 Hi there, I am David Agus. I'm a professor of medicine and engineering at the University of Southern California and together with the forum We welcome you and congratulate you for surviving till 2 o'clock on a Friday And we hope to keep your energy up with this session And I think when you hear the content and the depth of the speakers around it I think you'll all get very excited too. So we're a transition point in our field We're starting to see the outpatient side where no longer are doctors the collector of data The patient is becoming the collector of their own data Patients are checking their blood pressure going in with three months of a supply They have their movement pretty soon They're gonna prick their finger and send it a biochip to the doctor so the doctor's office visit can actually be something We all dreamed about which is actually talking to the patient rather than collecting data The inpatient the hospital side is always slower to respond But obviously critical most people experience hospital stays at critical events in their life acute stays When you're born when you have a child when you get acutely ill I will tell you most of my patients are never hospitalized So from when they're diagnosed with a cancer to if they Fail the cancer and you know ultimately die many times. They're never hospitalized that being said surgical procedures Something we all go through and the hospitals hopefully are going to change and I think you'll hear perspectives here that gives you a whole new Framework for the power of what a hospital could be and will be and probably should be So I first want to introduce the panelists because you know their perspectives because classic form style It's a very broad range of people from all different disciplines and I think each bring a unique perspective So starting on my left is Thomas de Rosa who is the CEO of well tower, and I'll let him tell a little bit about himself So well tower is a 40 billion dollar Public company that is the largest Platform in senior care. We own over 1,400 buildings in the US Canada and the UK And then we but we also treat and care for 250,000 frail to demented elderly generally 85 and up at any Given moment in any day our other business is what we call outpatient medical We own 16 million square feet of outpatient medical buildings throughout the United States What we don't own is a hospital and we'll talk more about that later Going around in a clockwise fashion Shamshir Vyallil is the managing director of VPS healthcare, which is based in the UAE Thank you I'm a radiologist by training when I started to work. I realized that I should not be confined to the basements of hospitals So and you know, I was born into a business family. So blood was into business I wanted to start one hospital. So the first hospital I started in Abu Dhabi and then that was nine years back Now we see almost 12,000 patients a day and we do only hospitals. So we have hospitals the clinics manufacturing facilities, so we believe in an integrated model and We feel that hospitals have changed and I feel that in the next 10 years You would see changes what you would not have seen in the last 100 years So we're excited to hear what you think those are in a few minutes Thank you Next clockwise is Sean Duffy who is the co-founder and CEO of Omada Health in the US Yes, I'm Sean. So Omada you can think of funnily enough almost like a digital hospital For participants and patients who are at high risk of diseases like diabetes thanks to obesity Where the in-person programs that have shown to be effective clinically are just hard to get to You know the research shows that you can make a big difference if you catch people right before they tip into chronic diseases like diabetes But it requires multiple touch points, you know weekly sessions lots of in-person visits, you know social support So we've architected those same principles, but online we match people into groups Bring them on a curriculum, mail them hardware and just make it so that we come to them Where you know where they are and people tend to live their lives in front of their screens So we figure that's where we should Capture them and help them and we've you know over the past five years become actually the biggest Provider of these digital interventions in the US and we are still just getting started Which tells you how far there is to go in the health care system in the country. That's great next is Betsy Nabel who is one of the greats in the field of cardiology Who had a leadership position at the National Heart and Lung in Blood Institute and HLBI and now leads one of the Premier Medical Institutions Brigham and Women's in Boston Thank You David. I Probably represent The academic integrated health delivery system Among the panelists here I would say that we like other academic centers provide for functions We provide exceptional care to our patients from prevention to acute illness to post hospitalization We engage in innovation and discovery through our research programs We educate the next generation of medical and scientific leaders and we serve our community locally and globally and I will argue that those four functions can be served regardless of the structure And last we have Sarah Daugherty who is the co-founder and chief technology officer This is the longest word we have in our sheet here telehealth robotics Well, we firmly believe that the title of a business should tell you a lot about what it does And that's exactly what telehealth robotics does we build and pair remote Technology to enable health care services around the world So we have a software system that a health care provider can log into anywhere in the world They can interact with the patient remotely to do telepresence And then they can also use the controls of the software like a video game to guide a robotic kiosk That can be dropped anywhere in the world to provide services like remote ultrasound Eventually remote primary care ear nose and throat exam and a range of other diagnostic services So talked a little bit about behavioral health wise bringing the hospital to everyone And we'd like to do that with hardware and diagnostic services. So break through that computer screen that Phone to allow for actual sort of physical exam Wherever a patient is so the weather that's a long-term care facility a prison a hospital that wants to through an integrated delivery network Better labor resource share a remote island like we were talking about before a lot of applications for delivering care That is for the right patient at the right time at the right cost So as you see we got very different backgrounds You know, we're seeing these trends in hospitals right now I have two patients today that are ongoing prostatectomies at our hospital and they're outpatient So they're going home after the