 Look at the 70% of global deaths are coming from non-communicable diseases. If we look at that and realize that nearly 100 million people per year are pushed into poverty because they have to pay for their healthcare out of pocket. If we recognize that nearly half of the world's population still does not get access to a basic package of healthcare services, it tells us that we still have a very long road ahead. And if we want to be delivering on the needs of populations, on the needs of individuals and families, we need to transform the healthcare system and we need to transform how we think overall about the care delivery. So likely we have to move from a hospital and curative system to a community and preventative system. We need to move from a silo vertical system to one that looks at multi-stakeholder and multi-sector cooperation. And we need to move from a fragmented and sometimes paper-based system to one that is fully integrated and has data interoperability and data-informed decision-making. And so what I hope is that our panel this morning helps us get to some of the how can we get through these transformations. And so without further ado, let me hand over to the moderator, Helen Clark, former Prime Minister of New Zealand, who will be the moderator for the session. Thank you, Helen. Thank you, Vanessa, and also a former Health Minister for my sins. But thank you for the leadership you and the way for giving on health issues. Now, we have clearly an audience in the room and it's going to be a little hard to see your questions. So please, if you want to speak, do speak up from behind. And we also have an audience online. And particularly for the benefit of the audience online, let's do the formal introductions of who is sitting at the table. We have Josh Shabana, who heads Apollo Hospitals Enterprise in India. We have sitting immediately here. We have Jeff Van Houten from Royal Philips. We have Prasanth Mangat, who is also a healthcare provider based in UAE. We have Nancy Brown from the American Heart Association. And we have Stephen Clasco from Jefferson Health, USA, who also doubles as a doctor. Just to frame a little bit further from what Vanessa has said, with my background in politics and looking at resource allocation, of course, health is always one of the most challenging areas because there's an infinite amount of what you could do, but the money is never infinite. So you're always looking at what's the best use of the health dollar and how do we minimize hospital admissions and length of stay? How do we support primary prevention? How do we support secondary prevention? How do we make our hospitals more effective? What's the role of technology? All the issues that we have a ton of expertise around the table on today. So in our discussion before, we thought we'd start with the people who have a background in health and in the advocacy around prevention and management of heart disease. Then we'll come to the providers and then we'll come to the technology people. So that's going to be our structure. So I'm going to start with you, Stephen, and you've kind of framed a question for us in the green room along the lines of what would our jobs look like in the future? So over to you. Yeah, I feel like a panel on future hospitals a little bit like asking folks what was the future of retail after Amazon started. And I had my wow moment when I was at Standard and Poor's and they downgraded the entire non-profit healthcare provider system because what they said is if you folks don't disrupt, you're going to become a commodity. And I think that it's really a math equation. 40 years ago, Bill Kissick from Morton wrote a book called Medicine's Dilemma's Infinite Needs Finite Resources. Sound familiar? And he was the first person to talk about the iron triangle of access, quality and cost. And he said, you're not going to break that triangle unless you're willing to disrupt the system. And the things are solvable. It gets down to healthcare becoming digital. It gets down to healthcare becoming global. It gets down to bringing population health and personalized medicine together. And it gets down to healthcare being consumer centric. Just a few examples. We can do all our shopping in our pajamas watching TV. But if we have a stomach ache in most places, you're going to get on the phone and get an appointment five days later. The technology is there. The data is there. We just haven't utilized it as providers. So how do we get care out to where patients are instead of expecting patients to come to us for care? I think part of it is getting away from just talking about the technology. We always talk about telehealth. We don't talk about telebanking. We don't get up in the morning and say, I think I'm going to telebank. It's just that banking went from 90% in the bank to 90% at home. We have to start to bring those technologies together. Second thing, we have to start to think about what the humans are in a new healthcare system. Because once we do have better augmented intelligence opportunities, we still accept physicians in most places in the world the same way we did before based on memorization, science, GPA, and medcats. And we're amazed that doctors are more empathetic, communicative, and creative. Jack Ma, last year at this forum, said, you know, when we created cars, we didn't try to get humans to run faster. Computers will always be smarter than doctors, but they'll never be as wise. So how do we start to choose physicians and nurses around empathy, et cetera? We also have to retrain our workforce. And finally, I think healthcare is the only sector in this entire forum that's not global, right? I go to the smart cities piece. You go to the finance piece. The head of finance in Shanghai is just as brilliant in the United States or Australia. But if you're the head of cardiothoracic surgery in Shanghai or Bangalore, and you come to the United States, we make you retake your residency. The things that are done for two-thirds of the world around things like acupuncture and area of adic medicine, in the United States are considered alternative health. That has kept us. So at the end of the day, I believe that we run an 18-hospital system. I believe that we will start to be paid based on how healthy our population is versus how many people come in to fill our beds. And I think that that's a revolution that has to start now. We have to align some of the payment models. The last thing I'll say is there's a great Upton Sinclair quote that said, it's hard to get somebody to do something