research products are primarily limited to genotyping common alleles, often based around single nucleotide polymorphism (SNP) technology, and therefore lack the sensitivity, breadth of genomic coverage, and ability to identify previously unknown variants that are important for driving scientific discovery and adoption into routine use. As more genome-wide analysis becomes available, the use of pharmacogenomics in hospitals will spread from its current limited use for drugs such as warfarin, clopidogrel, tamoxifen, and abacavir. cancer genoMics Somatic alterations in DNA mediate the genesis and progression of cancers. Rapid identification of these mutations aids cancer diagnosis and guides treatment, but has been technically challenging. The impact of next generation sequencing on cancer genomics during the coming decade will be more profound than, perhaps, in any other area of clinical medicine. As costs continue to drop and throughput improves, it will become increasingly attractive to re-sequence, analyse, and compare matched tumour and normal genomes for individual patients. This comparative data can be used for diagnostic purposes and to guide treatment. Such an approach has already been described for acute myeloid leukaemia and pancreatic cancer, and many similar studies will follow, driven initially by the research agenda, but quickly becoming adopted as standard for cancer treatment and therapy by 2020. Development of analytical tools is required and these will also require validation to provide feedback into the analytical process, and to enhance sensitivity and specificity of variant discovery. pharMacogenetics The WHO recognises unintended, harmful reactions to medicines as one of the leading causes of death in many countries. Such adverse drug reactions lead to more than two million hospitalizations and approximately $1 billion in healthcare cost annually in the United States alone. Pharmacogenetics describes genetic variations between individuals and their influence on the efficacy and side-effects of drugs. Use of more effective early warning indicators of drug metabolism and molecular pharmacology has the potential to reduce hospitalizations associated with adverse drug events by >> dEvEloPMEnTS In WHolE GEnoME SEqUEnCInG IndIvIdUAl RESPonSE To A dRUG time period 1990-2003 2003-2009 2010-2014 2015-2020 nuMber oF genoMes 2 (nih � human genome project and celera) 10 additional thousands to millions Many millions processing ~5 years ~ 6 months ~ weeks/ days ~hours eFFort (Fte)* approx. 5000 dozens handful <<1 cost ~2 billion 200 000 28 000 15 000 750 500 - 100 Drug toxic but beneficial Patient group Drug toxic but NOT beneficial *Fte: Full-time equivalents Same diagnosis, NOT on: www.pharmainfo.net basedbeneficial same prescriptipon Drug NOT toxic and Drug NOT toxic and beneficial CA NC TOUGH MEDICINE RM ER G EN O G M IC S 38 TEcHNoloGy UpTakE HEAlTHCARE next generation imaging � visualising at the molecular level medIcal ImaGInG will move upstream from the traditional visualization of the anatomical footprints of disease to visualization of the disease processes themselves. diffuse optical imaging will emerge as a technique for non-invasive in vivo imaging of biological tissue at the molecular level. new contrast agents will add molecular information to anatomical images provided by MRI. The real-time combination of positron emission tomography technology and MRI will provide detailed visualization of physiology within an anatomical reference, facilitating early detection of disease and effective monitoring of treatment. INTRODUCTION Recent advances in genomics and proteomics have identified a large number of molecules and signalling pathways that have the potential to promote or limit various important medical conditions, such as cancer, atherosclerosis, and infectious diseases. Molecular imaging is a rapidly evolving field of medical diagnostics, enabling early disease recognition and monitoring of treatment in ways that cannot be achieved with traditional imaging. Molecular imaging assists in determining a patient's response to a specific therapeutic agent, and enables visualisation of tissue metabolism and biochemistry, using labelled, biologically active compounds. Furthermore, by improving our understanding of the pharmacology of new drugs, it provides a mechanism for rapid translation of developments in cellular and molecular biology and other basic sciences into improvements in patient care. Finally, molecular imaging will enable screening of at-risk populations and application of the most appropriate and effective individual treatments. diFFuse optical iMaging Current technologies can provide good anatomical and structural images, but their ability to provide images of physiological processes, which are important in a wide variety of diseases, is limited. Diffuse optical imaging is an emerging, non-invasive technique for in vivo functional imaging of biological tissue at the molecular level, including protein interactions, protein degradation, and protease activity. A device emits near infrared light and a detector senses how the light path is altered, through either absorption or scattering, as it traverses the tissue. Contrast is provided by either exogenous agents (e.g. fluorescence, bioluminescence) or from endogenous molecules with optical signatures (e.g. haemoglobin, oxyhaemoglobin). Potential clinical applications include diagnosis of cancer and infections, and