charten» Medical meltdown unavoidable? She tap exercise regime that she and her primary care spedalist had agreed, also loaded on the card, The car also fitted in the exercise machine in the comer of her bedroom ¥ she did the sppointed walking and stair-stapping programme, tre relevant number of plspoints would be added to her| persoral health account. The carl also contained the care pathway-—designed like a metra map-for the only engoing course of care that she was current ceceiing. The Mashing ‘saton’ on the care map showed the nex step she ‘needed ta take to place a fngerprick of blocd In the blochip machine sha | "Smultaneously reed over a hundred common blood test ‘analytes and then sent the result to her doctor and care marge. ‘Allin all she now could not now imagine life when all these simple steps in managing your own health reied on paper records, memory oF needed a time-consuming vst te the doctors offs (One of the benefits of sears information i the power of comparison "While most doctors resent eirection from others, they thrive on feedback that tell them how they compare with peers. Feeeback on decsions made and costs incurred is used vary effectively by the best US physican groups. ‘The same power exts with whole systems. One simple comparison of diferent region across Ameria isthe cost per Medicare patient i cont revealed that 10 leading repins averaged $1500 less in costs per pavent fnrually than the national average, while achieving. better outcomes The means used by each region to achieve quality and control costs was dlferent-—hosptal consolidation In Achevile, elimination of unnecessary procedures in Cedar Rapids, and crast-community “quality collaborations! in Portiand, Imagine if each system could see not only what the others had done but the effects on quality and costs the Incontves bul into the system should do the ret System-wide information on best practices © also tho best way to resolve the tension between central drecton and local entwprencurism, As the Chief Executive ofthe NHS recently comnerted to me: ‘We have to stop trying to solve the same problems 180 diferent ways! (there are 150 diferent Iocat systems in England) ‘New mobile technology and social media bring a plethora of new options for informing. (or missnforming) people. As more and more of our communications transfers to mobile devices, we can receive both advice and prompts—for example to take our medication, “The main valve of integrated information isto open the door to integrated ‘are, end this is 2 good note to end on in describing our 10 levers. In US ‘experience, neleconstucted Integrated health systems (IMS), lke Kalser Permanente and. Intermountain Health, deliver consstency of care at Mfordable costs, and part af tel secret i information flow. Connecting family doctors with hosptal specialists, sending images automaticaly from radiologist, to specialist to surgeon, and ving both clinians and patient access 10 a ‘complete health record—these are all mare lcely to happen ane to influence cove fall are part ofthe same organization, In priveple, the UK NHS should Be able to operate as just such an integrated organization with a single information nervous system, This was the theory behind the ‘Connecting for Healt programme, underway over the last Tie years. thas celvered some benef, tke the ‘Choose and Book’ ability for a patient in a GPs surgery to select where and when to see a specialist However thas been wicely seen as an expensive white elephant and may not survive the next period of austerity in the NHS, But if we lose the ability to comple a comprehensive record and integrate care this would be a major lost ‘opportunity to knprove NHS performance Integrated health systems are hard to build and operate without intaling bureaucracy ard bariers to local irovation. but the fll power of integrated information to design and deliver care around the patent is probably only possible within an HS, Using the levers—achieving the impact (Our 10 levers require courage co use, since they take everyone out of thelr comfort rone—pavents, doctors, hospitals, and governments. The consequences wil be radical change in where car is detivared, and inthe roles of patients and professonas. We wil need fewer hospi, more investment in community diagnosis and treatment, more motile prfesionals and greater use of modem information technology But only such changes can make quality ‘are affordable and sustainable, Each lever alone makes a diference, but if pulled together they powerily reinforce each other, Some examples inclide: + Using evidence-based information to create best practice pathorays wil ‘enable more care to take place cusie specialized centres ‘Putting the right incentives in place will encourage patient responsibilty and engagement in prevention and selicare 1 More targeted approaches to creating new medicines