when their salary depends upon them not doing it. And we have a lot of that in policies where we talk about population health, but we still pay people to have acute care in hospital beds. Yeah, there's kind of maybe an evolution of the capitation payment model for primary practitioners, which a number of countries have, but it's never really been taken to the whole health system, as it were. Nancy, bringing you in from American Heart Association. You know, it's really interesting. Steve mentioned the word, it's all about the person. And I think that the thing we have to remember as we think about the future is that individual people still need to make decisions about living healthier lives. And when you think about what's happened, I can use as an example in cardiovascular diseases in this downturn of death rates in the United States because of the onset of fantastic scientific discovery. Statins, other medications, procedures that have really reduced the rate of people dying earlier from cardiovascular diseases. But you look globally and in the U.S., the social determinants of health are really standing in the way of individuals living their longest life. You know, when you think about the fact that 80% of the world's cigarette smokers live in low and middle income countries or in the United States in communities that don't have the same privilege as other areas, we have a lot of work to do, not just in inspiring people to care about their health and well-being, but also to address things that are not traditionally connected to the health care system. Earlier this week we were, and we were talking earlier today, about the Smart Cities Initiative, urban planning, you know, the projections of how many people will be moving into urban centers. And as that work is happening, how are we designing cities so that people can get physical activity and access to nutrition? We see this alarming rate of individuals taking up e-cigarettes, vaping, jeweling that we are very concerned about will addict the next generation of smokers. And so many of the things that bring people to Steve's Hospital are things that can be prevented. And so we have to think about the holistic environment in which an individual lives. What is their education level? How do we use advocacy to make our cities smarter? How do we make sure that all people have access to high-quality health care? These issues will continue, unfortunately, to be front and center so that as fronds is creating state-of-the-art technology for our health care systems and for us as individuals to manage our own lives, you know, we at the American Heart Association worry a lot that in the U.S. and globally not all people will have access to this state-of-the-art technology. And so we really need to think about that when we think about the future. And Nancy, what you've done great is really going at that 80% of health that doesn't happen at the hospital. Right. Because that technology got better, and we did a better job of taking care of somebody who had a heart attack or a stroke. You said, I'm going to go right after that 80%, which, frankly, the doctors hadn't been concentrating. That's right. And, you know, going after the 80% makes a big difference. And that happens by inspiring people. It happens by helping to make sure all people have access. And it happens through advocacy and public policy. You know, if you can't help an individual change their behavior, if you change the system around them, look at just what's happened with clean indoor air acts in the U.S. You know, this avoidance of secondhand smoke has reduced drastically and has been proven scientifically to reduce recurrence of heart attacks. And Nancy, you've pointed to the whole environment around people, because if you're in an obesogenic environment, if you're in an environment where the advertising still suggests that tobacco smoking is a desirable thing to do, you as an individual are up against a lot of externalities, right, that are going to modify your behavior in ways which won't be so great for your health. Absolutely. And if you don't have access to fresh food, and the only thing you can have is processed and packaged food, which is high in sodium and high in added sugar, you know, why are we surprised that there's an epidemic of obesity and type 2 diabetes? Yeah. So let's come to the providers. And in our discussion before, Shabana, you were talking about the investments that you're in process that I was making beyond the hospital, as it were. So I hear everything you were saying, and I think that people are not different. It's just that in the scale of how you have to provide it becomes very different when you come to a country like India and some of the others when you say that there are 1.3 billion people and all of a sudden the highest that a person wants to pay for a heart surgery is probably $5,000, but the government wants you to do it at, you know, a tenth of the cost. And then you start talking to see where do hospitals fit in and how, so your solutioning becomes so different. So then you think about how can we keep them out of a hospital? What is it that we need to do to create facilities around it? So, you know, we're all coming from the same place. You want to keep them out for other reasons. We need to keep them out because we just can't treat them. Nobody can build the infrastructure of hospitals in India. When we started 38 years ago, we had to change regulations that hospitals were not have been considered as something that, you know, banks would fund. So we had to change things around to build it. And then you start and understand and all of us, it still is there that when you talk about the future of hospitals, when you start designing a hospital, by the time it's built, it's probably obsolete. So you have that big challenge in terms of a facility and then we say, what can we do differently? So I'd like to actually talk about a couple of things that India does differently and some things that will probably be tomorrow's scaled models. So if you talk about, and that's necessity as the mother of invention. So we started a project with Philips to do an EICU. So who does EICUs? And this is something that we're actually putting in rural hospitals because you can, you know, you can train doctors, but how many of them want to move out of the city and live in a village? But there are people there, you want to keep them well. So it's not just in countries like India, but it's China, it's rural America, rural Canada. All these people have the challenges. So I think