Shifting Site of Care: Innovations in Health Technology & Delivery

When you visit a doctor, do you ever take the time to go through your bill line-by-line or request data on your quality of care? Do you make decisions around consuming medical services like you would, perhaps, food in a restaurant? The truth is very few people in the US ever see their healthcare bills in full and have minimal understanding of the detailed costs associated with healthcare services. In general, there are 3 main costs associated with a visit to any healthcare facility: (1) labor costs and expertise: physician / nurse / lab tech time, (2) space: waiting rooms, outpatient doctor’s offices, inpatient hospital rooms, and (3) resources: diagnostic / monitoring equipment, lab tests, and pharmaceuticals. Healthcare “consumerism” is a growing trend in the US, but in many ways has already shaped a number of health systems in developing nations – where patients have always paid “a la carte” for health services will full transparency into the incremental costs of products and services.

Consumerism improves the patient’s ability to make decisions around their care. When you decide to purchase a new TV, what are your criteria? Cost, quality, style? The more information you have to make educated choices the more competition there is to cater to your needs as a consumer. This is absolutely true for your health as well. Many corporations try to create “segments” of consumers based on patterns in purchasing behavior and decision-making (i.e. what are your priorities?). It is realistic to apply this same logic to health care services in developing regions. These countries’ decision-making processes and patterns are certainly different than the US, and often vary widely from each other. What is important to them as patients?

Information and Innovation!

It is believed that “competition drives innovation,” but in many ways information is king for consumer preferences. It affects how we perceive what is important and make decisions. Quality and cost are usually the two largest determinants for decision-making regardless of your nationality or economic status. New innovations that improve quality or patient outcomes usually come at higher costs than the previous offerings (e.g. Merck’s HPV vaccine). Innovations that improve cost usually involve shifts along the 3 cost sources mentioned above: (1) WHO provides the care, (2) WHERE the care is provided, and (3) WHAT resources are used to complete the visit. This is typically how a shift would occur:

WHO: Specialist (Endocrinologist) --> General Practitioner (Primary Care Physician) --> Healthcare Worker (Nurse, Dietitian, Psychologist) --> Peer Care --> Self Care

WHERE: Acute setting (Hospital) --> Specialized setting (Clinic) --> Community setting (Pharmacy) --> Point of care (Home)

WHAT: Medical devices (diagnostics / monitoring) with lab equipment and expert decision-making --> Medical devices without lab equipment or expert decision-making (usually reduced size and cost)

Often referred to as “shift in site of care” or “shift in provider of care,” technology is often a key enabler for the shift. This has countless applications in the Western markets, but especially in developing countries where cost is one of the main barriers for patients to access quality care.

Shifting to Simple, Fast, and Inexpensive (Not Cheap)

Shifting trends in the sites and providers of healthcare have been occurring for hundreds of years. With the goal to reduce cost to the patient – innovations must be more simple, fast, and inexpensive… but not cheap. Quality must be maintained or even improved to be considered successful.

One of the classic examples of shift in site and provider of care is the pregnancy test. Dating back to 1350 BC in Ancient Egypt, pregnancy was predicted through a variety of urine tests, evaluated by medical “experts” in a medical setting. A variety of mythical urine tests were used until the 1927 when the first high-quality test was developed: a bioassay of female urine was injected into a rat – if pregnant, the hCG present in her urine immediately induces ovulation from the animal. This was expensive and required many people and technological resources to perform. In 1960 an immunoassay was developed that allowed pregnancy tests to be conducted in a lab, without the use of live animals. This was cheaper and at times less accurate than the previous method of testing – and required a physician visit and waiting period for the lab tests. Finally in 1976, the FDA approved the first home pregnancy test (the e.p.t. kit). This shifted all 3 axes of cost – the test was now self-administered, at home, with one affordable, disposable device (now the only cost of the “procedure”).

This same trend has been occurring more and more with recent advancements in healthcare – largely with a focus on technology. But I would argue that you can produce shifts in care with innovations in health delivery processes and education, in addition to technology.

For example, the recent growth in “Minute Clinics” in pharmacies has taken simple technologies traditionally used in a doctor’s office and paired them with strict patient protocols (there is a reason you take a survey at the beginning to categorize your symptoms!) to allow a nurse practitioner to diagnose and prescribe treatment for an array of primary care needs. This improves affordability, access, and convenience of care (now only 15min of your time, and closer to home)!

Disruptive Behavior is Expected

In the business lens this is viewed as disruptive market behavior. Disruption is a form of innovation that produces a product that better suits the needs of the consumer: either through a less expensive substitute (low-end disruption) or shift in the basis of competition (new market disruption). Low-end solutions are especially appealing for developing countries. Here are quick examples of each:

Low-end:

• Amazon.com disrupted traditional bookstores with new and used books at a reduced price to what was available on the shelf
• Half.com disrupted university bookstores with a low-end market for used textbooks
• Netflix disrupted Blockbuster with a slower and cheaper service that favored consumer convenience and new process for ordering and billing

New market:

• iPods disrupted CD’s with a new market for electronic music purchasing, storage, and use
• eBay disrupted traditional online sellers with a new process for finding, purchasing and selling products online (it also opened doors for individual entrepreneurs to start online businesses)
• The Kindle reader has disrupted book purchases in stores and online – Amazon.com is demonstrating self-disruption with this invention!