visualisation of atherosclerosis. The advantages of this technology include its high sensitivity, rapidity, ease of use, and low cost, while the main disadvantage is low spatial resolution. Magnetic resonance iMaging and new contrast agents Medical imaging traditionally displays downstream injury, reflecting relatively advanced pathology. Although images may indicate disease severity, they cannot assess disease activity accurately. Magnetic resonance imaging (MRI) is a technique that provides anatomical and structural data of body organs and tissue. The range of increasingly sophisticated contrast agents that target specific molecules, cells, and biological processes further enhances its capabilities. For instance, monoclonal antibodies labelled with micro-particles of iron oxide can be used to target disease markers and provide early visualisation of disease activity, such as vascular and cerebral inflammation, ischemic stroke, and thrombus formation. The technique enables early detection of disease and monitoring of treatment. Mathematics is biology's next microscope, only better; biology is mathematics' next physics, only better. J.E Cohen oPTICAl IMAGInG PET/MRI IMAGInG optical imaging of the female breast. source: www.optoiq.com pet/Mri imaging of the thorax in case of lung cancer (left) and bone marrow imaging of the lower abdomen in the case of cancer. source: siemens healthcare. 39 HIGH MEDIUM lOW IN G M AG AN D NE NE TI W CR CO ES NT ON RA AN ST CE AG IM PE EN AG T/ TS IN M G RI AG DE ll IN G M AN AT D HEM SI M AT Ul IC AT Al IO M N O Al DI CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO pet/Mri Using a combination of modalities that integrate both structural and physiological imaging is emerging as an important diagnostic tool. Positron emission tomography (PET) offers a highly sensitive evaluation of the metabolic disease state, while MRI provides anatomical information with high spatial resolution. Scanners that are able to combine the power of PET and MRI into a single tool are contributing to a revolution in diagnostic imaging, with improved image quality and a potentially greater range of clinical applications. Combining PET and MRI into one modality is a comprehensive endeavour, and requires significant advances in PET detector technology, MRI system integration, and new software approaches. Many of these inherent challenges have already been solved. PET/MRI may have a role in future diagnostics and monitoring of neurodegenerative diseases, changes in mental status (depression, dementia, schizophrenia), and various cancers. Clinical adoption will depend on validation of its accuracy and on its cost-efficiency. >> Mathematical modelling in medicine contributes to improved patient safety and reduced healthcare cost through theoretical visualisation of inaccessible parts or processes in the body, enabling earlier diagnosis and supporting patient specific intervention planning. iMaging Mass spectroMetry Protein analysis is a vital part of the process of investigation of human disease. New, emerging technologies can assist in providing answers to complex and detailed questions at the molecular level. Matrix-assisted laser desorption/ionization mass spectroscopy (MAlDI MS) can be used to reveal the molecular composition of tissues ex vivo, without the need for the homogenization and separation procedures required by other technologies. The process involves the application of a matrix (organic solvent) to the surface of the tissue, followed by laser irradiation. This causes desorption and ionization of molecules that are subsequently analysed with a time-of-flight mass spectrometer (TOF). This technology, which does not require a target-specific reagent, can reveal the molecular composition of all types of tissues, with an anatomical reference. The proteomic patterns obtained from fresh-frozen tissues can be used for classification into histological groups and, in the management of cancer, to distinguish between patients with poor and good prognosis. The technology can also provide a fast, accurate, and cheap approach for determining bacterial species in clinical samples and may become the standard method for species identification in medical microbiological laboratories. MatheMatical Modelling and siMulation Mathematical biology is a fast growing research area, contributing to the understanding and prediction of disease. Mathematic modelling in medicine uses mathematical concepts and language to describe disease. By combining mathematics, physics and computer power with biology, the physical, biochemical and mechanical environments in the human body can be modelled. Multiscale mathematical modelling can simulate heart function, blood flow in organs, ultrasound contrast agents, oxygenation of tissues, and drug delivery. In cancer treatment complex biochemical and mechanical interaction between cells, nutrients, molecular factors, tissue, live cells and dead cells, is used to make predictive cancer models. As more complex models are developed, abnormal cell growth may be detected earlier, requiring less invasive methods for treatment. >> ModEllInG In MEdICInE IMAGInG MASS SPECTRoMETRy Mathematical modulation of blood flow in an abdominal aortic aneurysm. source: journal of biomedical engineering, 2009. reprint granted by asMe. illustration of molecular imaging mass spectrometry. source: analytical chemistry 2004. reprinted with permission. M AS S FF TOUGH MEDICINE