that the telemedicine part of it, so you can come into a very high solution. That is an EICU. We do tele radiology for around the world. And you do this at scale. And telemedicine is something that, you know, we have a track record of actually doing two million consults. And that's a large number. But we do think that that's obsolete today. As you said, you know, that nobody thinks about banking. So what we've done is actually put it there on a phone, on an app that you can ask people. And two months ago, I was in Israel. And they have the coolest of technologies, and everybody knows that. So what they did is that you can start monitoring your blood sugars, your blood pressure, and so many more parameters. All this can come, and they said the reason, so they have an autoscope and everything, and they said your mobile phone has the highest computing and the best imaging. So why do we have to reinvent that? So I think that is the disruptive technology. Our mobile phone is the disruptor and could be very well where the future of hospitals will move us in that direction. And a recent study that, you know, they said what would be your biggest disruptor, and like you said, they said Amazon. And Amazon hasn't even gotten to the act. Apple at least has, you know, they have the phone that is doing so many things. And in that, they said technology will disrupt hospitals by 30%, insurance by another 32%, and all the others. So you know, this is what we're looking at. We're looking at finding solutions, A for population, for scarcity, and also for the wonderful technology we have in disruption. So we truly live in exciting times. So maybe for Vanessa, this would be a good topic for next year's forum. Instead of going self-driving cars, we're going to have self-healing humans. Right. That could happen. As long as you can make it affordable. Prasad, how does this resonate with your provision? Yes. Thank you. Definitely, I go with Sundita's view. We are an organization who are active for the last 45 years in various economies. We are a decently large player in developed markets, including UK, Spain, and Italy. And we also have been, you know, concentrated on GCC, where we control one third of the market of the GCC, which is having higher possessing power. And we also have been recently very active in markets like South Africa. So to me, when I look at the entire health care problem, I divide that health care problem into three set of problems, which you know, which sometimes we discuss with Phillips on this particular subject. There is not an order of importance, but if you look at, there is this percentage of population in the world who pay from their pocket, who are effluent, who have the money to pay, who want the best of the best. So this, if you look at it, providers like Sundita or me in that market, to a certain extent, they are subsidizers for a larger platform for us. Then for them, the problem is different. From their perspective, whether I'm getting value for money, from a health care provider like us who are working in that environment, most of our health care resources are sucked by these high-value-paying customers. So how will you balance your health care resources to the other set of people? Then you also have a second set of problems that comes out from maybe around 25, 30 percent globally, but some economies like you may be in the US or maybe in the UAE, where we have 90 percent, which is sovereign, directly, indirectly supported insurance programs, where the sustenance of health care is primarily focused on how government can continue to fund this premium of insurance companies. There, the entire sustenance comes into the fact that we need to make sure that government should be able to pay for that for a longer period of time. If government system fails, none of us, the private health care providers, won't be able to work. The investments go completely futile. So we need to identify that problem, and how can you do that? That is where we believe this entire telemedicine, the teletechnology, like, you know, exactly what Sundar said, we also work on ICU, you know, tele-ICU. We also started the telepathology, whereby, you know, the resources. So if you look at it from a health care perspective, there are two cost elements which comes in. One is your consumable risks, and one side, two is your human resources. How can you optimize or maximize your entire, these two expenditure definitely is a key in the success of the second set of problems. Then we have a majority of the problem, which is 50 to 60 percent of the world, which is around 3 billion plus population, who are paying from their pocket the health care, which, as Nancy said, people who are entered into poverty because they spend money, or like people who are not able to enter into health care because they don't have money to go for health care, and the entire system is spent on to that. So there the problem, that problem, I think I completely go with your view that telemedicine, how the disruptive technologies should be used in order to find a solution for those set of people. We work today, today we work globally around 8.5 million patients who walks into NMC's facility across the world in different strata. So we started recently with a telemedicine program to reach into 3 million odd students in Kenya as a country who are on the puberty age of 11 and 16 where they enter into communicable diseases. So we started that as a pilot project and we are working on it. We currently started working on the, for the refugees under the UNSCR in Jordan using the telemedicine program. So telemedicine definitely has got big value in that strata of population, which definitely all the three problems has to be seen to be going in hand in hand. Otherwise providers like private providers who are multi-countries will find difficult to give, you know, there's no one solution that fits into every country and every demography. You remind us too of the global agenda for universal health coverage and how to make it possible. Right. And it's the sort of top priority for health and the sustainable development goals. But we keep coming back to technology as having a lot of answers. Yeah, that's a good thing. There's something to do for us. And just for everybody to know, so Philips, we focus on health and health care. And when we pivoted our strategy some years ago, we said consciously we are not only going to focus on hospitals, we are going to focus on the entire continuum of care from healthy living, consumers, how do you keep them healthy to early