Michael E. Raynor is a research fellow at Deloitte has spent years researching the importance of disruption in the corporate innovation process. He discusses his approaches in his books, The Innovator’s Solution and The Strategy Paradox, which are central to much of the work we’ve done with clients related to growth in emerging markets. From a product standpoint disruption can occur through advancements in technology (CD’s vs. cassette tapes), processes (Walmart’s supply chain), or changes in the larger environment (e.g. government policies, consumer perceptions, cultural values). Services can also be disrupted through technology (Kayak – online flight purchases), processes (iPhone apps vs. websites), and education/training that shifts the service provider (outsourcing / call centers). You could also argue that shifts in processes and service providers involve technology advancements as well – in many instances using technology that already exists in a new way.

Leapfrogging in Developing Countries

Developing countries are a playground for disruptive behavior. At Deloitte, I was able to work with pharma and medical device companies to understand future opportunities for disruption in emerging and domestic markets. Interestingly, innovation routes are sometimes more efficient in emerging markets: they leapfrog. A prime example is India’s expansion of phone service nationally; before landlines were ever installed in every home (very expensive, resource intensive), wireless cell phone towers were built to provide inexpensive, widespread coverage for cell phone users. As a result, individual cell phone plans in India are about $5-10/month with unlimited calling and data included. They never had to go through the heavy lifting of installing phone lines to the extent of many Western markets. This is now similarly true for the internet in a number of countries – many are wireless before wired.

What’s next for healthcare? How can existing technologies be used to help improve quality, access, and affordability of care? Are there opportunities to leapfrog or shift the site of care from a hospital - to a community center - to the home?

E-Health and Telehealth: A Promising Model

At the end of the day, there is an unavoidable need for increased affordability and access in developing countries, often limited by the lack of human and technological resources. Telehealth has been a primary focus for promising innovations in these regions for a few years now. I interviewed the Health Affairs Journal’s Susan Dentzer, Editor in Chief, and Philip Musgrove, Deputy Editor for Global Content, to understand more about their priorities and insights on successful innovations in developing countries. Through a number of articles in the journal, they suggest that well-targeted information and communication technologies (ICT), especially PDA-based technologies can have a significant impact on patient care. In another article they stress the importance of cohesive national policies and investments to build a workforce for e-health, telehealth and telemedicine to be successful.

When I was in India I witnessed a different application for teleheath than traditional health information technologies or remote diagnostic/monitoring equipment. Dr. Thomas’ diabetes center in Vellore is using an educational “telesuite” to provide training to physicians and nurses all over the country. His lectures are taped and then broadcasted over the internet or available for watching at leisure by CD. Another interesting model is illustrated by Deloitte’s Center for Health Solutions: a new mobile diagnostic business model was developed by a dermatologist that allows patients to use their cell phone cameras to photograph skin conditions and send the images wirelessly to the physician’s office. The office then follows-up by email/phone with either a prescription (high confidence of condition) or a referral to another provider (with potential conditions and solutions).

Deloitte has also cited the importance of enabling technologies for home care, or the “medical home,” for controlling chronic disease populations specifically. Point of care diagnostics and monitoring devices have the potential to change how people access and pay for care – in many ways making health more retail.

NGO’s as Innovation Engines

What role do NGO’s play in innovation? In addition to corporations, NGO’s are well positioned leaders to pilot innovative concepts in delivering high quality and affordable health to the masses. Project HOPE and the IDF efforts to increase the number of diabetes educators in developing regions is a prime example of a disruptive model to provide patient education. As resources at the healthcare worker level are still limited, could diabetes peer-educators be the next innovative model to effectively and efficiently empower self-care in patients?

There is a large opportunity for non-profits to focus on technology and process enablers for new community-based and self care models (e.g. groups of rural patients using one “home care” kit). Cell phones in general are remarkable platforms for telehealth programs whether they are focused on education, diagnosis, treatment, monitoring, or compliance: all of which can improve quality and access of care at a reduced cost.

As NGO’s compare outcomes among several “trials” for health innovations in developing countries, they have a significant opportunity to engage national leaders in expanded implementation of successful models. Programs that are adopted by the government regionally and nationally represent the ultimate success for an NGO innovation engine. Whether technology, process, or educational improvements are involved – it is certain that care will continue to shift with respect to who, where, and how it’s provided over time. Non-profits should seek bold opportunities to act as innovation incubators by investing in new and creative models that, if successful, could become future platforms for national and international healthcare relief efforts worldwide.

Sources:

Deloitte Healthcare Consumerism Study http://www.deloitte.com/view/en_US/us/Insights/Browse-by-Content-Type/deloitte-review/46fba7d2770fb110VgnVCM100000ba42f00aRCRD.htm

NIH History of Pregnancy Tests http://history.nih.gov/exhibits/thinblueline/timeline.html

Global E-Health Policy: A Work In Progress, Health Affairs http://content.healthaffairs.org/cgi/reprint/29/2/237?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=telemedicine&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

E-Health Technologies Show Promise In Developing Countries http://content.healthaffairs.org/cgi/reprint/29/2/244?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=telemedicine&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Connected Care: Technology-enabled Care at Home,Deloitte Center for Health Solutions http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_ConnectedCare_final_0308.pdf