prostatectomy, which you know, ten years ago That was a five to seven days stay at minimum and we're seeing that transition at the same time Obviously, we're still seeing lots of dollars being poured into hospitals. So let's start with an open-ended question ten years from now so in 2027 Where are we going to be I mean so when I go into a major city So let's right now talk about major cities. So a major city in a developed country. I go into a hospital in ten years What's it going to be like? I think it's going to be very different from what you see today You know, think about I'll take you to New York City my Two eldest daughters were born in the same hospital in the same wing on the same floor as their great-grandfather 100 years earlier And if I wanted to take them to see that hospital today They would be looking at one of the new luxury condominium buildings That has been developed in the West Village of New York City and that hospital was St. Vincent's Hospital and St. Vincent's Hospital was on the front line of the AIDS epidemic back in the late 80s and It's physical planned Could just not deliver Modern medicine today. I recently met with the CEO of a major hospital in a major city in the United States And he said to me just so you know, you can't get a Wi-Fi signal in 60% of this building. How do we deliver modern medicine? When you can't get a Wi-Fi signal, so I think the world is changing ten years. We're going to look very different I think ten years from now You won't see standalone hospitals according to me. I think it would become part of life. You would have People walking into a hospital drinking coffee having business meetings Doing their gyms their iPhones would be their primary doctors. They would have their data connected on to a central Artificial intelligence kind of stuff. They would be getting continuous advice So I think even today if you take a prostatectomy, which you were talking about it's all done by robots and you have the skills the Doctor stays, but I think the dependence on artificial intelligence and data is going to be much larger So I think there'll be a complete shift. There will be democratization of health care You would have people in the center, not the physicians or the hospitals. So I think we are here for some exciting times So you asked ten years you walk into a hospital what that experience like and I think you've got to ask also Why are there and what you're there for and I think ten years from now you're gonna be walking for something very specific And you might need a hernia surgery and the hospital is maybe not that large But that is just what they do they do hernia surgeries and how you got there was a digital mostly experience where you You know, maybe felt some pain you you open up your phone you view that experience as primary care You file a ticket it gets routed Maybe you get you know some diagnostics at a small center that collects any physical specimens that need that's routed Maybe you see someone and then you're sent to this hospital I think all the data systems you're saying verticals. I think I think that's where it's gonna go I think it's gonna be special in urban centers specialist verticals where volume matters for outcomes That's great. I Would reframe the question as well and ask in ten years. Why do you think you need to go to a hospital? and I would redefine a hospital as a Center where an individual is likely to undergo some type of invasive procedure For which they might need an extended period of continuous monitoring and That is best served by having a group of experts who can provide that monitoring And so it may be a vertical right care center as you've defined it But where we would like to take our health delivery system is as much into the home and into the community as possible why Because we think we can deliver better care at lower costs if you believe in value-based health care the definition being outcomes Patient-measured outcomes not process outcomes, but patient measured outcomes defined by cost We believe that outcomes will be better delivered at home in the community at much lower cost So I take you up on your why question also and and my answer would be that the Surberry name of a hospital creates a huge issue in health care right largely because people think that's the only place you go to get health care and to think about your health and They only think about their health when they're going there, right? So there are so many solutions already out there in the market like omata like others that allow you to take charge of your health in Your home But we have a kind of technology gap, you know an education gap around those tools that are available And I by opinion is that I think we're no longer going to have hospitals We're going to have points of care Whether it's in your home. It's your local community center. It's your pharmacy It's your school or your workplace and that's kind of core to the technology we're availing that it's you know Kind of drop clinic You do see a lot of clinics now that are on your street corner But the limitation that they have similar to the limitation of a hospital that you go to is that they're Only available the people who have expertise that are stationed there And so what we think is that they're having a virtual pool of providers who are available to each point of care Whether it's at your home through your phone or at your local community center through a kiosk like telehealth robotics You have this pool of physicians who work across the country and across the world and you can get availability from a cardiologist And then an endocrinologist and then a nurse practitioner to manage your chronic disease One right after the other so I would say not only are we going to change from the physicality of hospitals But we're also going to change from the localization of physicians to a particular hospital Instead having physicians share their expertise around the world. So sir and your distributed model of labor How do you ensure quality? That's a good question. So, you know, I think initially we're working on partnering with leading institutions to share that labor resource and And you know, we'll still have to go through the same qualification that Physicians go through now right in working with leading academic medical institutions You know, I think as we look more towards commoditizing The practice of medicine that will become a big issue and we'll have to think a lot from a regulatory standpoint And also from an education standpoint how we make sure that we have sort of equal quality of care across that network Betsy now you're in a hospital one of the best in the country that's considered really not exclusively But a tertiary care hospital the craziest hardest cases are sent to you In your model of the future, are you going to be much more primary care in