diagnosis screening and then the acute and episodic care and then the chronic care. So I laid that out as a continuum and in your introduction you already mentioned what can you do on preventative care and how can you make health care more efficient and how can you work on secondary prevention. And here in value-based care we often talk about access, product cost and outcomes. And so we need to tackle all three. Access is about the social distance of people. Will they get care at all? Productivity, I mean as I serve customers all over the world I see huge differences in efficiency. I mean I would say we can probably make hospitals 30% more efficient without huge interventions. And then you could redirect some of those resources to your primary and secondary prevention. And then of course outcomes I think science and technology will still advance further to make precision health work even better so that we can tailor it to who needs it. Now to envisage such a continuum you need actually a care orchestrator and who is the care orchestrator. That you could say is the consumer but actually the consumer has not always the knowledge when they're healthy they don't care and when they're unhealthy they need specialized knowledge. So if you talk about the future of the provider I see the role of the provider as the care orchestrator. And second notion that I would put on the table here is that we need to work towards networked care. So now we have a concept where we bring care into the community linked to specialized centers and somewhere we have an air traffic control which should focus on coaching people to stay healthy but should help to direct the right specialist care to fix people and if they have a chronic care how neat how do we support them to live at home in the community with a chronic issue without all the time having to go back to the hospital. So that care coordination can be greatly facilitated by technology. We already heard how access to specialist care in remote areas can be done via telehealth, tele radiology, telepathology, EICU which brings doctors into contact with patients in remote areas. But we need to take this a whole lot further where we get longitudinal information about patients which means we need to slide all the silos of information which is a horrendous issue today where we don't get a holistic view of patients when they come. So there is an informatics opportunity and challenge because once you have data both on population view but also on individual view you can become proactive. Now I can say you are trending in the wrong way or the right way if there is a digital twin kind of a picture of how people are doing with their health especially that is very realistic for chronic patients then we can exercise that role of the care orchestrator much better. We can be proactive rather than reactive and I think that will enhance the quality of life but it will also avoid unnecessary cost. So we envisage that through the cloud we are connecting patients and providers. Technology can make hospitals a lot more efficient and then I would hope that we would redirect that money both to primary and secondary prevention because all together we burn enough cost in the world and I think we could do more with that effectiveness and I think examples in India also demonstrate that you can do interventions at a fraction of the cost. Now that is not always popular and we all of course like to charge big bills but when we want to reinvent healthcare and healthcare we need to look at it much more holistically and some disruption will have to happen. It seems like a common theme among all of us is getting away from Phillips just looking at itself as a technology piece for us so when somebody comes into our hospital or we were talking even in the heart you are looking at how that interacts with the brain. What we have come to call it is healthcare with no address that the definition of Jefferson five years from now will be the care and caring we give wherever it is. I personally believe that most of the non-surgical healthcare that we provide in hospitals now will be done at home with a new level of provider that will go out to the home and do most of those things probably with better food and nicer TVs at home than they will have here. The other thing is that the whole equity piece a lot of those things are solvable and we talk about global equity but even within Philadelphia 6.2 miles away there's a 21-year life expectancy difference and we have six academic medical centers in Philadelphia so that gets to the 80% of education and housing and food the example I gave Nancy is we looked at readmissions for congestive heart failure and we always think it's what happens in the hospital and these patients allowed us to do digital footprinting of what they were doing. It turns out that we could predict who is going to come back by how many pizzas they ordered the first week because we put them on a low-salt diet and if they ordered two Domino's pizzas that week chances were they weren't on the low-salt diet. Because they don't realize that bread is the biggest source of sodium in a person's diet. Of course into the whole privacy issue which is a whole other. We have run with a health system in North America a program for congestive heart failure patients who very often have also other comorbidities and they're elderly and through a telehealth program that included behavioral coaching and daily measurements all that data was collected into our command center for care coordination and these thousands of patients this was a large scale trial we demonstrated that we could reduce re-hospitalization by 50% their enjoyment of life went up they felt better cared for. We're doing this at scale in India for condition management and diabetes for instance which is the big killer in India we're trying to get patients onboarded just for compliance and we've seen that we're able to reduce hospital bills we're able to actually insure them better and I think insurance is important that if you can get them and so now we've actually using data we're able to say that if you have this test and in this compliance we can actually cut down your insurance cost and these are models that are being used across the world saying that we're connected to the smart devices so we should think that that's another part of keeping people involved I was just going to say that you look at some of the great frontiers in heart disease management look at the new Apple Watch and the ability to detect heart rate variability and how that