Augmented Health(care)™: "the end of the beginning".

Lucien Engelen

AUGMENTED HEALTH(CARE) TM

The End of the Beginning

LUCIEN ENGELEN

Copyright © 2018

by Lucien Engelen Holding bv / Transform.Health

All views, statements and references in this book are personal reflections and vision. By no means intended to reflect the ones of any organizations they are affiliated to.

ISBN: 9789082874013

Version 3

Revised version and extra chapter added.

Table of Contents

Introduction to Augmented Health(care)™, The End of the Beginning

Prologue

Introduction

Theme 1: What’s Been Going on?

Chapter 1: The End of the Beginning

Chapter 2: Internet Emancipates Patients

Chapter 3: Signals That Point in a Certain Direction

Chapter 4: From the Valley of Disillusionment

Chapter 5: Uberization of Healthcare

Chapter 6: A Real Estate Perspective

Chapter 7: The Impact of the Fourth Industrial Revolution on Healthcare Real Estate (vignette)

Chapter 8: Hospital of the Future

Chapter 9: Missing Voices

Chapter 10: Patients as Equal Partners (vignette)

Chapter 11: Future Nurse (vignette)

Chapter 12: Value-Based Healthcare #patientsincluded™

Chapter 13: Marketing in Healthcare - The Future is Bright (vignette)

Chapter 14: Scientific Research

Chapter 15: Everyone Can Become a Researcher (vignette)

Chapter 16: Moving Away from the Biomedical Model: Systems Thinking and Doing (vignette)

Chapter 17: The Way of the Dodo

Theme 2: Cracks in the Systems

Chapter 18: The Digital (R)evolution

Chapter 19: 4D’s - Bird’s Eye View

Chapter 20: Exponential Change is Coming Gradually

Chapter 21: The Paradigm 10 Years from Now Has to Be Digital Health Based (vignette)

Chapter 22: Is Digital Health a Different Planetary System?

Chapter 23: Crossing the Boundaries of Our Sector

Chapter 24: We Need to Optimize the Chain with the Use of Data (vignette)

Chapter 25: Resistance

Chapter 26: It’s the Trust, Stupid! (vignette)

Theme 3: Taking Part is the Only Way

Chapter 27: The Day After Tomorrow

Chapter 28: To REshape or Not to Shape (2010 - 2018)

Chapter 29: Hospitals Are Internally Focused While Change Comes From the Outside (vignette)

Chapter 30: From a Doodle to a Mission

Chapter 31: Towards Collaborative Care (vignette)

Chapter 32: Innovation Distinguishes Between a Leader and a Follower

Chapter 33: The Future of Healthcare: Human-Centered and Tech-Enabled (vignette)

Chapter 34: What is Moonshot Thinking?

Chapter 35: Eleven Small Learnings That Will Boost your Innovation

Chapter 36: We Need an Innovation Atlas (vignette)

Chapter 37: Future Crooks (In Medicine)

Chapter 38: How One Case Can Set a Whole Sector Back for Years?

Chapter 39: Digital Transformation and Leadership (vignette)

Chapter 40: "There Isn’t a Problem with Medicine, There is a Problem with Leadership in Healthcare" (vignette)

Chapter 41: The Digital Patient: A Double-Edged Sword?

Theme 4: Where to Start?

Chapter 42: 9 shifts of Digital DNA framework in translation

Theme 5: This Revolution Will Not Stop

Chapter 43: Augmented health(care)™ explained

Chapter 44: The Future Physician: Augmented, Connected, Proactive

Chapter 45: Dreaming of a World with Circular Pharmaceutical Care (vignette)

Chapter 46: Quantified Self; Personal Discovery through Everyday Science (vignette)

Chapter 47: The GP in 2030 (vignette)

Chapter 48: Digital Humans in Health(care) (vignette)

Chapter 49: Space Health (vignette)

Epilogue: Writing this book has been an interesting journey

List of (public) REshape projects

Scientific Publications

Acknowledgments

Closing the Loop in 2018

Introduction to Augmented Health(care)™,

The End of the Beginning

Be my guest: You can read this book in 5 major themes; however, that can be read separately as well.

Theme 1: What’s Been Going On?

