Vision 2025 Forecasting the Future of Health Care

Making accurate long-term predictions about health care is far from easy. After all, advances such as robotics-aided surgery, 254-slice CT scanners, and stem-cell research weren’t routinely available to doctors as recently as the early 1990s; heck, they weren’t even using E-mail back then. Projecting 15 years from now is equally difficult, but we put four experts in different fields — surgery, administration, informatics, and cardiology — to the test, asking for thoughts on what the medical landscape might look like in 2025. The composite picture that emerges is undoubtedly exciting — but promises some tremendous challenges as well.

Surgical Precision

With the impressive innovations that robotics has brought to surgery over the past several years, you’d think Dr. Neil Seymour would be impressed.

He is — up to a point.

“Actually, compared to what the level of telerobotics is outside of medicine, these systems don’t represent the highest level of sophistication,” Seymour said of advances such as daVinci, which lets surgeons use ‘hands’ and a viewer several feet away from a patient to control robotic instruments inside the body.

“The space program uses technology that’s far more advanced,” said Seymour, chief of General Surgery at Baystate Medical Center. “So it’s not difficult to envision a much more capable robotics system that offers a visualization and precision capacity that would be hard to believe today. We’ll almost certainly see a progression from the current generation of robotics to the next.”

At the same time, “minimally invasive surgery will become more expansive, encompassing areas of surgery that aren’t currently so,” Seymour said. “That’s been the trend over the past two decades, and there’s no reason to suspect that won’t continue to be the case. We’ll see a push toward a lesser degree of invasiveness in virtually any surgical intervention.”

Baystate already employs innovations like natural orifice transluminal endoscopic surgery (NOTES), which allows doctors to perform operations using an endoscope passed through one of the body’s natural orifices, avoiding any external scarring at all.

Even that can be improved upon, he said. “But to get there, we’re talking about significant technical advances that we don’t have yet — new instrumentation, new ways to visualize operative problems.”

Seymour also sees a greater role for stem-cell research, from which he hopes scientists can one day grow organs for patients who need them, instead of relying on transplants.

“Work is being done around the country on exactly that goal,” he said. “They’re looking at being able to grow a patient’s own skin to be used for grafts in a severe burn situation where there’s little skin available on the patient’s body. Or the growth of cartilaginous structures to replace ears or noses, using stem cells to replace these vital structures.” If there’s a foundation of success in these areas, he suggested, it could lead to more complex applications of the technology.

These high-tech changes are already altering the way medical students are trained and the skill sets they’ll need to master in the coming years, Seymour said. But they’re also posing some exciting training opportunities.

Take patient simulators, for example, which are essentially lifelike, interactive mannequins on which students can hone their skills. Seymour sees a day not too far off when sims are programmed with a patient’s specific data.

“Before an operation, you can actually look at a 3D, realistic version of the patient, and you can simulate an operation before doing it,” he said.

And consider future advances in imaging. “I can imagine a time when a liver surgeon, preparing for a complex liver section, can look at a holographic image showing the position of a tumor relative to critical structures in the liver, and interact in the virtual environment.”

Likewise, Seymour sees greater precision in the use of marking substances that will help surgeons target tumors and other issues without harming any healthy tissue.

None of this will come without cost, of course (more on that issue later).

“The cost of medical care will have to be contained,” he said. “Considering what the costs are currently, this coming technology and sophisticated devices will be expensive additions. We need to find a way to fund the development of these potentially exciting technologies, and there’s really no getting around the problem of cost.”

Staying Connected to Care

Really, who wants to go see the doctor?

It can be an inconvenient trip. But as Americans live longer, managing more chronic conditions than ever before, they’re going to have to stay connected to the providers of their medical care. Vincent McCorkle thinks many of them won’t have to leave their home to do so.

No, house calls aren’t back, said McCorkle, president and CEO of the Sisters of Providence Health System, which includes Mercy Medical Center. The idea is something a little more high-tech.

“Baby boomers are pretty sophisticated,” he said. “I can envision them having a chair in their house where they can sit and send their weight, pulse, and blood pressure to their doctor. If they have diabetes or some type of pulmonary disease and they’re gaining weight or retaining water, the doctor gets a readout every morning and can see, ‘oh, she’s up three pounds. Let’s change the diuretic.’”

That picture represents a near future where patients and doctors are more connected remotely than they are now, and roles begin to shift.

“Providers will be much more interconnected, with more communication between physician offices, hospitals, and nursing homes,” McCorkle explained. Meanwhile, he noted, hospitals may be used less-often for non-acute patients, with outpatient care expanding, and what will follow is what he called a “downshifting” in the level of expertise needed to treat various conditions.

“Services that are now delivered by primary-care doctors might be provided by nurse practitioners,” he said — all this in an effort to serve an ever-growing, and ever-aging, population.

