PODCAST/CONSUMERS/TECH: Interview with Joseph Kvedar, Partners' Connected Health guru

This is the transcript of the podcast interview I did with Joseph Kvedar, from Partners Center for Connected Health. Coincidentally this past Tuesday in NYC, the Center, along with Continue Health Alliance and others, sponsored a meeting about the use of monitoring devices as part of a general strategy by leading edge employers to try to do something about the management of the chronically ill. There’ll be more from me about that later.

Matthew Holt:  Hi, this is Matthew Holt with The Health Care Blog, and I am doing another podcast. If you are one of those people who thinks that we have too much medical technology and too many medical facilities in America--I am deep in the belly of the beast. Sitting in the middle of the academic medical center triangle of Boston speaking with Joseph Kvedar. Joseph is the director of The Center for Connected Health. He also, for those of you who are paying careful attention, wrote an article in The Health Care Blog about Connected Health, just, I think, a week-and-a-half ago. Joseph, first off thank you very much for hosting me in your office.

 

Joseph Kvedar:  Delighted to be with you, Matthew.

 

Matthew:  You are also the Vice-chair and the Associate Professor of the Residency Program in the Department of Dermatology, so obviously you have a medical background. You know, that it's not unusual in the AMC for somebody who is an academic physician to be also prodding around in another area. This center was, until recently, called The Center for Telemedicine.

 

Joseph:  Yes.

 

Matthew:  Also it is an integral part of Partners, what you are doing in terms of outreach into the community with technology. Why the change to Connected Health?

 

Joseph:  Well, we felt that most of what we are doing these days is not captured by what people traditionally think of when they use the word "telemedicine." I have spent a lot of in time in meetings over the last few years explaining that. So it just made sense for us to adopt a moniker that was a bit more fresh, a bit more 21st century, and could really allow us to have people engage with us and our vision in a more effective way.

 

Matthew:  That makes a lot of sense. My friends at Cisco think that they invented the term and that the NHS and everyone else is copying them. But the concept around connection and health seems to be really taking off. You can guess if that is a good thing or a bad thing, but I think it underscores a lot of what we are talking about. Now some of the things you brought up in the brief piece you wrote for The Health Care Blog I think are very interesting. Just capture, for those people who haven't read it, the flavor of what you think the possibility of change that this kind of technology can bring.

 

Joseph:  Let's use the example of diabetes. So today your average diabetic often views their condition as somewhat of puzzlement, somewhat of an accident. They may or may not understand the relationship between diet, exercise, and glucose. They may or may not understand how changing their activity level can help their condition. They are really left with occasional, brief, hurried visits to their doctor, and a lot of instructions, and often very little in the way of a true relationship or connection with healthcare.

Now picture the same individual with a lot of physiologic feedback. Let's say an accurate step count, once or twice daily a log of their glucose readings that is contextualized with their diet and their activity, and a medication reminder system. And I think that is, for us, all of that is what we mean by "connected health."

So it is this concept of giving patients a great deal of feedback about their condition in the context of educational materials and motivators, and having that same information available to their provider. Really what it does on the provider's side is it enables the provider to no longer look at the office visit as the only way that you can get something done for that patient. You can get something done for that patient by looking at that information and sending them a message electronically, a lot of other things. And you can start to manage populations of patients. That is very important here as well because reimbursement, of course, is trending towards managing quality as opposed to units of service. And that is one of the reasons that we are taking this movement very seriously. 