US E SP EC TR O O PT IC M ET RY IM 40 TEcHNoloGy UpTakE HEAlTHCARE novel medical treatment � improving treatment and management of disease researcH and InnovatIon ensure continuous medical advances, some of which may improve disease treatment and management. Here we highlight just a handful of novel technologies that we believe will be used in treatment of disease by 2020. Therapeutic vaccines and nanomedicine will be used in the treatment of some cancers. Surgery will have better spatial guidance tools, and some surgery will be performed without even breaking the skin by using high-intensity ultrasound. But the news is not all good; increasing development of antibiotic resistance threatens to make some of medicine's most potent tools redundant. INTRODUCTION A myriad of potential new drugs, vaccines, and medical devices are currently being developed in universities and in pharmaceutical and biotechnology companies around the world. As these innovations progress through clinical trials, many will be unable to overcome the various technical, regulatory, and marketing challenges. However, some will surmount these obstacles and start to make an impact on clinical medicine. New technologies are a challenge to healthcare systems since their use often requires additional resources or redistribution of resources. Introduction and establishment of new technologies within healthcare routines may differ geographically, as competence and other resources are also spread unequally. Mri-guided high intensity Focused ultrasound MRI-guided high intensity focused ultrasound (HIFU) is a non-invasive, therapeutic alternative that could be used instead of surgery for treatment of tumours in some parts of the body, such as fibromas of the uterus, prostate cancer, and brain tumours. A specially designed transducer is used to focus a beam of ultrasound energy into a small volume, targeted at a specific location within the body. The focused beam results in highly localised (regions as small as 1 x 1 x 5 mm) temperature elevation (up to between 55 and 90�C), resulting in a well-defined area of necrosis (cell death). The procedure is referred to as "ultrasound ablation" and can be monitored by magnetic resonance imaging (MRI). Further advances include the heat activation of cytotoxic substances for the treatment of breast and hepatic carcinomas. This technology has the potential to eliminate the need for invasive procedures in cancer treatment. Additionally, it may be performed on an out-patient basis, thus reducing costs, decreasing the risk of hospital acquired infections, and promoting faster recovery. cancer vaccines Vaccines represent a significant success in medicine. In general, they assist in enabling the immune system to defend the body against infection, and to protect it from certain types of damaged, invasive, or abnormal cells. Traditionally, vaccination was not considered a treatment approach for cancer. However, the molecular recognition of human cancer antigens has allowed the development of antigen-specific immunotherapy for different cancers. Therapeutic vaccines treat an existing cancer through priming of antigen-specific T-cells and reprogramming of memory T-cells in order to delay or prevent cancer cell growth, to shrink existing tumours, or to prevent relapse. A 50 % increase in the total incidence of cancer is expected by 2020. Vaccination technologies have the potential for treating certain forms of cancers, without chemotherapy and surgery. CAnCER vACCInES TH1 response MRI-GUIdEd HIGH InTEnSITy FoCUSEd UlRASoUnd Uterine tumour CD4+T cell IL-12 NK Granulocyte Macrophage CD4+T cell IL-5 Eosinophil Focused ultrasound energy (near field) Far field Dendritric cell CD8+T cell Ultrasound transducer B cell Antibody Tumour-cell lysis TH2 response Treated region anti-tumour effector arms of the immune response. based on nature reviews cancer ovarian tumour treated with high intensity focused ultrasound. based on http://www.sirweb.org 41 HIGH MEDIUM lOW M FO RICU GU SE IDE D D Ul H TR IG AS H I O NT UN EN D SIT CA Y NC ER VA CC IN ES ER Y NE SU R CI ED I TI C M BO NO TOUGH MEDICINE CRITICAllY Ill WEAlTHY HEAlTH ExPENSIVE CURE TECHNOlOGY UPTAKE IN EACH SCENARIO robotic surgery Techniques are continually being sought to make surgery more efficient and safer. Robotic surgery involves surgery with the help of robotic technology, whereby multiple robotic arms are controlled remotely by a surgeon at a central console. The surgeon can visualise the incision more accurately through magnified 3D video. The technology therefore assists the surgeon to carry out micromovements, thus making it more precise. The surgeon may be located in the same room as the patient, or be in a physically different location. Robotic surgery is less invasive and causes less tissue damage compared to traditional surgery, and thus improves the rate of recovery, reduces the risk of complications and length of hospital stay. As robotics become smaller, faster and easier to operate, robotic surgery will become the standard of care in many surgical areas. novel antibiotics The development of antibiotic resistance in many bacteria has escalated into a serious public health crisis, and WHO has identified antibiotic resistance as one of the three greatest threats to human health. The rate of bacteria developing resistance to antibiotics is increasing, but in the past three decades only two new classes of antimicrobials have been