not just Boston, but spreading out or are you refining in one area? We are we are going to be both We certainly are going to be very much primary care But we also will remain tertiary care and when I say we I want to include Brigham women's hospital in Massachusetts General Hospital We're partners healthcare system. We are 60% referral primarily regional but national and international as well But having said that We believe very strongly In the power of the personal relationship between an individual and their health care provider To deliver good health to provide outstanding outcomes And to build a lifelong relationship that will foster health and wellness I want to Commend an article that appeared in the New Yorker this week by a tool gawande who is a surgeon at our hospital And he talks about as a surgeon. He was trained to cure people episodic one-time cure But as he has stood back He's realized that most improvements in health and wellness occur through incremental medicine and he gives several examples in this article and Talks very eloquently that our future is really about the relationship that we have with health care providers So I believe very strongly in digital technology as important tools That we will utilize that they will overlay on our electronic medical record to help health care providers better deliver their their care But I'd love to hear the two of you talk about What's the role of the relationship with the health care provider? Yeah, you know I'll just say, you know, I'm listening to you talk and and I would talk to Togo on day when he was here yesterday in the same circle and we were talking about Work, he's doing in Estonia related to community health care workers and I said to him, you know, what's the role of telemedicine? because a big part of the Work they're doing is relationship focused and you know, I think that that's an important part of this and in some ways We'll be able to better enable Physicians and patients to connect because hopefully that position will be freed up by the artificial intelligence And the better use of their bandwidth to connect with patients who want to connect with the same person each time so instead of, you know having Having to wait because someone's late or someone cancels you can connect in, you know Maybe to someone a patient that you've seen before who was waiting to see you But the alternative side of that is there's so many people without access and I think you know That's sort of the baseline It's great to have that relationship and you do see impact that comes from that But below that we have all these people who are not able to get access to to care And so I think that's probably for me the problem that we have to solve first is access and then relationship building Yes, so you're developing a system that in a sense use data driven has outcomes But the reliance on the physician is less than many health care systems Well, we always call it high tech and high touch because I do not think we could get any clinical outcomes in our program without people That as part of the system, I mean we match people to groups social relationships feeling loved supported like you're not alone As you go through the change is critical having a coach kind of providing oversight accountability Motivation is critical and I do think I completely agree that I think the brand to finish the relationship that folks will have with Whatever the system whatever their view of primary care tomorrow will be critical and we're Almost like a specialty center where we'd be referred, you know Practitioner would say hey, you know, you're at risk for diabetes There's this program and route through the EMR to Amata and then we feed data back the only area where I might You imagine, you know a world that could be different than what it is today is I think Right now when people talk about that emotional feel with health care that can deliver on outcomes They tend to think of that as a person and I actually think that tomorrow's world It's gonna be a brand you're gonna grow incredible trust with a brand and a system and all the associated people will be able to know you and Context of that brand in a way that makes them feel like, you know part of your team and And you know and that that is how you'll view kind of your locus of care in my opinion And I would add to that because the concept of brand today If you want to access the Brigham and women's brand you need to live in Massachusetts Mm-hmm. I foresee a day where someone who lives in Chicago Who wants to affiliate with Brigham and women's can do that and do that on a local basis We may live in it. We may see it one in the future a Brigham and women's ambulatory care How patient medical facility in Chicago, but today so what is the brand though? What the brand is a style of medicine treatment algorithm is the quality of care Mm-hmm. It's the reliability the dependability the trust that if you touch Brigham women's hospital Actually and Tom you you you are prescient because just this week. We are relaunching ourselves as Brigham health Because we believe very strongly and focusing on health and wellness We maintain and we restore health and wherever you touch us around the world You can receive that same reliable dependable high quality of care. No more women We're keeping the hospital name locally because we've had so many babies born at our hospital effects We'll never give that up, but if you hire a new doctor, I mean do they get do they go on a lot of computers? I hear here's how the Brigham and women doctors treat X disease What what is the brand that the brand is the? is the apprenticeship that a trainee comes and gets embedded in the secret sauce of Dedicated teaching and I'm looking at dr. Jeff Drazen who was one of my teachers when I was a house officer That has gone on for over a hundred years So it's not treatment pathways It it is It is a value system That says it is a health care provider whether you're a physician a nurse a social worker a pharmacist This is a culture. It's a culture. It's a value system and in though those values are then embedded linked With standards of care that are best practices that are evidence-based and have been shown to produce Exceptional patient outcomes at a low cost at the lowest cost possible You know in healthcare we always talk about two things quality and safety I Think it's a kind of over self because that has become part of the game There is nothing which goes without quality and safety But what is the value coming with it because today we have a problem The the cost is going up and the values coming down and that's only happening in healthcare you take manufacturing There's always the profitability which increases with the fourth industrial revolution But here the hospital operating margins are coming down. It's almost straight six to seven