Matthew:  Well let's talk about a bit about that organizationally at Partners first. For a start, Partners is what, ten years now since the integration? The old joke was, I am sure you have heard this one many times, but there was an old surgeon presented once who had something to do with, I forget in which part of Mass General he was, but the joke is that when he was a boy he resolved to hate three things: The Soviet Union, Yale, and the Brigham. And now two of them don't exist,

But now that it has happened, obviously in some ways the world has changed and in some ways the world hasn't changed. You know, the same sort of health plans by and large. There have been some changes in reimbursement in Boston and somewhat in California around pay-for-performance and quality, but not that much. You know, we haven't seen the dawn of nationwide Kaiser Permanente or that kind of thing. Which leads us to two particular problems coming up. One is how people are being paid, how physicians and providers are being paid to manage populations, and where that plays out. The other one is the issue of what we do have that we didn't have ten years ago. We have the Internet prevalent, we have connected technology, we have a lot more digital output within the four walls, or the multiple walls, of the facilities here in terms of imaging data and other kinds of data out of EMRs, and also out in the home and other places.

So let's take the technology problem first, because that is probably the simplest, although it is not simple. Your involvement at Continua Health Alliance, which was launched last year; and I know that it is not your day-to-day function, but give me a brief overview of what it is supposed to do and kind of where you think it is and the process it is trying to work through.

 

Joseph:  Well, Continua for us was a very exciting development and we continue to be very enthusiastic about it. Along with Kaiser-Permanente we are the founding provider organizations in Continua. Continua is a group now of 111 companies. Some of them are technology firms, some of them provide services, some of them are provider organizations. The goal of the group is to create a working set of guidelines that companies can develop to, so that products in the home-monitoring/home-telehealth space will be interoperable. Another goal for Continua is to create the opportunity for the market to move forward by encouraging novel kinds of reimbursement schemes and novel kinds of payment schemes that will improve quality at the same time we are managing efficiency in healthcare.

 

Matthew:  Now my understanding of this in assessment is that you and the folks at Kaiser have looked at the coming wave. You are probably two of the organizations who are furthest along in integration of internal electronic medical records systems. There are obviously at play a lot of activities but I still know that Blackford Middleton and his crew out at--it keeps on changing its name, is it CATL now?

 

Joseph:  CATL.

 

Matthew:  They are trying to figure out--they have the original Brigham system, the Partners system, then how many other hospitals and connected physicians with their different systems--but mostly EMR-based at this stage? Actually, do you know what the penetration is?

 

Joseph:  I want to say that our primary care doc's are at about 60% and our specialists are at about 80% or 80-90% utilization of electronic records.

 

Matthew:  Which, by the way, puts you the complete inverse of Sweden. [laughs] I saw a lecture from the fellow from Denmark yesterday at the World Healthcare Congress, and he was saying that they are at about 90-100% primary care EMR use all over Scandinavia. For some reason the Norwegians have got 90% inpatient, the Danes have got 30%, and the Swedes have got 60%. So Partners and Sweden are the inverse of each other.

 

Joseph:  Yeah, it is the reverse. For us it is largely a function of the fact that the community doctors are still in small groups and their migration path is less clear to them.

 

Matthew:  Yeah, and that is a huge problem which I don't think you are trying tackle in this particular part of the organization, because you probably have enough on your plate. Having said that, the issue is you and Kaiser see the potentially crashing wave of all these other monitoring functions. We have a couple of issues, not the least of which is that you already have all the interfaces between current systems inside and you don't want to add another 111 interfaces, or whatever it was that you said. So I assume that is a pretty prime motivator.

 

Joseph:  Yeah, it is. I think the vision that a patient can go to Walgreen's to pick up their blood-pressure cuff and to Best Buy to buy their communicator device and just plug them in is where we would like to see it go, and not have to send an engineer out to their house to make it work.

 

Matthew:  [laughing] Which may prove not cost-effective in the current climate I guess. Let's talk about that a bit, because there are sort of two approaches and this is actually not how it goes in most industries... Well, you can argue back and forth. But a lot of products--take MP3 players--somebody came up with the basic standard called MP3 and they wrote standards. Then all of a sudden there is this thing called iTunes and the iPod and now 95% of these MP3 players all look the same. The same is kind of true in computer software that has been called the "Windows operating system," which came out of one company. That is kind of a market that pretty much emerges. There are other things--UPC codes, bar codes, and that kind of stuff; where it came from more of the industry. The true standard came about perhaps first, and then started getting used that way. Do you see the possibility of it coming the sort of Microsoft or iPod way, or do you think it has to be a standards-based initiative?