discovered. Results of surveys performed by the Infectious Disease Society of America and ECDC/EMEA are not encouraging. Only fifteen new systemic antibacterial agents were identified that are undergoing clinical trials and that act on a new target or possess a novel mechanism of action. Of these fifteen, only two have demonstrated in vitro activity against Gramnegative bacteria. This low level of progress is partly because the current regulations and reimbursement schemes do not make investment in antibiotic drug development attractive for pharmaceutical companies. However, research is being conducted on novel approaches to developing antibiotics and includes the development of modified bacteriophages and the development of cationic antimicrobial peptides. Given the lead time for drug development, no new broad spectrum antibiotics effective against Gram-negative bacteria are anticipated before 2020. The increasing frequency of infections caused by multidrugresistant bacteria, together with the decline in research and development of new antibiotics, is creating a chasm between requirement and availability that threatens to return us to the preantibiotic era. nanoMedicine Disease pathology originates at the cellular level of the human body. Barriers with nano-sized openings, such as cell membranes, often prevent the direct targeting of those molecules responsible for disease. Nanotechnology involves materials with a diameter ranging from 1 to 100 nm. Nanoparticles can assist in the in vivo transport of diagnostic or therapeutic agents through biological barriers, providing access to otherwise protected molecules and identifying molecular alterations. In cancer treatment, nanomaterial can be used to transport chemotherapeutic agents that can attack and destroy tumour cells, and nanomaterials that are magnetic or fluorescent can be used as imaging agents in the detection of tumours. Nanotechnology has the potential to revolutionise established concepts in treatment and diagnostics. By providing a means for a targeted approach, nanotechnology may be able to offer significant improvements in patient safety. nAnoMEdICInE Total no. of new antibacterial agents nUMBER oF APPRovEd SySTEMIC AnTIBIoTIC 20 Imaging nanoparticle Nanomaterials can be used as drug carries with timed release of contents 15 Tumour 10 Drug-carrying nanoparticle 5 0 1983-87 1988-92 1993-97 1998-2002 nanotechnology in the treatment of mammarian cancer. based on new england journal of Medicine, 2010 administration, per 5-year period. source: infectious diseases society of america report on development pipeline. clinical infectious diseases 2009. Period systemic antibacterial new molecular entities approved by the us Food and drug NO NA RO 2003-07 VE l AN TI B IO G TI C S SAFE HOSPITAL 2020 tecHnoloGIes For tHe saFe HosPItal Improving patient safety is about reducing the risk of adverse events in healthcare systems. With the growing healthcare expenditure, increasing number of patients with chronic conditions and shortage of healthcare professionals; will we have made any progress towards improving patient safety by 2020? Might the implementation of already available technologies in healthcare systems contribute to safer care provided to more patients at a lower cost? 44 SaFE HoSpiTal saFe HosPItal 2020 Healthcare professionals maintain competence through computer assisted simulation before they are certified to treat patients. Clinical information is available on a digital whiteboard, facilitating an electronic and structured handover between healthcare professionals. AGENDA 1 Patient safety 2 Quality Patient safety and quality of care is continuously monitored and presented to the hospital board members. A CDFG H R T S U � N R P � S W X T D N R P � S W X T D N R P � S W X T D The surgeon follows up on the patient in her home after discharge from the hospital through video conferencing. 45 All patients are accommodated in single rooms with single bathrooms and wireless monitoring of vital functions. The patient record is available to the patient through a bed-side touch panel. The surgeon performs remote robotic surgery. A check list is implemented in the operating theatre. Information about the patient and automatic dispatching of healthcare professionals are sent to handheld devices to ensure optimal communication. Succsessful check in Welcome The patient uses her electronic health card for automatic hospital check in. She is issued a RFID wrist band for tracing of hospital activities, e.g. drug administration, equipment and contact with healthcare professionals. OTHER RESOURCES Go to www.dnv.com/foresight to order more copies, read electronic version, and watch videos about Technology Outlook 2020 Healthcare. Det noRsKe veRItas as ReseaRch & InnovatIon no-1322 h�vik, norway I tel: +47 67 57 99 00 I Fax: +47 67 57 99 11 www.dnv.com thIs Is Dnv Dnv is a global provider of services for managing risk. established in 1864, Dnv is an independent foundation with the purpose of safeguarding life, property and the environment. Dnv comprises 300 offices in 100 countries with 9,000 employees. Design, layout and print production: erik tanche nilssen as, 12/2011 Printed on environmentally friendly paper. � Det norske veritas as. all rights reserved. this publication or parts thereof may not be reproduced or transmitted in any form or by any means, including photocopying or recording, without the prior written consent of Det norske veritas as.