might ultimately interact with the kinds of systems Franz is building we can do that today we need the science to be able to help and we've got to train doctors on the other hand that's another point that data can actually bring it down to the so the future is close our biggest investment this year has been on wearables so let's just picture this technology exists it's all got to come together you'll go to sleep in your pajamas monitor your heart rate monitor your respiratory rates if you have asthma when you wake up you're Alexa or your home pot instead of just playing the daily podcast we'll say your respirations were little labored the AQI out there is X maybe you should take an extra inhaler today literally that will be where where healthcare starts at home that's on the secondary prevention level what I'm interested in is from the point of view of the person who sees themselves as healthy they're not used to the doctor you're ringing up and saying oh by the way I had an alert from your Fitbit so it's kind of also got to change the way people are thinking about their own good health and I want to bring you back in on that Nancy because you're so powerful and advocate around this I think it all comes back to what does it take to inspire people to realize the most important thing they have in life is their health you said this at a meeting we were at dinner we were at the other night friends health is wealth we're affluent that can afford the wearable devices very focused on getting their steps we were talking about how much we're standing up because our watches are being us to to stand up more but you know I think this idea of helping people protect the health that they have most people are born we often say most people are born in ideal cardiovascular health and it's their lifestyle or the environment around them that makes that deteriorate over time there is no magic bullet it's helping to inspire people to want to eat right to make sure they're not smoking cigarettes and to get exercise and to manage their health with their health care provider but it's also this changing communities and environments let's give people the best chance possible to not be exposed to cigarette smoke to make sure that there are healthful foods available those things are all important in prevention you might have noticed we have a very articulate panel but we also have a lot of expertise in the audience so if anyone would like to come in at this point yes over here please I would like to raise some partnerships working in hospitals this is very important because we built with the sign and we also operate but what is the future because the governments don't have money so there is a big need of hospitals over the world what are your thoughts of doing this if you have any experience in private public partnerships in hospitals we did the first one in India and it's it actually turned into a quaternary hospital in New Delhi with the government and then we went through 20 years of expertise about how so the first fundamental thing in a PPP is we have to assume that something will go wrong and what have you done to be able to address it as the government changes so you have to put that together and having said that there is no moving away from it because if the government is planning like in India for instance and I don't know about Mexico but in India the government today spends only 1.5% of its GDP on health and that's nowhere near enough they need to spend like other countries maybe 5-6% more they have committed another 3% still not enough when they want to look after 1.3 billion so now they are calling in to the government sector and saying that why can't you come in and find solutions take over our existing hospitals which we recently did a week ago that were managing the services and this is going to be the model that you can go state by state and in India it's a state it's a federal health is federally run so I do think that the future glad you brought it up hospitals cannot but there's a lot of context in this isn't it in my country if you even mentioned putting a public hospital over to private provider to be a public revolt but other countries are starting in different positions I'm saying that as a neighbour but in my country it would be seen as very difficult but there's different context where there's not provision and where there's a role to come in as you say I have a few examples I thought you were only cricket frenemies you could say of course what is I mean personally I believe it should be policy setting and the guardrails and the direction I've seen many countries where government run hospitals are not the best run hospitals right so countries also where they are well okay there are exceptions but so whether it's Brazil Turkey, Saudi Arabia many other countries they start now PPPs to actually move public old public poorly run hospitals into PPPs which are in the cases where we are involved special purpose vehicles where we all invest technology companies hospital operators and we go at risk and we basically work on excess productivity and outcomes what I talked about earlier and then the governments can supervise that and hold us honest and it is a model that works and I think this is a way to modernise healthcare in all those countries that and also free up then resources to actually do more on the population. So in this particular case you know exactly I go with exactly what Francis is saying we have a business model where we run PPP models in multiple countries for the government of UAE and other governments we run in countries which are rich economies like UAE we also run highly war shattered economy like Yemen we run in sessions we run in Morocco where exactly what Francis said where there is a risk is distributed in multiple players and we as a provider comes and works to improve the patient experience and clinical outcomes patient experience and clinical outcomes definitely have an impact on the total cost of money that has been spent by the government and the infrastructure so infrastructure is a committed infrastructure so the technology comes in from the provider the technology provider and healthcare provider works to improve the KPIs which are the ambition is countries like UAE to take it to the US gold standards but other economies to go into the better results of the world we have seen results in UAE this is we are working Yemen this is the third year that we are working and over the period of time we were able to really take it to the global standards which effectively is