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The Future of Healthcare CITRIS Research Exchange September 13, 2006

Ravi Nemana Executive Director, Services: Science, Management & Engineering Center for Information Technology Research in the Interest of Society (CITRIS)

Ruzena Bajczsy, Shankar Sastry, Mike Eklund

Outline Î Brief Introduction Î Where are we headed? ►

Challenges & Trends in Healthcare ► Role of Information & Communications Technology (ICT) ► Role of Technology Innovation and Service Innovation

Î What can we do?

How CITRIS efforts come together in Healthcare ►

Ubiquitous, embedded sensing ► Elder care ► Security and Trust in health care systems ► Services: Science, Management, & Engineering

Î What does the future hold? ►

Services in Healthcare ► Healthcare ICT Services Innovation Center

Î Questions

September 13, 2006 2

Trend: Healthcare Demographics Age Distribution of the US Population Source: 2000 US Census


Age groups where care burden is greatest

45,000,000 40,000,000



Population shift will increase care burden

30,000,000 25,000,000



Current workforce shortages pose difficulty with care burden at this level

15,000,000 10,000,000 5,000,000 0 85 and over

75 to 84

65 to 74

55 to 64

45 to 54

35 to 44

25 to 34

15 to 24

5 to 14

under 5

Age (in deciles)

B. Lowensohn, Kaiser Research

September 13, 2006 3

Trend: Healthcare Workforce

Total Medical School Matriculations -- 1994 to 2005 18,000

# S tudents / year


y = 56.35x + 16021

14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1994








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Sources: CDC, NCHS & AAMC

Trend: Worldwide age wave is coming 2002


Percentage of Population over 60 years old Global Average = 10%

Percentage of Population over 60 years old Global Average = 21%

SOURCE: United Nations ▪ “Population Aging ▪ 2002”


Table compiled by the U.S. Administration on Aging based on data from the U.S. Census Bureau.

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Courtesy Mike Eklund

Trend: Elder care is returning home again Home “grandma”

Poor Houses / Almshouses “pauper”

Insane Asylum “inmate” Only way to save costs but increase quality is via home care (includes self care). Home care is fastest growing segment of health industry.

Productivity of Home Care services is poor.

of e l Ro ial soc tions! nec n o c

Home “grandma”

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Assisted Living “resident”

Nursing Home “senior citizen”

Hospital “patient”

Trend: Parent Support Ratio: 1950-2050

As the number of elderly needing care increases, the number of potential caregivers decreases. Today, 1 in 4 U.S. families care for an older adult.

30 25 20 15

No. +85


Persons 85+ per 100 people 50-64 years old

5 0

Source: U. S. Census



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By 2005, nearly 40% of U.S. workers will be more concerned caring for a parent than a child.




Trend: End-Stage Care Evolves into Long Term Management Advances in Care… ►

Organ Assistance and Substitution Bioartificial kidney Closed loop artificial pancreas (Xeno) transplants Cardiac assists Genetic testing and tailored therapies Gene therapy-- cardiac and cancer Drug delivery systems: Stem cell therapy on the horizon ■ ■ ■ ■

► ► ► ►

... Lead to longer and better quality of life... … but higher costs ► Increased demand on delivery systems and clinical care personnel ► Increased role of technology Cardiac replacement with a total artificial heart as a bridge to transplantation. Copeland JG, et al. N Engl J Med. 2004 Aug 26;351(9):859-67.

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Trend: Cancer is Tamed but Not Conquered Î

New rules of engagement ► No longer a matter of winners and losers and at any cost (old paradigm of cytotoxic chemotherapy) ► Instead, opt for a negotiated truce by longterm treatment and lengthening quality survival ► Cancer “survivors”


Cancer Æ chronic disease ► like diabetes, cardiac rhythm disorders, and osteoarthritis.