percent You go for a IT implementation Even I believe partners ended up in a loss with their new installations MD Anderson laid off 900 people We have tried affiliate from our part of the world. We have tried multiple partners, but there is no standardization We couldn't live with any partner for more than two or three years because what happens in US doesn't apply to the Middle East or Africa so I think we need to look at it from a global perspective Look at it as a universal health record rather than Sub-focusing on one recipe which nobody knows. I don't think you can explain. What is your secret of your success? Not your From the hundred years, so I think we need to value what it is. We need to see what is the recipe We need to do data analysis why somebody coming out of Brigham is ten times better than coming from somewhere else So I think that's what I'm trying to push out I mean, how do you be iterative and data-driven if there's it's a secret sauce. Well, I I want to I want to clarify because I would say something that the secret sauce may be applicable to Our region in the United States, but that's that's geographic Your secret sauce is going to be very different because it's going to be culturally The the degree to which we can partner together and share our secret sauces and figure out where the commonalities are And respect our differences to me. That's the opportunity. That's right. I think yeah One other thing I'd add to the brand question, you know for hospitals that approach us and are interested in working with technologies like ours and Their brand focus is actually on innovation So how can you show your patient population that you're at the cutting edge in terms of optionality from a treatment perspective? Reinventing medicine and and treatment plans and I think that you know for businesses like ours That would be a big part of you know, why people come right? They're interested in different ways to approach their health care and also why we might partner with health systems to get a prescription Essentially, so, you know, maybe you need chronic care management or maybe you need chronic ultrasounds, right? Because you just had a procedure and you need follow-up care how do we kind of work with hospital systems to Focus in on that component of brands, which I think now as technology becomes more and more important in Attracting patients and differentiating yourself in a metropolitan area from other hospitals We see that as really driving a lot of hospital sort of brand focus So brand focus based on technology not just on the secret sauce in the culture Well, I think they're sort of integrating that into their secret sauce, right? So we also see a lot of trainees that kind of work with us in some of our clinical trials And they're being encouraged to think in an innovative way about the treatment plans that could be delivered, you know, not saying no right away to a Disease state that traditionally couldn't have been treated and also giving Optionality for the way that you might approach your health care and your follow-up from a hospital visit, right? So, you know, I we were talking with people from Kaiser Permanente and they said that 50% of the people that they work with Opted in to a telemedicine visit Right. So if you are able to provide a lot of ways that people could interact with your health care system I think that's starting to be a big part of marketing opportunity for hospitals from a brand perspective. We're talking about health care Like a consumer product and I think that's very interesting because traditionally health care has I think at least in the US been thought of as Entitlement not necessarily a Consumer choice you went to wherever you were told to go and That made you know, I think what you're hearing today is is really changing It's much more obviously target to bigger cities where there's a lot of choice But you know you have a business model that basically your business model is stay away from them exactly So it's a very interesting dynamic, right? Your goal is to keep the patients out from their hospitals exactly and it's working It is working. We we take what is the most at-risk population for the Brigham The 85 and up frail to Demented that is they are the largest consumers of acute care and Betsy used a word that I always use Wellness so what is it that we do? We provide wellness to this population. What is that that is nutrition? It's hydration It's physical mobility It's socialization cognitive engagement to the extent that that mind can be cognitively engaged And one of the big diseases we attack one of the biggest diseases that affects this elderly population. It's called safety because that 85 year old with dementia is one fall away from a cascade of Healthcare issues that land that individual on the doorstep of the Brigham And they become a very complicated Expensive low margin to money-losing proposition for the hospital. So we're trying to prevent that and In the US. This is a private pay model. So people our population those 250,000 people that we're taking care of right now are paying out of pocket and they're paying dearly for it between $8,500 a month and $20,000 a month I think I would say the work that Tom is doing is one of the best partnerships that I could have There's nothing that I think our our care provider community wants more Then to people then for our our patients Our individuals we care for to be well outside of the traditional hospital By the way a month your place is the day in her place Yeah, yeah, and that's that's a major reason But I think we should be talking about scalable models I think we should talk about disruptions and health care industry is very Risk-averse because of the issues of quality safety Ten years back who would have thought Apple would be so keen on health care So I think the disruption would come from outside of the industry because we think so conventionally We still think about fall or Dementia we want somebody like them to come forward with New ideas new technology which could lead to disruption and I think that's what we are all waiting for Otherwise, we won't see a hospital of the future. I think after ten years. We would still See Brigham only in the US or confined to Boston But what we want is across the globe a chain which can make things work Standardized protocols clinical safety guidelines we can reduce the cost for governments That's a big issue right now because when we go to any government, they're asking what is the value? What is that you can reduce the cost? So we need to answer one more question I want to go to the audience for more questions Each of you have a system that basically generates data So you could say we're also involved in care and value care and helping people But you're generating data historically. We've never used that data Yep