In 2007 the first iPhone was introduced, forever changing the way we interact with technology. Back then, who would have figured that these powerful supercomputers in our pocket would become such an important part of data collection for medical purposes and clinical trials? The world has changed fundamentally since the turn of the century: technology grows at an exponential pace. Omnia mutantur nos et mutamur in illis: Everything changes, and we change with it.

That notion seems even truer in 2018, and beyond. The way we interact with new technologies has radically changed our social, cultural and economic systems, health(care) included. We are entering a world of Augmented Health(care)™, as I coined it in this book.

What are the main changes I have witnessed in healthcare and technology in the past eight years I’ve been in health(care) innovation and part of ‘the system’?

Theme 1 will touch upon some major developments from an international perspective. With a number of noted guest contributors, I will dive into the emergence of #patientsincluded™ and #nurseincluded™ as an unstoppable force, the digitization of the healthcare sector and the need for alternative business models, coming from international tech companies such as Apple, Amazon, Google, with a strategic focus on healthcare.

We will begin with the earliest uses of the Internet in healthcare – mostly as a source to search medical information – and fast forward to crowdsourcing medical data and other novel ways of doing clinical research.

We will share about the future of real estate. At Radboudumc, we are about to begin the biggest real estate transformation in years, building a hospital that is fit for the future. But how do you build a future-proof building in an era of exponential technology? It’s like building a plane in mid-air.

As Rene Bleeker points out, a strategy must be built on bricks, bytes and human behavior.

These are not mere abstract visions; these are real things that are happening right now, this very moment. Want to know what’s been going on in healthcare? Start here.

Theme 2: Cracks in the System

As we continue to live longer, we are not necessarily living healthier: more and more people develop one or a multitude of chronic conditions, which will inevitably cost money and demand services in terms of healthcare. We will have a huge number of people that are moving into retirement age: a silver tsunami, as HIMSS CEO Hal Wolff calls them in his contribution. These are the economics that will drive the next ten years within our healthcare systems.

What are these cracks in the system? How do they manifest? This theme will not only focus on the increasing pressure that (inter)national healthcare systems are facing. As I will argue in this book, our medical systems mostly comprise of logistic processes - I reckon 80% - only 20% of our time and energy goes to medicine.

Solving current logistical inefficiencies in this system could be a possible solution. Therefore, we need a new perspective on supply chain management, delivering service and customer excellence, as experts from outside healthcare are eager to point out (see, for example, Michiel Muller’s vignette: We need to optimize the chain with the use of data).

At the same time, digital healthcare seems like a different planetary system altogether. We come up with separate names, separate reimbursement models and separate workflows when it comes to digital health(care).

And as long as a separate digital portal or an app per institution to access your medical records is needed, a challenge (at least, in the Netherlands) continues to be posed, and we will continue to experience inefficacy and information asymmetry in the domain of healthcare. The only solution to stud these cracks in our system is to fully embrace the digital transformation.

Theme 3: Taking Part is the Only Way

Stop talking, start doing. It seems so simple and logical; yet, most people find it so hard to make the first step and just begin. It’s is one of my mantras that I must have shared at least a thousand times on stage: taking part is the only way.

We’ve seen over and over again the hurdles that we’ve discussed in all of those sessions prior to the start appeared to be different ones in the end. You have to get your feet wet, get into the mud and take the messy, slippery road of innovating in healthcare. It is the only way to excellence in the end. You can’t learn how to bike from a book, can you?

In this theme, the learnings and experiences from the REshape Center and the innovation department at the Radboud University Medical Center that I was granted to found in 2010 take center stage. How do you manage innovation? How do you prepare an organization – in our case, a university medical center with as many as 13,000 students and professionals – for the future? What can you learn from our mistakes?

Theme 3 takes you on a – by no means all-encompassing - guide for innovation. What is a moonshot project? Why is focusing on the day after tomorrow so important, yet so hard for most teams or organizations? How can you possibly tackle resistance in your team, amongst your colleagues or in your board? What is the role of leadership and management in organizations when it comes to innovation?

For those interested in our journey of innovation at REshape, I have included some of my memories and recollections in this theme as well by including some of my Linkedin blogs (still stunned it has over 750,000 followers already) from the earlier days to give some perspective.

I have not only been using Gartner’s Hype Cycle to handle the predicted breakthrough moment of technology; we used it internally as well, as I noticed that every innovation project was practically going through the same phase of the Hype Cycle. I started to try and influence a specific portion of it, more as a guidance of how projects evolve. In my opinion, Speeding up the Hype Cycle could increase the actual access to and the use of innovation and adoption of the #patientsincluded™ model.