This trend will be driven partly by predicted changes in the way doctors and other providers are paid.

“Now, payment is on a fee-for-service basis; doctors are incentivized to see patients as many times as possible and provide as much care as they can,” McCorkle said. In the near future, however, hospitals might receive a bundled payment that covers not only a patient’s hospitalization, but also certain post-acute care. “That’s really going to change behaviors and drive a lot more coordination between hospitals, nursing homes, and home care,” to name a few, he explained.

Overseeing a health system that encompasses several different types of care, McCorkle takes a wide view of health trends, but he has smaller, common-sense improvements on his mind as well. Take, for example, the problem of patients neglecting to take their medications.

“Some of them have so many, they can’t keep track,” he said. “But there are some emerging technologies, like smart pill bottles, where, every time you open the bottle, it sends a signal to a repository that can track what time it was opened and how frequently, things like that. We’re starting to address medication adherence outside the clinical setting, maybe on your BlackBerry. There are some interesting ideas out there.”

If that’s a relatively mundane use of technology, others are more ambitious. For instance, molecular medicine will see advances as well, he said. “We’ll be able to look at biomarkers in people at the molecular level. There will be more customized information about you, and we’ll be able to offer early, individualized treatment options for people. Technology will still be a good driver.”

Yet, there are other factors, outside of the health care system, that need to change if Western Mass. is to become truly healthy, McCorkle said. The region ranks first in Massachusetts for cocaine and heroin addiction, which strains the area’s behavioral-health infrastructure, led by Providence Behavioral Health Hospital. And then there’s the education gap.

“In Springfield and Holyoke, half the students graduate from high school,” he said. “That affects the health status of our community, because the less educated you are, the less healthy you tend to be.”

That’s a problem that local civic and educational leaders have been trying to tackle for many years. Surrounded by large-scale challenges of its own, health care can only make sure it’s there to provide a safety net. And maybe a chair.

Beyond Big Brother

“George Orwell has been very influential on the American psyche,” Dr. Dirk Stanley told The Healthcare News. “Other countries have a national medical database, and people don’t have a problem with it; they see it as a benefit. But here in America, we’re very focused on privacy.”

Stanley, a hospitalist — and, informally, an information-technology expert — at Cooley Dickinson Hospital, was speaking of the skittishness that many people feel when they hear talk of creating a nationwide database of medical records that would, in theory, be easily accessible to doctors.

The benefits of such a system are obvious. For one thing, having a patient’s medical history on hand would significantly cut down on unnecessary tests and possibly dangerous contraindications from unknown medications in the body.

“Someone shows up in the emergency room, short of breath, and the doctor’s first question is, ‘what medications are you on?’” Stanley said. “My guess is that 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of people don’t know. They’ll say, ‘something for my heart,’ or ‘something for diabetes,’ but they don’t know the names, the doses, the frequencies” — which is especially true for an older individual who has a caregiver assemble a daily cocktail of pills.

A doctor can call the pharmacy, but not every drugstore is open 24/7. That means guesswork or, more likely, extra, otherwise unnecessary tests that can be expensive and time-consuming — all because there’s no way to access a patient’s files.

“They don’t have access to the right information because we don’t have a nationalized health care record,” Stanley said. “Why not? Well, there are political reasons — some people object to the government collecting everyone’s health information.”

Privacy is another reason, he added, noting that the Health Insurance Portability and Accountability Act (HIPAA) is so far-reaching that it can be cumbersome even to transfer health records from one hospital to another. But the main problem might be technological — that is, how to create a centralized database when the computer systems of different providers can’t talk to each other, and patient record numbers are completely different from facility to facility.

The answer, said Stanley, isn’t a national patient ID number, because that wouldn’t solve the issue of getting different computer systems to communicate. What he envisions — and what companies including Microsoft and Google have already started working on — is a ‘health portal’ concept, whereby patients would build an online record of their health history and, crucially, have control over who gets to see it. Accessing the file would be simple for any provider, since all it would take is an Internet connection.

“To solve this problem, we need to change the way we think about a patient’s medical records,” Stanley said. “We’ve had this paternalistic view that, even though you own your information, the medical record itself is owned by the hospital. It has to become a more patient-based record to address some of the privacy issues. The only way to sell this solution to the American public is to allow patient access to the record so that the patient can decide what he wants in the record and who has access to it.”

The cost savings — from eliminating unnecessary tests, avoiding diagnosis and treatment errors, and other efficiencies — could be massive, Stanley said, arguing that, under a centralized records database, every U.S. citizen could have health coverage at the cost we’re paying today to cover everyone minus the 50 million or so that are uninsured.