Historically, you know that data is in you know lots of trees that have been cut down and made into little pieces of paper We now through lots of convergences have the ability potentially to use that day and actually to get better and to improve And so what's your viewpoint? I mean, what do you think it's going to go? Are we really going to be you know when you search on Google your search today is better than your search yesterday? When we treat a patient or I treat a patient the same as it was decades ago I think it's a very big deal Actually just this morning we crossed 13 million weight readings at a model longitudinal after three years It makes it the biggest longitudinal data set of these programs the world and but I always say especially in our space Where most of the solid science is in person You can't sit as a fly in the wall of every in-person program and use your insights Quantitatively to make it better So this is an area where we've invested quite heavily with a very robust data science team Every single product initiative that we put has a pair data scientist that architects to product change as a What's their background well the person who leads our team was a particle physicist right was at CERN looking for the boson found the boson Called her today Look what do I do next right then was a radiation your physics for a while You know and then wanted to get out to the valley and explore this and that very atypical background for you know What what we do, but that's who runs our data science team And it's having massive massive power because you don't put a program like this in the oven set of time or hear a ding And call it a day like you are always making sure that every single person in your program now is making the program better for tomorrow's join And they're all consented the data. I mean that's obviously a complex That's right. All analytics are done, you know, anonymously. You don't need to you don't need to kind of provide You know the individual level data in in that when you make the nobody knows who the data scientist is Privacy is gonna be a big issue. I think cyber cybersecurity We need to talk about encryption of these data as you know Electronic health record would cost more than hundred times of your credit card So we need to be careful about standardizing Securitizing private type, you know, the privacy should be maintained. So that's a good point to think about I would argue that the individual Health data belongs to the individual and I would challenge Sean and Sarah to think about how An individual who might have had an inpatient experience at my hospital Goes to one of Tom's facility for extended care travels to UAE and visits one of Shamsir's facility and then touches both of your technologies. How is that person? Going to integrate all of that information in a way that if they touch another facility or touch one of us again They've got all of that material Explain what that is we we treat our data as as if we are a hospital or to our interpretation of HIPAA is that we are Covered entity which actually allows for Interplay and diet and work between hospitals and totally ways and our licensure model is that the person of our Participants on our data. We have a license because we need to use it, but that's where we put the licensure model Yes, I would just respond and say you know I think for interactions with the kiosk that we intend to maintain there's sort of optionality there So if we're working within a hospital system, we would be providing the hospital system with that information But there's still obviously a huge issue with you know sort of universal EHR and also with PHR, right? So how do we build a tonic health record and personal health record? You know in that environment, I think that becomes very difficult in an environment like a community center. It's a totally different model, right? So how do you? Provide that information directly to the patient and that's something that we're thinking a lot about so can the patient get their ultrasound now? So you mean get their their image. Yeah, so the image is less important than the diagnostic endpoint, right? And that's what we're trying to think a little bit about you know with that virtual And what if I want to take it to another doctor to look at it? What if I want to show? That's true. You know we're on the earlier stage of things More interested actually from a data perspective right now and how we Create the best exam and over time we'll have to think a lot about how where that exam is delivered I think right now our focus is in the hospital environment And so you know that's where we're going to be providing those images and looking to partner with hospitals that Prioritize providing that data back to patients But eventually you know as we move into different spaces I think that'll be important the other thing I just wanted to mention is from a data perspective You know, I think there's a lot of opportunity to you know, like you were mentioning Improve the interaction and improve the treatment. So we are looking at ways to use data and artificial intelligence between patients to make that experience and getting an ultrasound for example quicker more efficient and helping the remote position Better interact to your point earlier with the patient while they're doing the exam and not have to worry as much about the controls And artificial intelligence solutions and data from previous patients that will help us with doing that We need the data to drive outcomes. You know, how do we know we're achieving a good outcome if we don't have good data? I live in a sector that has not used data historically and we've just Partnered with the Johns Hopkins health system to establish data protocols around our resident population because we know we are Achieving fewer visits to the ER at Brigham and shorter length of stays when someone is admitted to a hospital bed and We need the well recognized Data Protocols so we can use this data and share this data and so it's early days, but we're we're we're making an investment So and I love that but are you in that data set you have is it fragmented or do you get the Brigham's data? When the patient's admitted to the Brigham may come back to you Does that data go back to you and you complete picture? It probably not as Efficiently as it should and we're working towards that Operability of system because your system doesn't talk to the system you have and doesn't talk to my system. So I think We need to standardize Electronic health records because in any hospital you would see 10 or 12 systems working and you go to an emergency room We have a doctor who spends at least 60% of his time keying in the data on our on the EHR It's very complex and even in an outpatient room the time is more so I think we need more similar solutions interoperable where