Advances: drug delivery, imaging, genetic testing, pharmaceuticals, IT, MIS, nanotechnology


Earlier, more accurate diagnoses; better staging; improved outcomes

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Trend: Shift to Earlier Intervention Drive Delivery System Reconfiguration The Tools: Î Faster, smaller imaging devices Î Biomedical sensors Î Point-of-care diagnosis Î Genetic testing, profiling Î PACS and CAD Î Remote health services Î Data capture, transmission and response

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Trend: Blockbuster Drugs Wilt as Customized Therapies Blossom Factors Driving Customized Therapies: Î

Loss of patent protection for portfolios


Genetic testing


Diagnostic and therapeutic targets


Increased role of imaging


Fragmented and smaller target populations


Higher risk, lower yield for developers


Genotype tailored therapy for many conditions


Targeted gene therapy


In conjunction with implantable sensors

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Trend: Smarter, Smaller Surgical Devices Drive Volume to MIS Where is the growth occurring?

Surgeons no longer need to directly see nor touch the tissues on which they work. MIS moving toward using natural body guides and orifices for access. Open Areas: - Dexterity improvement - Networked OR - Micro-robotics - Auto and remote navigation for diagnosis and treatment - Energy-based surgery

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MIS Procedures: Î

Pain, discomfort, disability, or other morbidity more often results from the trauma involved in gaining access than the actual surgical procedure itself.


Hospitalization is more often to recover from the trauma caused by accessing the surgical site than the actual procedure itself.


Tremendous productivity and cost gains result from MIS, for both physicians and hospitals Æ Adoption

Mack, M. J. JAMA 2001;285:568-572.

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Trend: Patients Accept “Bionic Man” Model o


p q


r n o r u tr u vr w u

r v t


s u

September 13, 2006 14

s p


Trend: Convergence of Sensors and Jewelry

Language Xlator (CMU)

Body Gateway (NASA)

Pulse oximetry Blood Press. (MIT) Cell Phone as gateway Fashion addresses the stigmata of care Patients: bearing greater costs of care– for self and for family members Self care is a real possibility September 13, 2006quality, productivity, Approaches that address 15 efficiency and timeliness are needed.

Courtesy Paul Wright

Trend: Liquidity of Information Changes Dynamics of Care Factors Driving Access to Care: Î For Clinicians: New modes of operation ► ► ► ► ► ►

Orders, medical record, results, images Evidence Bases Æ Payment ripples Patient communications (RPM) Billing and payment information Æ Spy v. Spy with Payors Language Interpreting New Risks of medical practice

Î For patients: Revolutionary change ► ► ► ► ► ► ► ►

Web-enabled access to the physician Access to their medical record Financial settlement Communication & Research ability Early intervention to prevent acute episodes Second opinions / review evidence-based studies Increased participation in decision making 24/7 access to care and services

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Sehda, Inc

Trends: ICT central to Health Care Nearly all medical technologies will transmit something…. ► an image ► a report ► a point of data … and IT will capture, process, sort, send and store these streams. Decouples diagnosis & treatment Separates “brainpower” from “manpower” Integration into daily life, new sites of care The Future: IT will consult, broker, predict, suggest, and act on your behalf ►

E.g. IT as “traffic cop”

The Challenge: integrate these into the service processes of healthcare September 13, 2006 17

Trend: IT and Pharmacy / Lab Robots Robots that carry out simple, repetitive tasks with precision and accuracyÆ Automation

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Trend: Service Innovations– Out-tasking Task-specific robots that function to help automate the care delivery processÆ Labor Arbitrage

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Trend: Service Innovations– Robots Robots that aid surgeons and rehabilitative therapists in the delivery of care to the patientÆ Productivity & Outcomes Improvements

MIT Stroke Rehabilitation Robot

September 13, 2006 20

UCB/UCSF Laparoscopic Telesurgical Workstation

Domestic Robots Robots used for the delivery of healthcare in the home or assisted living facilitiesÆ Unclear

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Other Service Innovations: Remote Presence Î Expansion of eICU concept Î Robotics + Remote Presence

Æ New models of care Î Ancillary services

The Challenge: Navigation

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Trend: Workforce Shortages Only Soothed by Technology Deployment An increasingly instrumented world… Î

Sensors for monitoring embedded in patient beds


Point-of-care testing


Monitors with direct download to medical record


Slow release implantable drugs


Inhalable opioids


Closed loop implantable devices


Smart systems for provider alerts

… increases the Noise-to-Signal ratio!