 

Joseph:  Well I believe that the value-add in this space is around the service layer and not the technology, and therefore I think the standards approach could work. I don't think whether I buy my blood-pressure cuff from A&D or Omron is really going to be where I add value here, but rather how I deal with the data coming from the device and improve quality of care using that information. So for that reason I think--every industry has some components of it that are commoditized and some components of it that are not--and in this case I am comfortable that the commoditization can be at the sensor/technology level, and that the value-add will be at what we do with it in the service offering.

 

Matthew:  Let's talk a bit about that because there is sort of two links here. One is what it is going to look like. And the other is how fast it is going to come.
Over the other side of the bridge here in Cambridge, a report put out by the Forrester guys about--I say the Forrester guys but actually it was mostly from a Forrester gal (NOTE: I've since found out that it was Mike Barrett who coined the term and did the first reports at Forrester. Liz Boehm has been "stewarding" the series since 2003).--was put out about four or five years ago now and it has been updated ever since. Called "Healthcare Unbound" it made some pretty aggressive predictions about how big, 35 billion dollars by 2015, for this market. Which is not bad growth from pretty much diddly squat a couple of years back, in ten years.

There has been a huge amount of interest, of course, from some of the other technology players. You have got Philips and Intel and Cisco and all these folks whose primary interest always is in the dollar signs they see associated with this. On the other hand, there are issues that the primary payer of most of that, the biggest single payer is going to be Medicare, which is doing a number of tests in the related space of disease management at the moment. Now, to be fair, those tests have not really typically been using in this kind of technology but what they have been using is sort of the precursor technology of nurse call-centers and that kind of stuff. That is not going very well at the moment. And there have been some questions about how successful Medicare Health Support has been. A couple of the players have dropped out. So I am kind of wondering what is your sense of how that is playing out and how you think the reimbursement side of this is going to play out.

 

Joseph:  Well, we know that 2% of Medicare's patients utilize about 50% of their resources. We know that something is going to have to change. Here at Partner's Healthcare we made a bet that we should be prepared for them to change fairly dramatically how they pay us. We think the horizon for that is towards the end of the decade, the very early part of the next decade, so we are very busy at work. We do have another lever here which is our local health plan market pace is quite heavy in pay-for-performance. There is another reason for us to be involved and we can talk about that at another time.

With regards to Medicare, I saw the two-year report on Medicare health support as well and the rather glum numbers. I would say, I'll confess I haven't read the detail yet because I just saw it the other day, but I can almost predict that, without any disrespect to anybody, many, many, many of the efforts have been tried to date are utilizing technologies to try to do what we already do better. What we really need to do is utilize technology to do something completely different. We firmly believe, and our efforts have shown to date in our own system, we are not the only people who have made this observation, that if you move care closer to the patient you can unlock value. You can keep people out of the high cost parts of the health care system quite convincingly by moving care close to the patient and leave quite a bit of money on the table.

The nurse call center model, I would just remind you, for those 2% of patients the real value requires a provider to make a decision about something. Let's take the example of congestive heart failure. If I am in the home and I could say to you based on our technology, gee your weight is trending up, it looks like you're short of breath today, you really need help. Now having a nurse phone you and ask you about that at that point from a disease management firm is not particularly helpful because you need to go to the emergency room. If we send a nurse out to your home and give you another dose of diuretic we could keep you out of the emergency one. It does require provider intervention at that point. Very long winded answer but our feeling is that the use of the technologically close to the patient and to keep decision-making closer to the patient is going to keep them out of the high cost part of the system.