Theme 4: Digital Strategy

The digital evolution is impacting the way we work, the resources we use, and the nature of technology itself. If organizations hope to respond swiftly to change, reap the business benefits of new digital innovation and attract top-tier talent in the future, it is a given that their operating model must evolve accordingly into a digital TOM (Technological Operating Model).

For a lot of organizations, however, the digital strategy that they have identified does not fit into their current (traditional) OM: it’s like trying to fit a UK plug into a US Power socket, or a square peg into a round hole - as they say. I have joined forces with Deloitte, to translate into health(care) the nine significant shifts they’ve identified that will influence the model of the future. That needs to be discussed in conjunction with each other as they are highly interdependent.

This theme is the strategic core of this book. It is not a handbook, nor a blueprint or a generic approach. Consider this ‘Digital strategy’ merely as the start of a framework for the various steps one could outline to determine whether or not they’re ready for the things that lie ahead and to offer some assistance.

Theme 5: This Revolution Will Not Stop

A book on healthcare innovation would be incomplete without a brief look into the future. I am immensely grateful for an international team of guest contributors who shared their vision of healthcare in 2030, whether it is the future of pharmaceutical care (Claudia Rijcken), the digital skillset needed in an exponential age (Daniel Kraft), or how an average day of a general practitioner looks like (Bart Timmers). I am hopeful that these vignettes will transpose readers to the future of healthcare.

In this final theme, I share my own vision on the future of healthcare as well. We will be entering an era of Augmented Health(care)™, a layer of smart technology and data that comes around us and helps us make better decisions. With us, I mean everyone who is involved in the healthcare sector: care providers, patients, family, government, industry and informal caregivers. Whether that layer is projected via glasses or in another way such as on your phone, refrigerator or smartwatch is not that important.

What matters most is that in the future, everyone will have the precise information they need to be able to do their profession or work well, follow a therapy adequately, or receive the right information at the right time. With Augmented Health(care)™ healthcare professionals and patients are given digital tools to process and analyze the ever-expanding oceans of data in a meaningful way.

Note: as some of the images depicted in this book are difficult to read in this small format, I have put them online on my website:

http://www.lucienengelen.com/book/images

Prologue

Omnia mutantur nos et mutamur in illis: Everything changes, and we change with it.

The world is changing, society is changing, technology is changing, and so health(care) is. And it does so at ever increasing speeds. Platforms like Facebook, Youtube, Spotify, and Amazon have entered our life and are here to stay. Many of these platforms did not exist 15 years ago, and some of them will no longer exist in 10 years from now.

Healthcare apps for smartphones, portals and big corporate electronic health record (EHR) systems struggle to adapt to a new reality where algorithms and platform thinking emerges. Where patients are in control of their own personal data, everything is INTERconnected and traditional healthcare systems (still) are just INTRAconnected. They will enter the ‘End of Life’ phase of their current product cycle.

While many digital health critics at present address privacy and security issues - next to the looming market domination by modern tech-titans - I expect these new global corporates will be compliant to the European GDPR sooner than many of our healthcare institutions. And although

I share the worries on the risk of monopolization by tech corporations; I trust the current and future governance systems to handle this. Even though we will see hiccups on the way like recently with the ‘Cambridge Analytica files’ - officially not a ‘data breach’ but a flagrant crossing of ethical borders - I believe that law will follow the practice.

New players like Apple, Amazon, and Google (Verily) first explored the healthcare scene and now aggressively fight for (the data of) patients, offering a consumer-friendly user interface and removing the friction that the traditional silo-structured healthcare industry has been reluctant to address.

Meanwhile these tech-titans create interconnectivity ‘by design’ and on a global scale. Together with their ambition to enter the health(care) domain at an increasingly speed as you can see in this graph below. In it I have pictured the announcements of these non-traditional players into the healthcare arena over the past year, starting May 7th, 2017. I think this picture needs no further explanation.

We have entered the fourth industrial revolution where everything will connect with everything. In this book, I elucidate on the four pillars of change that I sense healthcare is facing: Delocalisation, Democratisation, Digital, and Dollars, hence my 4D’s.

Why are we at the End of the beginning?