reducing the spend of healthcare of the government I'm so glad you asked that because I think we're about to enter a golden age of public-private partnerships I think more and more there's an understanding that it's not a vendor-vendee relationship anymore it's a little bit more France that it's let's go into this together we're working with a company called Color Genomics so we took our 30,000 employees and offered them with Color Genomics free genomic testing with subtyping there's five different disorders that make a difference and literally they were willing to go at risk with us because we're self-insured to say look we think that the care the outcomes of cost and the access will be better because of that and we'll share in that I think the thing that has to happen though we have to start to mix both worlds together of technology and provider I think the EMR is a good cautionary tale the EMRs were developed given to us and I've told other people the only technology in the history of the world that because you've paid for that technology you have to hire more humans so it doesn't get confused so what we're starting to do with our friends at Silicon Valley is we're embedding faculty and medical students out in these companies and they're taking their engineers and they're on my cabinet they're sitting with me at Jefferson so they actually understand what our problems are and it's actually changed some of the business models that they're going to say we're solving a problem that doesn't exist so this is the problem they have so I think as you start to do that and get patients and providers and social agencies and all that money that's being spent to disrupt healthcare in Silicon Valley and around the world together and actually talking to each other it makes a difference. Let's come in again from the audience right behind me, Robert Garrett. I agree with all of our panelists that more and more healthcare is going to be delivered outside of the four walls of the hospital and I do agree that our smartphones will actually deliver a lot of healthcare into the future but being that this panel is about the future of hospitals what do you actually see more walls of the hospital still doing in the future there's no doubt more medical care is being delivered already outside the hospital Steve you suggested also more surgery being done outside the hospital so are hospitals essentially going to be intensive care units or do you see with the aging population and the onset of more chronic diseases a more broad role for hospitals of the future? I think that's been one of the big controversies as I've talked to the provider pieces of the forum you know this eight years ago people were saying with the baby boomers aging etc we're going to need so many more hospitals then of course you know with the value based stuff and keeping out of the hospital so I think this is what I think I think that hospitals that provide acute care surgical care obviously intensive care will actually boom I think what you'll see is in communities like the areas around Philadelphia have 43 community hospitals some owned by different for-profits that really have a low acuity index I think those hospitals will be at risk I think we'll probably have less hospitals and the hospitals that we have that are providing good cost access and quality I'd like to see literally if things are failing we have hospitals with leapfrog these in our place that are doing secondary care those hospitals need to frankly fail and other hospitals are running 60% census rates so I think we'll see less hospitals I think we'll see some retraining of some of those nurses and other healthcare providers our number one college at Thomas Jefferson University is the college of emerging health professions what jobs can we start to give certificates for don't exist today home nurses community health ambassadors etc but you know in a great system like yours I think what will happen is we'll get a continuum of care across your hospitals so that they're doing the right procedure for the right patients at the right time in that context also technology will start playing a role I call it the air traffic control of healthcare right where you will have your clinical and operations planning and if we can predict that patients will come in rather than they show up at the emergency room they need to go should this patient go to your tech care center or should we rather have them in the community in a cheaper bed while you can still through telehealth give specialized care to that secondary location but that means that the whole network becomes a networked care organization unscheduled care can happen today we are now moving almost 70% of our non trauma non ambulance patients are in an efficient ED in fact we actually built an urgent care center literally like a block away from my hospital because we might say we ought to see you but we don't need to see where all those trauma and ambulance patients are coming in we can see you a block away and by the way if you need to come in the hospital we can still see you but that's a conscious management of traffic but that's very by medicaid patients and everybody but I think that I can't agree with you more that hospitals will happen but the rate at which it will happen is very different based on countries with this so it might happen faster for you all it will definitely happen in India but the rate of what we need first you have to serve that and then we can move on to that because you didn't have the hospital so the future I think has to be tiered context exactly if you look at it one is availability of hospital you know America may be an exception or the UK not just maybe an exception but an economy is where we work you know we have seen that one is availability of money exactly what Sunita said about India a few years back India today has availability of funds for healthcare but there are a lot of markets across the world in markets like for example we are looking at Mexico as one economy where we find in certain markets either availability of capital is scarce or the cash is available expensive so once you enter into 15% plus you know financing cost models this healthcare will definitely will not flourish in those economies so again the number of people who are coming out of the medical schools you know if you look at it we went to Nigeria we have operation now in Nigeria so even if you look at Nigeria as an economy Nigeria has been producing medical professionals now in the US or UK a lot they are not ready to come back