 

Matthew:  Let's talk a bit about the practical examples that you are currently doing within the Connected Health Center and obviously the rest of the players at Partners. Give me a couple of examples of some of the programs you are currently running and what kinds of things you are doing in those programs and what you are seeing as a result.

 

Joseph:  Sure. The granddaddy is indeed the congestive heart failure management where patients use a weight scale, blood pressure cuff, and an oxygen saturation meter, pulseoximeter, also on a daily basis. So they take those three vital signs on a daily basis and they answer some disease management questions as well on a tabletop tablet device. Two things happened there. One is obvious which is we get better data about them. The one that wasn't obvious to us is how it draws them into their care and they become owners of that process and it is a real compliance booster partly because they are involved but also probably because they know we are looking. They very quickly learn the relationship between salt intake, fluid, and heart failure. It's very effective. We showed that, in our own study, we cut admissions by about 40% and skilled nursing visits to the home by another 40%. The Veterans Administration has had similar results in a much larger trial. So it is very clear that you can keep very sick patients out of the high-cost part of the system with this kind of technology.

 

Matthew:  Which actual technology are you using? I know Veterans has done some stuff with Health Hero on that. Do you have homegrown stuff that you are using?

 

Joseph:  The vendor we use for that is Vitalnet. They are one of a number. The technology, once again, is actually fairly commoditized; but their service is unbeatable and they have been a great partner for us. So that is one.

We have an interest in medication adherence. We have two or three studies going on independently, in other words just to examine various tools to encourage adherence and monitor adherence. One of them has to do with a smart pill bottle. When you open the bottle it sends a SMS text message. We capture that and then feed it back to a device in your home that changes color. It looks like a piece of furniture. So the nice part about that is we say we are moving the doctor's office into you home without looking like a doctor's office in your home. It is quite effective. We are just finishing up a trial on that, and the patients are quite enthused about it. One gentleman said "Well, it really helps me bring my whole family into my care. They know if I have forgotten to take my pills. I know. And it is a very unobtrusive kind of reminder."

Another example of one we are going to do in the next few months is using multimedia mobile phone messages to promote adherence. That is a trial that is in collaboration with AstraZeneca and their innovation center. We are about to actually engage with the folks here that are doing Medicare health support, to look at the opportunity of offering a medication adherence program for those patients. Because, unlike in the commercial population where we can get claims data, we have no way of tracking adherence, let alone promoting it in the Medicare population. I mean, adherence is such an important problem. Worldwide it is about 50%. Anytime anyone has measured it they have always found it to be a bit less than that. So, most people take their pills, we think, on the order of 30% of the time they are supposed to. It is like the forgotten opportunity. Once you have written a prescription as a doctor you think it is done. The pharmaceutical companies think their job is done once they have detailed me to write the prescription. So we are very excited about adherence, we see enormous opportunity there.

We are just launching now a program; this is the last one I will tell you about, just for, again, a sort of smattering of what we are doing. But we are just launching an innovative program with the storage vendor EMC. They are a large Massachusetts-based self-insured employer. What we are going to do with them is offer some of their employees with hypertension a self-management system that involves a blood-pressure cuff. And as that data is fed in through their phone line we will capture it and apply some rules to it to give them a customized patient-facing website, which will educate them about their readings, their trends, and how they can manage their pressure better. At their option they can print that out and bring it to their doctor, but we are not demanding that they interact with their doctor. We are actually going to follow how they interact with their doctor. So the innovative parts of that program are, us a provider, working directly with an employer. That is one innovation. And the other is that the program is very patient-centric and it is optional to involve the doctor. What we will be measuring is their total cost of care--EMC is very concerned about that-- and how often they use their physician, and of course, how their blood pressure does. So, that is something that is just rolling out now.