data is shared and Ownership of the data is an issue who wants the data. It's the individual So we need the consent of the individual to give him the best So I think that's something that we should think about one of the issues that was discussed this week and is being led by the World Economic Forum is beginning to standardize and set international measures of patient outcomes And once that's done that will go a very long way To helping achieve interoperability. There's interoperability is certainly that the technical components But it's also standardizing the taxonomy the language the patient outcomes and having shared sets of standards That's great. Well, let's go to the audience and let's See the interest I see a hand, but no face because you're You've got one We're gonna bring you a microphone It's it's first I have a thought and then and then a question So I represent the shareholder of the largest hospital chain in Asia We have hospitals in Singapore Malaysia Turkey India and China and I've been building the chain over the last 10 years So first the thought is the general hospital isn't going away All of the things that you guys described might happen. It might shrink it might specialize But it's not going away the numbers we ran Particularly in our markets is if you just look at the demand for healthcare and you take every supply side disruptive force We discussed and apply it to the model the demand for healthcare beds is still still widening not even shrinking Yeah, and that's because of aging a population aging population large populations, etc The supply demand mismatch is so big right now that there are people who are simply dying not getting care So, you know, it's gonna increase. So God knows how those hospitals will get built. We'll do our best So we love your reactions to that particularly you guys Let's just finish that question is I have a question on the All of this can be solved and hopefully will be solved with disruption from data I define broadly you guys talked about a number of things the question we can't get our minds around is who owns the risk Because a lot of the technical issues around applying data to healthcare problems are just a matter of time It's you get the right tools in place apply the right people the data collection the interoperability all these are solvable issues The one we struggled with is who owns the risk because if you put the risk of Self-treatment in the patient's hands often they don't want to take it and they're not even conscious of it These are very complex issues and particularly with esoteric treatments more complexity is very very hard And unless we figure that out, where does the risk reside the disruption won't happen It's a good boy who wants to take it on So I can talk about the first part, which is the shortage of pets so if you look at it regionally if you're taking there for example the Coming in off P funds that has changed the game you see P funds all around Getting into the metro cities, but if you look around the tier 3 you don't see any activities going on Yeah, that's what that's the problem though. You know there is a tier 3. It's like the remotest of the smaller villages Where there is no data people don't have access to good quality care so I think we need to Change the model of Payments now I think in India they're going to introduce the insurance schemes Which is a big which is going to be the biggest insurance company in the world So we want to have access to care which is going to improve and it's not just hospitals We want primary care clinics a quick reach to a doctor or a telemedicine facility building just hospitals It's not the solution. We're going to add up to the cost when you build a bed and somebody walks into a hospital The cost is going to increase and we have to address that issue. That's right. I would agree with you I recently visited Cuba Which many of you know is about 11 million people about the size of the state of Florida And over the years the Cuban government is invested in health and education So that every Cuban has a primary care doctor a primary care Center in the community And they have health statistics which are comparable with the United States, which is is quite remarkable Their secondary and tertiary care system is not as developed But they deliver incredible outcomes for the amount that they invest in in their health system That's a system where most of the care is delivered in the home in the community and not in a hospital setting So I wonder as access has improved in Many regions of the world that historically has had poor access whether alternate forms of alternate Their care can be delivered through alternate structures and not just hospital beds And we see that interconnected Network of whether it be in my case senior care post-acute care Working with acute care, which will likely allow us to run acute care centers perhaps with fewer beds and More profitably and deliver better outcomes that are flexible under a variety of reimbursement models That's right If you if you look at this purely from a business perspective That the adage is that if you invest in hospital structures and hospital beds It's it's a heavy investment in capital and fixed structure And then you've got to maintain that capitalization Whereas if you invest in more flexible structures and really invest in the people in the technology Who's going to deliver care that that is being proposed as an alternate business model So I would maybe challenge you to think about that So well, let's get to the second part of the question because I think it's it's critical is that you know We have this data. We're learning from it. Sometimes machines are learning from it and who's assuming the risk? Yeah, I'd like to address that so you know, I think I Actually, there's a lot of advantage to the fact that there is a fair amount of risk associated with Data and I AI integration into healthcare and what I mean by that is that doesn't means that the physicians aren't going away Right, so, you know, I think we talked to a lot of people who are concerned about the encroachment of robotics and AI on their Acumen on their training And if we we're not in a position right now from an industry standpoint Nor from a technology standpoint to eliminate someone with that high, you know sort of training and expertise So, you know, and we think about the business model though for at least the foreseeable future There will always be someone remotely interacting with a patient who has expertise that's connected to a clinical network That's respected and vetted and that is the organization that's assuming the risk And you see that even with tele-radiology companies who aren't using robotics and aren't delivering care, you know in time They are reading images and still there's someone remotely who's taking responsibility and