because of the social system that exists in those economies so a nation who spends not money in medical schools and if there is a brain brain happening in this will be again a second impact third extremely simple but lack of clear water good drinking water in those economies whatever we try we talk about genetics screening globally we talk about preventive mechanism for the effluent rich of the 1 billion the 3 billion suffers because of lack of drinking water which can have a big impact so exactly I resonate what Sundita say that the future will be different to 3 different set of people in the world you know somebody like in US it may be in a different manner but those developing economies like in Saudi Arabia or like India will have a different issue but those coming from certain other parts of Middle East some in North Africa from the West Africa or some part of Latin America definitely will have a completely different problem that has to be so the future of healthcare has to be seen in 3 different manner but I think those 3 sets of people exist in every one of our countries we brought one solution which on this particular subject we started working with Cincinnati Children's Hospital or Boston Children's Hospital which also we start working with a big NHS system where there's definitely a cash trap in the system you know either the government has to pay academic institution doesn't have money to like exactly what you said the NGO funding is coming down nobody is ready to put on money on those activities how will those institution going forward continue to be flourishing if we don't have such institutions globally or academically inclined institution doesn't flourish the global healthcare and to really go into a really doomed state Steve come back in on the medical professional education because you have a lot very interesting things to say on that so look I think that we have not changed either our curriculum or the way we select physicians for 50 years and I think so the simple fact is we're talking about all this predictive analytics augmented intelligence that's hardly in the medical school curriculum by the way there's almost no population health in most medical school curriculum at least in the United States and in the UK in fact I gave this talk to one of the top 10 medical schools in the country and I was talking about quality and population health and food and the Dean was upset that I said they don't do enough and said you know we have a whole day the third year population health think about how ridiculous this is think about how ridiculous this is that most of these folks that apply to schools major in chemistry or biology take four years of just learning chemistry or biology then the first two years of medical school is sitting in a classroom chemistry and biology doing multiple choice tests we merged our 192 year old health science university with a design university and we have this thing with Princeton where we're taking kids after their first year at Princeton and we're saying you have to major in something cool you know not chemistry not biology could be anthropology could be French art just become a good person take the minimum amount of science courses you have to take and then you'll get into Jefferson after your four years and they get an MD master's in design because we merged with a design school the second thing real quickly is that we have to retrain our workforce because we think in departments we're here for any of this stuff to happen and we're going to bring care to patients patients don't think in departments if you have a headache you don't think do I have a normal surgical headache a neurologic headache a psychiatric headache or a family practice headache but in most places around the world you have to go to four different doctors we got an ALS center of excellence for one simple reason and this sounds so simple we actually brought everybody when the ALS patients came in down to where they were and the place that had the center of excellence in Philadelphia made them go to each different four because the neurosurgeons wouldn't be caught dead on the floor where the neurologists were because they didn't like to mix those things so I think we need a fundamental retraining of the humans because we're going to have robots next to us and we've trained doctors to be really good robots it doesn't make any sense Nancy I want to bring you back in because you know the population health perspective the life of the work that you do come back in on me I think the whole issue of what is the role of hospitals I'll just bring it from the patient point of view and to the point Steve was just saying you know it the thing that's most important when people are receiving care is that they're in the state of mind where they can accept the care and their family under knows and understands what's going on and I think we believe really strongly that all of the new technologies for people to be able to be at home instead of being in a hospital that will make a huge difference in terms of outcomes for patients and for their families having people in a hospital where they're being shuffled around and nobody understands and things aren't clear that really is not good for outcomes the other thing I want to mention is the organization that writes guidelines in the United States for cardiovascular disease for stroke and for all of the risk factors you know blood pressure cholesterol you think about how positive this new healthcare system that we're envisioning today can be for the implementation of guidelines which ultimately are being put in place so that patients can live long and healthy lives last year we published as an example new guidelines for blood pressure that drastically in the U.S. changed the criteria for what is considered a person with high blood pressure the day after the guidelines were written 110 million people woke up in the U.S. that having high blood pressure that didn't have it the day before those guidelines would say you know first line therapy is you know exercise and nutrition but you know how do you get the healthcare system and doctors to understand what these new guidelines are and how to help patients understand the lifestyle things not just let's give them more drugs and so these new healthcare systems that we're hearing about in the technologies that Franz is talking about can fix that problem because in the U.S. it takes on average this is a horrifying number 16 years from the data guideline is written until it's fully implemented in practice and patients