 

Matthew:  That is pretty exciting. And you have touched on two things at least there, which are just such obvious problems not just for, but obviously more so for, people who are a little older and have issues with more medications. But two things you have touched on. One was the regularity of collecting information from diabetics. Here’s just a ridiculous story: I have a great friend who has just had a baby, very beautiful baby, but had got gestational diabetes while she was going through pregnancy. A very, very sophisticated person, MBA from a school just across the river there, works at a big company, namely starts with G and ends with oogle, as tech-savvy as you can imagine. And she said to me, "Oh, I've got gestational diabetes," and we actually went to lunch, she takes out here test strip, pricks herself and says, "Yes, I have to record it all." What does she do? She whips out her notebook and she has been writing it all down. And I'm going, if she isn't the prime candidate for getting some of this;  why have anything to do with that?

 

Joseph:  Remarkable.

Matthew: And the other personal thing is, me. I have, well I have now got insurance so I can tell you this, I have gout, which I developed a couple of years ago due to my general bad lifestyle over the years. And the problem is, I take Allopurinol every day and it is fine, it never comes back; but of course, there’s the issue of remembering did I take it right in the morning? Now, it is the only one drug I take, and I can't remember whether I took it or not most days. So for somebody who is taking a bunch of drugs you have got to measure, no wonder. No wonder! It's not like we should be surprised this is a problem, the surprise should be is why we have not really figured out any way to do anything about it.

 

Joseph:  So, one of the fun things to think about, Matthew, is we are sort of bound by viewing our world as slices of diseases, those of us who work in healthcare, because that is how we collect data. And indeed, as we pitch these programs internally here at Partners we are forced to pitch them in that context. What can we do for our diabetic population, our heart failure population? But really the opportunity is around things like, let's get everyone more active, all right, let's get everyone on better medication management. So we also think about our interventions in terms of platforms. Activity monitoring is a platform, medication adherence is a platform, electronic communication with patients is a platform. And we tend to build solutions to those various diseases using common elements of those platforms so we can use them over and over again.

 

Matthew:  So let's talk a bit about, you mentioned some building platforms. And some of that is the issue that there is Partners and then there is the rest of America. To some extent there is Kaiser, and then there is the rest of America. You have got the issue whereby clearly... Well, give me an idea of what is the scale of some of these programs. How many patients have congestive heart failure, for example?

 

Joseph:  Yeah, it is still small. We have done just between 300 and 400 last year, heart failure patients. It is growing by the month but it is still not thousands.

 

Matthew:  So these are still pilot projects.

 

Joseph:  That one is not a pilot any longer but it is still in its rapid growth phase.

Matthew:  I guess part of the issue is we have two things going on. One is that in some places you are using vendors, obviously I am sure that there is your stuff embedded here because you are Partners, and obviously how a lot of that is. There is at least one of the big medical records systems that you mentioned here. You know John Glaser at Brigham and Women's, and I am sure there is a lot more going on. You have a lot of smart people here and out in Blackford Middleton’s group who are building stuff and designing stuff and putting it all together; and that is something which does not exist in the rest of America.

The other issue, I guess, is you also, as you mentioned, you have Blue Cross of Massachusetts leading the pay-for-performance program. I don't know what share of reimbursement yet that is going to be coming back to you in some other way if you manage to keep the 40% of people out of the hospital who would have been in the hospital before. I don't know how you are getting rewarded for that exactly, but presumably you have a local payer who is doing that. And basically you are trying to encourage this, I hope.

 

Joseph:  Yeah, all of our local payers we now have pay-for-performance contracts with. The message is that they are getting quite specific. So let's again take diabetes. Hemoglobin A1c is the test that we follow for diabetes, it is an indicator of long-term how well your diabetes is doing. For us, there can only be a certain percentage of patients that has a hemoglobin A1c over the number nine, and we have to make sure also that there is another larger percentage under seven. Those two numbers are fixed, and if we don't meet those numbers then we lose a big chunk of change. So it is very specific, and it is getting more specific for more conditions. I think that is the thing that people should be aware of. That for us to play the game locally and to continue to be a high-performance system, which is what our CEO's vision is, we have to engage with our payers in that way. Because, we believe that we can offer higher quality care, we should be compensated for that. We also feel like we should be accountable for it.