wil strexnine and speed their development, avoid waste, and enable more systematic processes of care +» Better chronic care processes, including remote patent monikoring will sith the design af lower cost delivery systems, with the deployment of| the right level of expertise at each poin, equipped with best oractice Information «© Tracking personal health signs via integrated patent-accessibe ealth records and predictive too's wil prompt the patient. wits counseling from doctors or health coaches, to detect health warnings exly anc take preventive action ‘crsrress Medical meltdown-—unavoidable?couseres Medical meltdown —unavoidable? + The abllty to capcure and intorpret the results of care across populations and through the lfedme of indicus will enable much more targeted or personalized care + Empowered patents, equipped wit portable heath information, wil play a ‘much larger pati selecting sxoviders or locations at which to receive their «+ Elminating inafectve care given to ineviduais who wil not enti, oF wil sul bad side-tecs, wil improve outcomes and reduce waste «+ Rigorous analysis of outcomes thrcugh national benchmarking systems wil propel the improvement ef productiviy + Compassionate and cast-effectve end of life care will be delvered at home bby monitoring patients remotely, and supporting caregivers wth expert advice ‘The greatest benefits come from pulling these levers together, and the best way of doing this sin an incgratec health system, The case for integration Invepated Heath Sytime can achive & number of things that are hard or npostle in vod’ trey fragmented heal landscape, Fst, by containing both primary and secondary care pofesiorls and fates they can optimize where care fe elvered without = sugale for fonds and fr patient control between communty. and hospkalbased doctors. Secondly, they can take respons forthe coninuum of care for population of ptm, making Chronic dsesse management more szaigiforvard. This enables tem (© ompete on part outcomes and costs, and focus on the tal patent cexperlence, no on elated encounters. WF ther budget are alocted on per capa basis, and they have along: term relationship with the popuaton for which they ae responséle, they rave the Ieee to Ives prevention ad nthe procesce ane technology for ehronieeecase management Ins fe contact to doctors, eines, and hospitals whose contacts wih patients ae temporary and deel only wih immediate heath need ‘As technology eveives and best practice pathways change, an IHS can re ‘work how patents fow trough the system, without the need to constancy Tenegotiat relationships betwen specalsts a thelr primary care cllesgues. Fraly they can bl itoprated formation systems and mandate thei se by al her profesional In other wort, the ability ofan INS to incegyate care around the pion, and to think an st fr his lng-term health neds, puts mos ofthe 10 levers vthin reach How can we get therefrom here? in the US, such eyeteme have already proven thelr longterm appeal bur aspects of hein ieurance tll prevent ther achieving tel fi potencal Incentives for plan members to stay with a plan fora number of yeas, or to retain membership under smi terme when changing employers or retiring, ‘would increase the incentive forthe IHS to rake long-term investments, Inthe UK, incentives need to be put in pla ‘community cinies or hospitals, and primary care doctos, ia order that the coveral system can be commissioned on a population basi. Ultimately the IHS may own all the dinics ard employ athe doctors but thisis nat necessary asa first step. Where doss competion come i? In rsjor urban ares, ike London or Los Angeles, there is room for a small number of comgeting systems. This competion for the loyalty of plan members and forthe share ofthe health budget, willbe onthe Bass of outcomes and costs, In rura.arees, there may be room for only a single system, but incantives can to be cesigred for them to compete in performance with their peers caring for sinlar populations elsewhere inthe county, ‘Whether within an IHS or by design of a system that pulls togethe independent units to actin 2 similar way, the goal mus. be t0 use the ten levers t0 transform the productivity of healthcare, while maintaining or improving ts quality. We need to reverse the impact of the supply and demand ceivers i we are to achieve sustznablty (see Figve 35). Fea CU Rees eyriane Teal ve saan inogaon rough ‘Hartes Medical meltdown—unavotdable?