Let’s destroy, in creative terms, the current healthcare services model and rebuild it to make it even better. We all need to understand and accept that the ethics of healthcare provision not only depend on good intention but also on the quality of the outcomes obtained. Article by Julio Mayol, Head of Innovation, Hospital Clínico San Carlos (Madrid).
It is now 2016, eight years on from the declaration of the start of the last financial, economic and social crisis of the 21st century. And we are still discussing the future of healthcare systems, analyzing the reasons behind their decline, searching for the culprits among chronicity and technology without finding any definitive solutions. For this reason, I would like to start the year by appealing to iconoclasm. Let’s destroy, in creative terms, the current healthcare services model and rebuild it to make it even better.
To start with, healthcare systems arose as a result of the expansion, first by Bismarck and later by Beveridge, of the “medical act” of a self-employed professional that had been practiced for centuries. Given that medicine was very safe but not very effective, the physician (the self-employed professional) obtained his fees for the service provided, not for the eventual outcome. This business model, with widespread social validation, was and is governed by an ethical architecture derived from Kant’s categorical imperative: given the good intention in the provision of the service, its very goodness is independent of the result obtained. In other words, the social contract is for measures, not results. It is undeniable that this model has been successful, especially during the second half of the 20th century, when medicine strengthened its scientific basis and the progress of knowledge made it more effective but, at the same time, less safe. And then in the 21st century it slipped into a profound financial crisis sparked off by a number of factors (population explosion, increased life expectancy, ‘chronification’, the rising price of technology, etc.) and yet not caused by them.
The causes are inherent to the model itself. Basically, there are two causes: the “cost disease” described by Baumol (in the healthcare sector, salaries are constantly rising which, in contrast to other sectors, is not associated with increased production) and the lack of connection between health outcomes and costs, as described by Porter.
As a result of the above, all current health systems share three main characteristics:
a. Unmanageable (thought they are administrable): a lack of connection between outcomes and costs
b. Unpredictable in evolution: the desired results have not been defined
c. Unsustainable (more with the same, or the same with less): there is never enough of whatever you need.
It is hardly surprising, therefore, that we are constantly discussing and analyzing the sustainability of the healthcare system, albeit fruitlessly. Up until now, the solutions that have been proposed and implemented, even partially, tend to be as follows: providing a smaller quantity of services, or lower quality services, or increasing their price; resorting to volunteers, outsourcing the management or provision of healthcare, and increasing productivity by technological means. However, the results of any of these measures, with varying compliance, has not managed to solve the five major problems affecting every healthcare system (Sir Muir Gray):
1. Unwarranted variation in quality and outcomes
2. Patient harm
3. Inequity due to misuse of resources
4. Waste of resources without maximizing value
5. Failure to prevent preventable disease
Only a few people recognize that a model structured around service provision is no longer valid and needs to be changed if we are to achieve a value-based healthcare system. For us at the Innovation Unit of the San Carlos Health Research Institute (IdISSC), the transformation of the healthcare system will only prosper if we can manage to undertake a simultaneous process of innovation in three areas (Figure 1) in the next twenty years.
Firstly, with regard to social innovation, it will be necessary to make a change from the current rigorous Kantian “categoricalism” to consequentialism. In other words, we all need to understand and accept that the ethics of healthcare provision not only depend on good intention but also on the quality of the outcomes obtained. To do so, we need to promote the measurement and publication of health outcomes (obtained by ICTs) in a transparent and non-punitive way (in much the same way as patient safety).
With regard to innovations in the model, we need to start changing the financing/payment framework towards one that is associated with the complete cycle of care and both individual and population-wide outcomes. Obviously this entails a change from the vertical healthcare structures, in isolated towers, to other more horizontal and patient-oriented ones (not service-oriented). All of this would entail the transformation of the system from one centered on service provision to another based on value for the three main stakeholders in the system; patients, professionals and politicians/managers (personalized value, scientific-technical value and assignment value, respectively).
Finally, it is necessary to develop technologies that increase the precision and accuracy of healthcare and which generate data that can be analyzed and exploited (information and knowledge), so that decision-making support systems can be built (based on value) for the three stakeholders mentioned above. I am taking the liberty of proposing the following eight areas with the greatest impact:
Image: new hybrid techniques that merge images to the point that the human body is anatomically and molecularly transparent, codifiable and understandable by artificial intelligence systems.
Omics: The combination of biology and sociology will better explain the factors and determinants of states of health and illness with the help of bioinformatics.
Sensors: In a transparent way (i.e. non-invasive and non-intrusive for the patient) it is possible to obtain data remotely (above and beyond the usual data: pulse, EKG, blood pressure, temperature, oxygen saturation, respiratory rate), along with their geographical position, with the potential to monitor, diagnose and analyze quality of life benchmarks.
Point-of-care technologies: Microfluidics and nanotechnology make it possible to analyze biological samples (even in the picoliter range) by means of miniaturized systems at the patient’s point-of-care (bedside, home, etc.) with results in real time.
Telemedicine: Communication technologies, associated with decision-making support systems, need to connect patients with healthcare professionals. Quality healthcare must be both convenient and accessible to the general public, even in remote areas with fewer resources.
Mobile medicine: apps for smartphones or tablets that make it possible to self-manage diseases with high prevalence and low complexity, and also make quality healthcare accessible without the need for additional human resources. There are solutions that make it possible to learn by playing and also quantify this learning.
Robotics: small, highly precise devices designed to carry out specific tasks automatically which help to eliminate repetitive tasks with limited added value and the risk of causing fatigue in the people who usually undertake them.
Big Data/IA/Data: increasingly complex algorithms that are capable of understanding ‘natural’ language, with access to structured and non-structured databases, which identify new associations, correlations and causalities that up until now had not been accessible.
In short, a high quality, sustainable healthcare system for all needs creative deconstruction that only innovation can bring us. And in each of the vertices of the triangle of innovation (social, business model and technology) there are infinite opportunities for progress.
By Julio Mayol, Head of Innovation, Hospital Clínico San Carlos (Madrid)