 

Matthew:  And if you don't feel accountable enough, the CEO across town (Paul Levy at BIDMC) is putting it on his blog. [laughs] So that would probably be newsworthy. Probably the only major hospital CEO in America writing a blog everyday, and a very interesting one it is too. I am sure he gets lots of readership over on this side of the AMC corridor. Having said that, there is still the issue that it is not like that everywhere else. I guess the question is: do you think you are going to be able to create programs and patterns that are easily replicable across the country if we get wider scale pay-for-performance?

 

Joseph:  I guess I would answer the question slightly differently if I can take liberty. Which is...

 

Matthew:  I can change the question. [laughs]

 

Joseph:  Well, the question is, who cares enough to pay for something? And I believe one of the reasons we are working with EMC is because it is the employers that care. So I think if you design something--again, let's go back to the Continua vision--that is modular plug-and-play on the technology side, that a patient can either purchase quickly on their own or be given a box and plug it in; and that we wrap a service around that that involves educating and motivating them to care better for themselves, and making care decision-making closer to where they are; that we will show that healthcare utilization will go down. And employers will want that. So that is our belief and how we are moving. The other one, again, we mentioned this earlier, but Medicare is like the elephant in the room here. And however they decide to deal with their “2% is 50%” problem, it is going to involve some different mechanism of reimbursement than straight fee-for-service. And we want to be prepared for that.

 

Matthew:  Yeah, I think it has to. You know I was at the World Health Care Congress the last two days, as you who were reading the blog know. And it was clear that there are now some, as you may have heard from Steven Burd at Safeway, it is clear that employers are kind of done with the way things have been. It was kind of OK, but really now they have just gone through the first time where they have actually had their profits go up and their healthcare costs go up faster. Previously, they only ever cared about healthcare costs when they went up when their profits were down because there was a recession, but now it is just too big a number for them to ignore. And I think I was actually a bad bit of mathematics because it overstated the case for him, but the CEO Craig Barrett from Intel made the statement that, well, he figured out that it was $7, 500 per individual in the U.S. And I have a family of four, then that is $30,000. If you do all the math, I can hire an engineer in India for a whole lot less than that. So the healthcare alone is growing...

 

Joseph:  The outsourcing.

 

Matthew:  Yeah. So, having said that, I think, as you said, Medicare is the elephant in the room, because employers have been, they have tried to do stuff before. You know, we have a declining share of the market in large employers. Small employers have got no leverage, can't do anything and they don't even have people. Talking about small hospitals not even having enough IT, well small employers, even medium-sized, don't have HR people who have the ability to develop these programs. Even the large ones, I was talking to the PBGH members, and they have issues managing some of this. Those are the really big guys, Wells Fargo, they have got people on top of this stuff, but the medium-size employers have issues. Do you think that the big employers in any one market are enough to be the tipping point or be the driver that actually pushes enough interest in the providers? And the providers go, "Well actually we can do OK doing it this way," and take that back to the payers? What do you think?

 

Joseph:  Let's just think about a few developments. And remember--I shouldn't say remember because I haven't said—I look at this through the lens of a disruptive technology concept, Clayton Christensen's framework.

 

Matthew:  Also across the street. Across the river, sorry.

 