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Bottom Line Health care is a service … ► ►

Heavily knowledge and information dependent Highly customized, co-produced delivery

… and full of services problems ► ► ► ► ► ► ► ► ►

Labor force productivity Service supply chains Appropriate automation, outsourcing / out-tasking Coordination of services Service levels & quality provision Service engineering Service innovation and scaling services Information processing, engineering, and visualization Demand Management

NAE + IOM: “Building a Better Delivery System”

… for which science, engineering, and management offer possible solutions Î Technology Innovation AND Services Innovation ► ►

New tools to care for patients and New ways to increase capacity in the health care system

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Trends: An Historical Context



Affordable Transportation


Standard Parts


The industrial / technological revolution helped us to perfect the art of making things of value.

Computing Power





Services *

Is there a “services revolution� underway to help us perfect the art of doing things of value? What does this mean for health care? With the help of Jean Paul Jacob

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What is SSME @ CITRIS? Î Services: Science, Management, and Engineering (SSME) is a new

academic curriculum and research area Î Aims to improve the performance of services by applying scientific,

engineering and management disciplines to the configurations of people, technology and business. Î Improves the predictability, productivity and quality of services Î Provides Berkeley graduates new skills and tools to contribute to,

participate in, and thrive in a services world. Î Is this a new science?

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SSME @ CITRIS / Berkeley Academic Advisory Board: Henry Chesbrough Robert Glushko Rhonda Righter Shankar Sastry AnnaLee Saxenian Paul Wright




Role of Services: Science, Engineering and Management ENGINEERING SCIENCE

Data & Information




Health care areas where SSME can help: ► ► ► ► ► ►

Information Security Services Decomposition, distribution, coordination, design, deployment Services Infrastructures and architectures Embedded Sensors & Telemedicine Information Processing, software, visualization Modeling and Simulation

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Example: Modeling and Simulation Î Problem: New services can’t be tried in a laboratory;

poor planning tools ► Result: trial and error, high labor cost, high inertia, poor scaling from pilots Î Approach: use modeling and simulation as a virtual

laboratory for health services and service lines ► Potential to reduce trial and error, adverse outcomes, and improve profitability Î Specific areas: ► Reynolds

number for modeling patient flows, health system disaster response (Recrit) ► Architectural Planning – virtual reality

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Example: Sensing the Environment

Fire Response

Vineyards Great Duck Island

Building Comfort, Smart Alarms

Elder care


Elder Care Factories


September 13, 2006 Wind Response Of Golden Gate Bridge

Soil monitoring

Example: The ITALH System Records continuous sensor data Fall Detection algorithms Radio communication (Bluetooth) Triggered Reporting

Nokia 6680, 6630, 9500

ts n e rim in e p an Ex ay c i w r r e e und sh- Am etting i s Finn r Care CA e , d a l E September 13, 2006 om n o 31 in S

Wearable Fall Detector

Fixed Sensors

Berkeley Telos Motes with sensors embedded in living environment

Security: TRUST Portfolio Integrative Research Project Themes ► ► ► Community Support Friends

Extended Family

Legally Authorized Reps

Immediate Family

Primary care Specialists

Patient Provider

Business Consultants

September 13, 2006

External accreditation orgs


Claims Payer Fraud Processors Detection Subcontractor s Clearinghous Medical es Insurers Information Bureau


Internal QA

Clinical Trials Sponsor s

Admin. Staff

► ► ►

Secure Network Embedded Systems (Wicker, Mulligan leads) Identity Theft, Phishing, Spyware and Related Issues (Mitchell, Tygar leads) Electronic Medical Records (Sztipanovits, Bajcsy, Eklund leads) Trustworthy Systems (Wagner, Aiken, Reiter leads) Network Security (Joseph, Birman leads) Seedling Topics