I think this current digital transformation is at the End of the beginning. In an era where data will be continuously and easily gathered, analyzed for new patterns and used for machine learning at meticulous speed, technology will ‘augment’ the way we deliver health(care). Not only in industrialized countries: due to the proliferation of network coverage, Augmented Health(care)™ will become accessible to all people worldwide, enabling citizens to stay healthy and professionals to help people with a condition even better than today.

Some people try to change healthcare by focusing on the quality of care and service. Others focus on safety or healthcare economics. I choose to focus my work and research on the impact and opportunities digital technology can bring, transforming health(care).

Healthcare has been subject to waves of change in the past centuries when developments came together. We are on the brink of a new wave right now. Although we all want to progress and we need more sustainable health(care) to cope with societal challenges such as aging populations, we also face a daily struggle with the implementation of new tools.

In this daily struggle important issues like workload, reimbursement, policies, culture, knowledge, and information are all roadblocks in the way to a gentle transition. We need to remove these impediments and change the way we educate and train health(care) professionals, change the way we pay for health services, and change how we measure and research digital health(care).

It requires continuous awareness of the ever-changing technological horizons. It requires a thorough implementation of those innovations and the incorporation of digital tools and a digital mindset in daily workflow, becoming the new normal. It is almost like building a plane while it is already in mid-air. Maybe we should call this an ‘adaptive digital transformation’.

This book is neither a guide nor a plan. Health(care) organizations, their contexts, and their cultures are different. These external and internal influences vary in each and every organization, which implies there is no blueprint for innovation. Hopefully, this book will offer some actionable guidance on the next steps, to take on the challenges that lie ahead of us.

I stepped into this arena almost seven years ago, and it all began with a shared ambition to address change. But back then, there was no detailed, worked out plan at REshape, the Center for Innovation in the Radboud University Medical Center. In these early days, we’ve experienced that a shared vision and awareness are powerful motivations for change.

Adjusting over time to the level of awareness, we are now facing a bigger overhaul, because our organization is ready for the next steps. Merely building awareness, weaving concepts, presenting a compelling vision, and inspiring people does not suffice anymore. The need of the hour is to address the how-to-question. How to create meaningful digital tools for professionals and patient, how to organize and align stakeholders, how to scale digital health solutions?

This how-to has not been addressed adequately yet. To me, it appears that a whole network of healthcare innovators across the globe is struggling with the same issues. Some individuals and organizations have a plan; some have partial success, while some fail. It looks like we are all ‘writing the book’ as we speak; yet, we need to create tempo and build capacity.

Back then when we started REshape, I would have loved to have a book to learn about that first phase. A tour d’horizon of what is next when you start working on health(care) innovation. While some people think their organization can bypass that first discovery phase, or simply hire someone to do this - or even stop exploring and testing at one point in time – however, I would urge you that this exploration is nothing short of vital.

You really have to ‘live’ through this phase with your own people. You have to feel the joy and the pain, as my friend Chris McCarthy - who ran the innovation center at Kaiser Permanente for twenty years - likes to say. What I am saying is this: you can’t learn how to bike from a book. To innovate in healthcare, you have to experience it.

Although the current increase of demand for scaling is valid, there is also the risk of losing sight on the constant change that will be permanent if we myopically focus on scaling. The world will not pause to change. There should be a fair balance in creativity and room for exploration, as well as implementation and scaling.

In the journey towards this publication, I have interviewed some great friends that we have partnered with over the past years. Some of them have written a brief perspective on the changing healthcare landscape. They have enriched the broader picture with their ‘vignettes’ throughout this book.

This book is merely a reflection on the seven-year innovation-journey at Radboud University Medical Center (Nijmegen, The Netherlands), my work as a faculty member at Exponential Medicine (Singularity University, Silicon Valley) and as CEO of my small company Transform.Health. At all these positions, I have always been aiming to create sustainable health(care) change by collaborating with great professionals, with patients, and with the latest useable technology.

This book titled Augmented Health(care)™ encompasses all my personal and professional learnings, the joy and pain, the lessons from others and my observations over all these years. I wish it was available as a direct ‘download’ from my brain, but since we’re not in that exponential era yet and since there still is no USB plug in my brain, we had to write it down ourselves ;-)

The way this book came about is a journey in itself, through the integration of modern and classical tools and means. You can learn more about it in the chapter, how this book was made.