are receiving the benefits so all of these changes in the healthcare system and in technology will make lives better for patients we now actually take our applicants and take them to an art museum and say tell us the story so that they can start to put stories together and bring that together because I've delivered 2,000 babies and you know it's easy to deliver from baby to a normal oh it's easy for me to say but it's it's incredibly difficult delivering an unscheduled down syndrome baby every single time that that would happen doctor what does this mean and there will be a robot next to me pretty soon there will be much better taking pictures of the baby and saying what's genetically wrong but it will never get to what does it mean means what does it mean in my image of a perfect baby and I want future doctors to be able to talk about the impact and the fact that this is a beautiful baby that we can help you take care of one thing I should have said the most important thing in the future of hospitals is not forgetting the human touch and you know nothing is more important to a patient than having a nurse or a healthcare provider sit next to them and hold their hand and describe what is going on and helping people through that experience we should never forget that the walls and the technology matter and I think the future of hospitals if we had to say it would be using all the technology to allow the humans to spend more time with the patients because right now it's so that's possible it's not enough let's say some of the faults with the current EMRs are that they are claim systems and they take time away from the patient right whereas if we have much more context specific technology with AI we can automate a lot of jobs and make time available for the patients and you don't want to miss things that's what technology is about not to be able to diagnose fast that's the most frustrating for a patient and in India when they're paying for it out of their own pocket and you send these people for a test so they say oh the doctors are going to get something out of it so they're sending us for an MRI or you're asking us about these extra tests and we said well we're not solving for you know we're not solving for the 100% we're solving for even that 1% if we miss it and they go into an event that for them is 100% so I think that hospitals of the future should be way more caring and clever and accurate about diagnosis and the serriums of care also between practitioners within a hospital is huge and get more complex if I compare that to an industrial system coming out of the industry you would weed that out through process automation through checklists through best practice adoption across the board and technology can help do that I would advocate that I would also free up money to do other things in the one hope I would hope to get the whole healthcare world economic forum and we talk about the future of hospitals that we don't get too caught up in what's going to happen 10 years from now what we can do today because at the end of the day things haven't changed enough globally there's a quote I like to use from the NBA where Jason Kitt went to Dallas Mavericks and he said I'm going to turn this team around 360 degrees we do a lot of turning things around 360 degrees we have this technology we have the human touch we have great leaders we have an outcome change because we haven't concentrated on the social determinants of health exactly the same exact point from this when you look at it I run more than 30-35 hospitals across the world the last few years we have been really working on using something like LEAN and things like that to standardize your procedures today some of the most procedures are highly standardized like how you work in industries, in manufacturing sectors and then maybe over time if I claim myself to be successful as a health care CEO I'll say that all the procedures are standardized but that only solves a portion of the global problem the practitioners in my 30 hospitals who runs health care in cardiology or in diabetology completely are different in the same in the same set of NMC network itself I see 20 diabetologists working in 20 different forms in one place I see endocrinologists saying that diabetes should be with me and when somebody say that endocrinology say that diabetes should not be with me to that extent so the future of health care I'm not talking about hospital should be to standardize at least 5 or 6 or like the top 6 or 7 health care problems to be standardized for example in AHA is doing it on the patient so specific areas where we can have a standardized form and that be given to the doctor today we run a team of peer review of doctors and every time it comes to a situation that it comes to my office where the doctors start having problems among them and that is a big challenge in the health care system the protocols and procedures that you follow administratively or non-clinically is not coming on the clinical phase and clinical phase if it is done maybe to a great extent the time spent on EMR can be more standardized time can be spent more on patient and the result also will be standard and unified across the world we can learn from aviation right there are certain things that still require you to be human but the checklist is not if you are a Delta pilot you don't go to Delta if you are doing a blood test 200 or 180 you know whatever it is but I said we are not going to have any trouble with this panel talking and we have just about talked ourselves right out with one minute and nine seconds to go so really to kind of bring it to a head I completely agree with what Steve said about the future of the hospital certainly for a society like mine and like yours and it is going to be the acute it is going to be the intensive, it is going to be the emergency and then we are going to depend on a whole spectrum of other things happening to support the home care perhaps the less intensive community-based facility the training for the people who are going to be doing that the role of technology but then we also have the other context where countries actually don't have enough hospitals yet at all or services and that has got to be built perhaps informed by the trajectory that the hospital system has gone in other societies absolutely and technology regardless of the context rich country or poor is going to have such influence in diagnosis prescription support of the patient and so on so thank you fantastic panel please give them all a big hand thank you thank you