Joseph:  Also across the river, indeed. If you look at it that way it is kind of no surprise that anyone in the current value chain that has offered something has not been that successful. I think the reason employers have not been successful is that they have tried to get their health plan partners to work on this, and the health plan partners will say to us as providers, "Gee, I don't hear much for employers," then turn around and say to employers "The providers don't want to participate." So, I don't mean to blame the health plans, because as I said, everyone in the value chain is wed to the current way we do business. So I would say if you look at, as a provider if you look at a few trends, it is time for us to pay real close attention. One of them is retail clinics. You know, it is possible that those patients with acute conditions, five years from now will be not even seeing us for those because it is so much easier to go to a retail clinic. The other is watching the way people manage their health savings account dollars. Most of that money gets spent on alternative health, as opposed to stuff that I provide as a healthcare provider. So again, as that grows, and it is predicted by, I saw data the other day that by 2010 or 2012 health savings accounts are predicted to be about 40% nationally of the market. So that is again a chunk of healthcare expenditure that is not coming our way. Then there is the pay-for-performance and Medicare. So everywhere you look there are reasons for us to feel like the current reimbursement model and the current care model is going to be disrupted. We have to pay attention to all those, and it really speaks to the need to start to think about doing this differently.

So, in answer directly to your question, I think the reason employers have not been able to do it is that they have not had the simple offering of a solution that could help them. That is why we are so excited to see how our project with EMC turns out, because that could be an example of something that could really work.

 

Matthew:  Yeah, and you are getting some clearly leading-edge employers like the Pitney Bowes' and the Safeway's, and I think from the folks at Dow Chemical just the other day, about taking on that kind of activity. So I think there is a lot more activity there. And clearly, if the answer is in five years they have had another series of 10%, 12%, 15% a year increases an have gotten no improvements in the outcomes for their employees, they are going to be less happy. So I think you can argue across the board that things certainly have got to change. The question exactly is of course, when. But that leads us to another issue, which is you mentioned the "health plan" word in the middle of that, and we haven't got to that so far. It is interesting that there are not any health plans, other than Kaiser which is largely a technology function of being a provider not a health plan, that is in Continua.

Which leads us to two questions. One is, what is the role of health plans in this whole piece? And the other one is, who is going to do the role of the overseeing, the monitoring, and the collection of all that data? Both, which organizations are going to do that, and perhaps more interestingly, what is that function in terms of the professional context?  So let's talk first off, where are health plans, in your view, in this whole sense of monitoring at home activity.

 

Joseph:  Well, the large health plans with a national footprint are becoming, I would say, quite aggressive to get into this space now. For instance, Aetna has purchased Active Health. They have not done anything yet in remote monitoring, but I know they are thinking hard about it. United Health Group, I recently heard them present about personal health records, and their feeling that that's a space they should own. I know Aetna feels the same way. So you can you can start to see them lining up. And if you were a cynic you would say that they are trying to disintermediate the provider. I don't necessarily see it that way. They are trying, again, to provide their customer--the employer--with a better service offering. So, the health plan has an enormous opportunity because they see all the claims; and they have great systems for knowing who you are, what your conditions are, what you could be enrolled in. And for sure for the foreseeable future one of the big success metrics around Connected Health is going to be choosing the right patients. So plans could do a lot here. If we were to try to glibly go into this business alone I think we would find that the plans have a lot more value than we give them credit for. Now the other topic you brought up was...?

 

Matthew:  Well the issue of who is going to be doing this organizationally and professionally. So what I am getting at here is two things. First off, who does this live with? I mean this is kind of the combination of disease management nurse advocacy for the patient and intervention. Does that live within health plans or within a big provider organization? Does it live within some third party that doesn't exist-- the disease management organization in a different flavor?

The other question is, a lot of this has got to do with essentially the desegregation of medicine. I forget who it was but it might have been... I'm blanking. I saw a great talk last year from it. It was somebody from either Geisinger or Partners or someone like that, who was talking about there are too many $200-an-hour doctors making $20-an-hour decisions and we are not focusing that correctly. A lot of this has to do with the kind of basic stuff you are talking about. So give me a sense of both of those. Who do you think is going to be on the other end of the wire monitoring this stuff? And what is the care of congestive heart failure going to look like in 20 years, well, 10 years time?