Computerized records have been shown to save money — which could then be reinvested in patient care. That possibility is enough to keep Stanley — who was originally a computer programmer, and became interested in medicine after working with hospital informatics — up at night, thinking of the possibilities.

“I’m one of the few doctors who understands this issue, who has doctor skills and the computer skills to fix it,” he said of a challenge that has become a passion for him.

“How am I going to save more lives? As a doctor, I might save a couple thousand. But if I can help fix the health care system in terms of informatics, I might help save a couple million lives. I can be a translator of sorts; I can take doctors’ ideas and translate them for the people building the software, and I can take IT-speak and make it accessible for doctors.”

Sure, Americans would have to be sold on the idea, and implentation would likely be a drawn-out process. But he sees the idea as “safe, sane, and secure,” once questions about computer security are addressed, and the courts work out how records are accessed if a patient is unconscious, among other issues.

“This is a national problem, but we can achieve our goals,” Stanley said. “The obstacles are not insurmountable. It’ll take a lot of work and a lot of pain to rein in this problem, but at the end the benefits will be clearly demonstrated.”

Heart of the Matter

Heart surgery has come a long way just in the past decade, said Dr. Jeffrey Leppo, citing a fast-growing emphasis on minimally invasive, laparoscopic procedures and the emergence of robotic precision to aid doctors’ hands. But there is a limit to what the next 15 or 20 years will bring.

“It won’t be stuff you see on Star Trek, with McCoy passing his wand over the body. That would be much better,” said Leppo, the Cardiology chair at Berkshire Medical Center.

Still, he said, there will come a time when people will come to see opening patients’ chests as “barbaric,” though it will remain necessary in some cases. That’s partly because — as other doctors we spoke with mentioned — surgery is becoming less invasive all the time.

But there’s another possibility on the horizon that could, in many cases, eliminate the need for heart surgery at all.

“Some of the most exciting stuff is the emergence of gene therapy,” said Leppo. “There was a big flurry of studies a few years ago of injecting genes directly into the heart muscles, trying to get a genetic change and restructure the heart, and potentially reverse some of the damage. But the engineers were not able to deliver that. It was basically an unsuccessful project.”

However, “hopefully, by sometime around 2020, we’ll actually be able to do that, figure out how to insert genes into different tissues in the body,” he said; in the case of the heart, that might mean preventing cholesterol blockages and other serious conditions. “If we can change the genes, we can cure people, as opposed to doing what we do now, which is plumbing.

“It’s like saying, ‘I have hard water, so I’ll keep replacing bits of the pipe,’ when you’ve never changed the water system,” he continued. “What we have now might make us feel better for awhile, and it might slow the process down, but it does not prevent it. Surgery, stents, they don’t prevent new problems from developing. They don’t cure them.”

The impact of gene therapy would, in fact, reach far beyond cardiology. “The control of a lot of diseases — cystic fibrosis, diabetes, lots of things — may benefit from a gene marker,” Leppo said. “We could change or ameliorate the disease if we find the gene controlling it. And we’re getting closer as more genes are identified. It would be a real breakthrough.”

Stem cells are another potential gold mine for heart research, Leppo said. The heart can develop irreparable muscle damage from heart attacks or long-term disease, but scientists believe they might one day use stem cells to generate new tissue.

Meanwhile, “diagnostic technologies are growing rapidly, involving all imaging modalities — X-ray, CT, MRI, echocardiography,” meaning more accurate diagnoses, and earlier in the disease process.

In fact, Leppo doesn’t see much at all standing in the way of continued progress and innovation — except for one pesky problem. And it’s a massive one.

“The biggest challenge for all of us will be the cost of care,” he said. “It’s a much bigger problem than most people realize. The projection is that, in 20 years, Medicare will pay out in excess of total federal revenues. President Obama is right: if we keep ignoring this, it will destroy our entire economy.”

At the same time, he said, “there’s no other society in the world as developed as we are that doesn’t provide health care to its citizens universally, and I find that outrageous,” he said. With almost 25{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the $2 trillion that flows into health care each year in America eaten up by insurance overhead, he argued, the system is in need of change.

Bottom Line

Leppo isn’t alone; Seymour sees the same game-changing issue in his own crystal ball.

“There’s a concept that we as Americans deserve the best, and opposition to the idea that cost should be any prohibition on the level of technology that can be brought to bear on a health problem,” he said.

“But we’re now having difficulty with our accustomed level of prosperity and just paying for the most basic medical care. There will be conversations about which services may be vulnerable in the future., It’s a very difficult exercise, and one we’re not accustomed to.”

In McCorkle’s view, the next 15 years or so will bring about “disruptive or transformative solutions — and there has to be a willingness on the part of health care organizations to transform and change.

“But there’s going to be some good news,” he added, “and there’s an incredible amount of opportunity and potential.”

Welcome to the future. And good luck paying for it.

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