‘guoerzns Medical meltdown-—unavoldabtet rs However, the best way to get 2 sense of how the 10 levers can combine to transform the quality and productivty of healthcare is to revit ne and her family doctor, Dr Clive Patterson, in 2030. The 2030 Vision Jane's care has bacome wuly patent centred Genetic and other tests have ‘ven her and Dr Patterson 2 scientifically based sense for which condsions fhe Ie most at ree, and how she can improve the exis by her festyle, She owe which of the alments her parents suffer are potontaly in her fture and what she needs to do about ther, including anrua screeing tess and aly etary supplements Her annual ful body scan automatically signals whan signifeant changes have occurred that might signal a pocental tumour er other abnormality, [And depending on the amount of change and the probably from her profie, ner dactor can ofder a blood test. a more detaled scan or simpy | "watchful waiting ntl the next annual check Her medication history, aller@s and key aspecss cf her care plan are loaded o7 a smart cara, updated with every vist 20 the doctor or pharmacist ‘nd because she is enrolled in a personal heath plan she receives 2 morthy “health score’ that deal the points she has earned from health-promoting activites, ike her personal exerele plan, and compliance with her medication | (since her mary Bister pack signa the taking ofeach pil) So she has 3 porsonal health managoment plan to suit her unique biology and unique cecurrstances. With their permission, she can also see the | relevant pares of her familys plan — spell important for her enléren and ageing parents The integrated information system connects hor to her doctor for routine queries, weekly checks or requests for an appoinument, and delvers al the felevent information to the Or Patterson's dsitop, If sho get 2 dlagnoss of a disease ~ acute or chronic ~ she can quicsy access the sources of medal texpercee most relevant to the disease, including aatontlevel ‘heath briefings’ by wellknown video doctors. She can also connect to other | patients and learn how ther dsease was treated, what they ‘elt about the |process. and the atepe they took to got the best cutcome. When she receives treatment herself the system prompts her to report kay outcome measures, adding ta the systems dstabase ‘With most commen condlions now testable rather than potently fata, she has lost the fear of the urknown that kept previous generations from ‘onsuting the doctor, and lost te feeling of helplessness in the face of 2 agnosis Pt simply, she isn control {Contin “The changes to Dr Patterson's life aero less profound. As he enters his fice and voice activates his information system, he automatically ecelves all he needs for an afiacve day in the cli. Fst, the list of key medical markers ‘or the patients he is actively manageing, with their overright readings, compared with recent trends. The care pathways that are dspayed| help him decide if intervention s needed and If he need: to call the patent In. Second, he sees his e-mails, neatly arranged in three folders: paler ‘quotes, responses ‘rom other medkal professionals cn his patent care teams, and biomedical research pcates on those dlsases In which o| specialises ‘When he has dealt with these, he sees his fist patent of the day. His health card updates Dr Paterson's system wich heath events or care] received since his list ist. His symptoms suggest a severe respratory| Infection, so he aks him to wale along to the cline’ dagnostc laboratory 10 idaney the gram-negative bacterin that is caus the trouble, Based on the rasult, the system recommends the most effective antbiotc and the care| pathway thatthe patent shoule fellow, including an automate chest Xray i Seven day If the symptoms of pneumonia should appear. His second patient shows him the sore knee that reste from a fil, and the flag on that patents chip directs Dr Peterson tothe recent MRL scant shows a meniscal tear that could easly have worsened to the point of needing surgery and s0 he shows the patient a st of potential knee| specialists to consul, with the localons, casts and outcomes achieved. He| also gives the patient access to health education software with an| 'nfermation presenptin’ containing images of the protlem, the treatment and the potential eects of ant-rfammnatory medication and prysiotherapy. Patient number th-ve is a long-term Type 2 diabetic ted with with an| acifcial pancreas, combining pancreatic stem cls with a stars biocompatible device that gives a reachout of the insu, ghicose and HbATC reacings for the last month. The decision support system indicates that the] Implant may need replacement Patient four has aegun to sufer from palpitations and needs an ECG. The| spparatus analyses abnormalities automatialy and cannests toa dataset the regonal cardiology centre. Comporizon with the traces from other patients highighss a high probability of a cardiac evert in the next few| Imonthe aad recommends an immediate refer. In parallel Dr Patterson} orders the proteomic profile tht he knows the specialist will ned to check for atherosclerosis Inveligent anticipation, personalized medicine, and speedy, costefecive response to problems: this Is Healthcare 2030, f we use our levers to full effet. ‘crsrrens Medical meledown—unaveidable?