 

Joseph:  Sure. Well one point I would like to make, and I should have made it earlier it think, is that one of the drivers for this adoption curve is the fact that we are in a provider shortage mode now; and that is not going to get better, it is going to get worse. The rate of chronic illness growth has far outpaced the rate at which we are training healthcare providers. So we have already lost the capacity in nursing. Just check in with your primary care doctor, they are an incredibly beleaguered lot. So, we say we have lost the capacity challenge. If the way we do business requires that you come into a facility to one-on-one meet with someone who is in short supply, and your problems list is growing, you can see that eventually we need to figure out a different way to do that. So you brought up, I think, two excellent points. One is that we do, in our current system of doing business, have highly trained and highly expensive physicians making a lot of decisions that they really don't have to make. The beauty of this kind of a technological approach is that it enables the richness of data that comes from the patient on a routine basis, enables that decision making to move close to the patient, in some cases we believe with the patient. So we like to say that in certain cases we can make you your own primary care doctor if we educate you well enough. And that is part of our vision. So one way to reduce demand on a short supply of workers is to offload some of that work back on to you, the same way that you go the airport now and you check yourself in and you print your own boarding pass and all those things.

 

Matthew:  I always say that the beauty of Amazon.com was it turned me into a bookstore clerk.

 

Joseph:  Right, exactly. So I think we expect a lot more of healthcare to go in that direction, because it will have to. Now the issue about sort of who provides the front-line service, I could say that it is a non-physician clinician. We have already sort of established that. And it will change over time because the richness of the decision support will get better and better and better. Things that we manage now by humans making decisions, we will be able to automate as time goes forward. Again, we will have to do that because we continue to have provider shortages into the long-term future. There are no plans, this is a policy issue but there are no plans to train more doctors, there are no plans to train more nurses.

 

Matthew:  Well I have got to say, so yesterday, well I may be talking out of school here, I had lunch at a meeting where Jack Wennberg was. A great argument broke out about this, and his view would be that, obviously under the current system we have too many doctors. But there is a difference here, which is that the excess of doctors is due to many things, maybe we have the wrong kind of doctors perhaps, or not enough of some others.

 

Joseph:  Well, they are not using themselves appropriately.

 

Matthew:  That is I think where he would be. But I think what you are suggesting is that, look, if we are going to figure out a way to control the cost and improve the quality at the same time, they have to at least act differently.

 

Joseph:  They have to act differently, and he and I would agree on that. So it will be a non-physician clinician, there is role for pharmacists, there is a role for nursing assistants; again, it doesn't even have to be a nurse practitioner, which is sort of people's second guess now. Because the richness of the information coming from the patient is so robust that algorithms can help you make decisions, until you get really complicated clinical situations. So when you say what will it look ten years out, my vision for what the doctor's life will be is you might see a morning worth of five patients that each need an hour, because they are really complicated and they are really sick and you just need that time with them, at some point you need to be with them to make some decisions. But then you might spend your afternoon surfing, surfing various dashboards about various populations of patients that someone else has already triaged for you. Say, well these are five diabetics that maybe need some of your intervention, do you want to change over to insulin, do you want to change to a different oral anti-glycemic. These two heart failure patients, their weight is trending up, we think they need a change in their Lasix dose. This person with renal failure may need a different dialysis program. And you just go through your list the same way that you and I go through our email. When providers hear that and they can actually absorb it, they start to smile. The problem today is that we ask them to do both, because we are in that funny mode where we are still doing things the old way, and we are asking them to start to adopt a new way. So when I talk to doctors about this vision, they say, "I'm excited about it, please don't overload me with data." And that is why we need that front-line function to triage and select.

 

Matthew:  You heard it right here, the future of physicians is a happy doctor surfing, not quite the Internet, but measures of his patients and doing some more remote management but then also getting to dive into the really complicated stuff, which I guess is, I think, where we need them. Well, that is great. I have been talking with Joseph Kvedar, who is the director of the Center for Connected Health at Partners' Healthcare in Boston. Joseph, it has been great talking to you. Thank you so much.

 

Joseph:  It's been a real pleasure.