has indemnity You know to make sure that that result is Delivered in an appropriate manner and also is reliable What to say a doctor or a health care provider, you know, I think Healthcare is very segmented and we intend to continue to make use of that Segmentation largely so that we can make sure the providers are kind of provisioned as they're needed For the right patient at the right time But it's that sort of physician or provider network that is responsible. So it's more augmented decisions, right? That's right So our focus is on how do we use the technology that's available now to augment the capabilities and the acumen of Physicians and we spend a lot of time with physician networks Educating them on the opportunity that these technologies prevent present to increase quality of care But not to replace their role Good, I still have a job Yes Hi, my name is Javier. I work in Ophthalmology in Mexico It takes 12 years of studying to do a cataract surgery in the average Country, right? And one of the things that I've seen is that we really want to lower the cost increase How many people reach et cetera and the big big barrier is a secret sauce of all these Ideos in crassie of people that have come through the medical systems and don't want to use artificial intelligence don't want to use Many of the amazing things that are happening So how do we need to shift our educational system for doctors to be wired for the future because it's not happening Great question. I commend you and I think you're absolutely right When you think about your 12 years of training as an eye doctor to do cataract surgery You had a number of tools available to you during the educational process And you also had mentors and teachers who helped you learn how to use those those tools I think of medical education in the same way except we're going to have an amazing new set of tools Provided by these individuals and others And we're going to need mentors and teachers who are facile in those tools Mentors and teachers come in all shapes and sizes It can certainly be the ophthalmologist who's been doing procedures for 15 years And is very experienced knows the traditional secret sauce But it can also be an individual who is well trained in artificial intelligence and knows how to use Artificial intelligence and get it in your medical record system To help you make proper decision-making about who are the best candidates for procedures or for this particular individual What's the what's the best protocol the best procedure and that's right set of medications to use So I just think we have to get clever And be open to using all of the new tools and data sense going forward There is a major historic lag between progress and between changing medical education to reflect that project At the same time it takes 13 years on average for 50% of docs to adopt a new technology We are slow and I think I'll start I mean I was talking with the dean of the medical school about how surprised that he was that the incoming class has Incredible computer science skills, you know so many medical school students are in and they view and the dean has none by the way They like instead of learning cursive program feel like hack it on Python Like that's you know and then and then what happens is you practice you learn you see clinical problems that all of a sudden You know what I have a sense for how software can solve it and I've appreciated how the tools will help me And it's just gonna take time. We have to wait patiently, right? But I want to educate the dean as well as the students. Well, the students Never seen or understood. Yeah, there's an online Andre And I was wondering if you can comment on the ways we're gonna move towards reimbursement We're working towards bundle treatment But as we expand this continuum of care inside and outside a hospital with very different level of Specision of hospital. That's one question. But also within a standard bundle How we take into account the biological heterogeneity of patients to measure the outcome and Therefore just a reimbursement That's a complicated question Yes Let me just start by talking about financial risk So the payment model going from paying for volume under traditional fee-for-service to paying for value under a paying for Outcomes under a value-based system At least in the United States There is a Slow and progressive movement towards value-based health care. There's a lot of geographic variation on how quickly that train is moving Under the Affordable Care Act, we would say the train has left the station now. We don't know what repeal and replace is going to mean But I do think I don't think they do either But I think those health systems that have Experience with moving towards value-based health care and global payments find that the care is so much better That the train has left the station and I would include my health system And the only way to solve the insatiable demands for more beds without more beds is through a volume, you know You know value-based health care, so we've charged on outcomes from the beginning of our model We bill according to the percent weight loss we get the person to using existing fee-for-service infrastructure And you know we found our customers love it because they know the fees are always proportion to the epic We're having it also is really interesting from the data side because to your second point like how do you tailor and adjust? You know based on demographics when we actually measure those we can have all right Here's the here's the things that we know from data to matter to a person's success and and kind of adjust populations Come up with expectations and targets I'll quote Mark Harrison who leads Intermountain Health and during the meetings this week He told the story about how most of our health systems. We still are partially paid Fee-for-service and partially paid global payments But are moving to global payment and delivering care as if we were all global payment and mark said that His board the Intermountain Health has set goals around Procedures and their goal is to reduce the number of tonsillectomies by 50% that they found their ear, nose, and throat Docs were performing too many tonsillectomies. So in those areas where there's deviation away from benchmarks You're going to see systems wanting to But it's also segmenting patients So I mean what you alluded to is that they're more complex patients and they're easier patients They're patients who are known to have a worse outcome and not and the better We can find great patients through technology the better We're going to be able to do appropriate value-based care and really move the needle forward because we're all different But the value-based system promotes Collaboration so think about we care for people with Alzheimer's very complex Alzheimer's That that