Public Health


State Licensure Law Enforcement


Bioterrorism Detection

Empower patients: National Security

Access to own medical records ► Control the information ► Monitor access to medical data ► Increase “liquidity of information” ►

From: Dan Masys: “The nature of biomedical data”

Trends and the Role of IT & SSME Shift to point of care (POC)

ƒ POC can be ANY location ƒ Capturing data, identification, location

New Devices

ƒ New data streams, real-time evaluation ƒ Security issues ƒ Language services

Info explosion & liquidity

ƒ ƒ ƒ ƒ ƒ

New Approaches to care

ƒ Image / ICT dependent ƒ Data fusion required ƒ Productivity innovation ÆRPM

New Reimbursement

ƒ Patient safety & quality ƒ Evidence-Based Systems ƒ Report Cards

Workforce & Retention

ƒ Remote Access and Productivity ƒ Patient Experience ƒ Trust Retention

September 13, 2006 33

New data presentation mechanisms Context-sensitive information Security & Safety issues Personal health records New Market Dynamics

Services Infrastructure Layer 3

Layer 2

Layer 1

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HEALTHCARE ICT SERVICES & INNOVATION CENTER • EHR and PHR sharing • Clinical Data acquisition • Evidenced based care / mgt. • Virtual service laboratories • Security and trust architectures • Policy languages • Social models of care • Aggregation of embedded sensing streams • Integration of new layer 1 tools • “Population care” tools • Imaging modalities •…

Major Healthcare Trends

Shift to Earlier Interventions Drives Delivery System Reconfiguration

Smarter, Smaller Surgical Devices Drive Minimally Invasive Surgery

Patients Embrace the "Bionic Man" Model

Cancer is Tamed but Not Conquered

Demographics, Disease incidence, and Workforce pressure costs

Elder care moves back home

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End-Stage Care Transforms to LongTerm Disease Management

Liquidity & growth of information changes dynamics of care

Blockbuster Drugs Wilt as Customized Therapies Blossom

IT Takes Center Stage

Workforce Shortages Only Soothed by Technology Deployment

Sensors & Communications Infiltrate All Aspects of Daily Life

Services and Healthcare @ CITRIS Layer 3

Layer 2

Layer 1

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The Bottom Line Î

Much of the technology on the horizon helps optimize existing capacity


Re-engineering required for new capacity in the health system


Central role for innovative Methods, Technologies and Tools ► ► ► ► ► ►


Self Care Remote Patient Management Social Care models Consumer Devices and incentives Gaming & Entertainment Security

New Science: Services Science, Management, Engineering (SSME) at UC Berkeley ► Initiate

a new approach to jump start service innovation ► Promote multi-disciplinary talents, tools, methods, and skills in the workforce ► Expertise in reconfiguring healthcare components

September 13, 2006 37

Conclusions Î

Broad trends lead us to interesting combinations of technology and service innovation approaches ► ► ► ► ►


Healthcare and Services are new major areas of focus within CITRIS ► ► ►


Coordinating existing projects Supporting new projects HEALTHCARE ICT SERVICES & INNOVATION CENTER

Many cooperative efforts ► ►


Services architectures Services decomposition and engineering Embedded sensors, imaging, information & communications technology Re-engineering the capacity of the health system Promote adoption through productivity gains

Within CITRIS and other Academic Centers With international research partners and corporations

Corporate and governmental partners and collaborators will be essential for large scale deployments and ongoing research and development

September 13, 2006 38

The Future of Healthcare

Ravi Nemana, MBA Executive Director, Services Science Center for Information Technology Research in the Interest of Society (CITRIS) University of California, Berkeley 510-642-1083

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Innovation in Healthcare What hope is there?  

Poor Houses / Almshouses Poor Houses / Almshouses “ “pauper pauper” ” … but higher costs ► Increased demand on delivery systems and clinica...

Innovation in Healthcare What hope is there?  

Poor Houses / Almshouses Poor Houses / Almshouses “ “pauper pauper” ” … but higher costs ► Increased demand on delivery systems and clinica...