The combined mission of my work at REshape and my other endeavors was and continues to remain is to prepare healthcare for a soft landing into the future. I do hope that sharing these reflections and assumptions with you can help and inspire you to (re)think and encourage you to come across the opportunities in this current era, to change health(care) for the better.

I’m grateful for the past and current executive board to have the courage, the boldness, the vision and trust in sending me out there to be their scout, ambassador, and rebel for change. Everybody thinks they’re innovative, but it takes more than throwing some money against the wall and putting up a shield "innovation center’. The majority of the things they allowed me to do have a long lead-time, before having any impact.

Sadly, health(care) innovation is not impervious to tokenism; some claim that you can change or even fix health(care) overnight. It is neither about technology nor about the process; it is about bringing about a systemic change in the culture of an organization. As we know, culture eats strategy for breakfast. Having remained stuck in there with me for over seven years, the ‘seven years itch’ is definitely to their credit.

And last but not least - my stellar team - what can I say: you are my fuel, my northstar and my passion. Being able to guide you is an honor in itself.

All of this takes time, dialogue, and understanding from those surrounding us. There is no quick fix, no silver bullet, and our world will never stop changing. So let’s get on with it!

@lucienengelen, November 2018

Introduction

And then there was a painting...

We can hardly speak enough of empowerment in the painting "The Doctor" (1891) by Sir Luke Fildes, a nineteenth century snapshot resembling how healthcare was delivered back then. A Victorian doctor would visit the house and sit down next to the patient to examine, observing the different stages in the patient’s illness. A little child is lying on the bed, with her parents gazing on helplessly from the background, awaiting the decision of the doctor rather anxiously.

Without doubt, a lot has changed since 1891. The majority of doctors’ house visits have become a thing of the past. People have become more empowered, both in healthcare and the society as a whole. Technology has played an important role in making it possible to do things differently, bringing in new strategies in the hands of a lot more people.

But most importantly, patients and their family members have moved out of the shadows of Sir Luke Fildes’ painting, from helplessly awaiting the verdict of physicians to becoming empowered, well-informed individuals, with a wide range of technological tools within reach.

Apart from technological advancements, there are scientific breakthroughs as well. During the course of history, the combination of science and technology has been profound. In the future, we will see an even more intimate marriage of the two, a future where science and technology intersect.

Think for a moment about how Florence Nightingale created one of the earliest data visualisation. In 1854, Nightingale, a nurse working the British Army ‘in the East’, created a diagram of the causes of mortality amongst the British Army to illustrate seasonal sources of patient mortality in the military field hospital that she managed.

Nightingale’s visualization demonstrated that sanitary conditions such as bad drainage, contaminated water, overcrowding and poor ventilation were causing the high death rates in India. Her breakthrough work and research drastically brought down the mortality rate in the army, whilst also improving the sanitary conditions in India as a whole.

We can hardly envision the circumstances that nurse Nightingale had to work in. Try to imagine all the hours of hard work she had to put in her visualization. The countless, repetitive administrative tasks, the endless lists of names of sick and fallen soldiers. Imagine for a minute that she would have the technology to automatically collect, process and analyze that data to make models, visualizations and eventually see the impact of improved sanitation for the army in India.

Even though Nightingale was born into an upper-class and well-connected British family, it was her gift for mathematics, her crisp mind, her knowledge and her variegated experiences that brought her to the notion that sanitation could be linked to high mortality rates. Her prior experiences and human ingenuity were an essential factor.

Technology might have accelerated the process, and even raised the impact of her clarity. For me, it would be a fine nineteenth century example of what I refer to as Augmented Health(care)™, or healthcare extremely supported by technology. If technology can support and augment human capabilities, all one needs to do is to imagine what this could mean for humanity in the future.

The profound effect technology has on our lives can best be witnessed in remote places, where access to medical facilities and basic primary care is limited, and medical knowledge is scarce. In these areas, technology can help deliver often critical healthcare via mobile phones, smartphones, or even SMS. To speak with a doctor with a video consultation, get a prescription online or monitor pregnant women via SMS-service. It bears testimony to the fact that healthcare is, in my opinion, for almost 80% a purely logistical operation.

Gaining access to a physician or nurse often is merely a logistical challenge: enter digital tools and these logistical barriers can be surmounted. The patient is going to the professional, or a professional is coming to the patient. Translate that thought to the current state in healthcare and a logistical issue continues to persist: data has to go to the professional or