live with us When they land in an acute care hospital bed, they are among the most for it for an orthopedic issue They're among the most complex cases for a hospital to manage. So we are establishing relationships between hospitals and our facilities to manage those individuals and its early days, but Perhaps we'll be sharing in that bundle. We're a private pay model. We are we do not get reimbursement from Medicare or In most cases, there's very little private insurance, but we're moving in this direction I would say technology has a role to play in this also and and you know to your point about having to do more procedures And you need to using technology to get better estimation of what the treatment plan should be looking at people who had the same Issues before right and then I would also say for repeatability. So in the ultrasound space There are a ton of ultrasounds that are done Again and again because the diagnostic endpoint can't be reached with the first image, right? And that's the case across imaging. So how do we use technology to enable value by You know using data analysis using artificial intelligence to better interpret results I think you talked about oncology, which is very interesting because oncology and UAE is different from oncology in the states because the genetic setup is different and We try at least three different combinations before we realize that it's working on the patient So I think we need to be talking about precision medicine or personalized medicine We need to be compounding DNA Mapping so we need to reduce the wastage. So I think we need to come up with Universal health records where we share intelligence and no longer Yes Hi, Sue Valeriat from San Francisco, and I please appreciate your Work with the older people as I have 287 year old parents who I play Catching when my dog walks through and knocks them down, but on the other end of the spectrum at Brigham The Brigham women are they looking at technology made me moving women the only healthy floor in the hospital maternity OB out say with Ultrasound and data from mr. Duffy and throughout the trimesters and then The risk involved that he brought up with moving them out of the hospital and home burst I don't even know is that there's a plan for the future. Yeah, absolutely. In fact We used to deliver 10,000 babies a year. We now deliver about 6,000 And those 6,000 are primarily women at high-risk And part of our maternal fetal medicine program Many of the babies who are delivered end up on our neonatal intensive care unit, so we in the tertiary center It's it's referral risk high-risk and Sick babies our normal birth Fine-large been moved to our community hospitals and whether Anyone is interested and call the midwife Circa 2016 I'm referring to the PBS series on called the midwife. It's a charming program about midwifery in in East London in 1950s and 60s Who knows? You know, I would ask a tool he has studied childbirth in India In very rural provinces and has shown that if you can institute a checklist of very simple Parameters that you can actually make childbirth much safer even conducting at home Yes Debra restaurant Cornell Tech and open mHealth, which sort of gives away my line Which is that I know you all suffer from The silos that your major EHR provider has gave you and makes it hard to do the interoperability And we now when you've all referred to the wonderful work that's coming along that you can do from data from the individuals And our tool was talking to Collins about this yesterday in his interview saying now We need a science of how to interpret these data It's not going to come out and out by a time at a time And we can't leave it to Almata to have to invent every digital biomarker that's going to work for them so What can we do to have the mobile and the digital and the IOT delivery of that data? Contributed science to give us something more like the internet and less like our silo died I you know, I think we've all experienced here at the World Economic Forum The ability of the world community to come together to solve common problems And I would suggest that that this is a common problem that is worthy of the international community coming together to solve Data standard data standards data standards We all talk different words to describe so if you're calling a broken leg you're calling a fractured leg no matter What technology you have it's very hard to harmonize the data sets There's six major ones that exists in the world some leadership has to go forward and just say hey We're doing this and people will get upset, but the field will move forward Yes, just throw it With home instead senior care and you know obviously with the surge in the aging population To me it seems as though the two most scalable assets we have are family and home So you started the session out by imagining what the hospital would look like in 10 years How do you imagine? Expanding a family's capacity to care. How do you imagine the home? What would it look like? What would be there to help? You accomplish health care That's a really really great question I Can only speak to an experience we've had over the past year Where a group of our internists fresh out of their medical training? Have set up a home hospital program as actually a randomized study and They took individuals who came into the emergency room with pneumonia and they asked them to participate in this study and They were randomized to receive care for their pneumonia in a house at traditional hospital or at home and As part of the qualification for entering They had to have a certain functional capacity and they had to have a Support system with certain functional capacity. So you standardize that across both groups If you were in the hospital, you receive this the standard care antibiotic study. Yeah, if you were home you had you were rounded by your internist in the morning and Company would be a nurse practitioner or a PA the You know, since you get the medication or whatever The nurse or or equivalent would come back every eight hours so that visit three times over the 24 hours And the care was both for the individual and the family to help the family has to be brought to help instruct and at the end of the randomization The early results show that the time to feeling well again was shorter that The patient reported outcomes the patient experience was much more favorable The family's experience was much more favorable and the cost was And the food was better On that positive note, we're ending the hour and I thank you all for participating It's been a remarkable group of panelists and I think the exciting thing in today's Davos This is actually a positive session I think we all had a positive outlook of what's going on and certainly we need to bring it to that some of the other disciplines And I thank you very much