As health enters the fourth industrial revolution, many countries share a common vision

Health Care Current | October 29, 2019

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies, and provides updates and insights on policy, regulatory, and legislative changes.

My Take

As health enters the fourth industrial revolution, many countries share a common vision

By Stephanie Allen, Deloitte Global Public Health Care Leader, and Australian Health Leader

It doesn’t matter where I travel in the world—I am often struck by the similarities rather than the differences in health care. Worldwide, health care and health systems haven’t changed much since Florence Nightingale was a girl. We still use hospitals to care for our sick. We treat them, and we hope they get better. But this is all about to change.

While every government approaches health care a little differently, upcoming research from the Center for Health Solutions shows that many countries face similar challenges and share a common vision for the future of health. There are three main catalysts for change:

  1. A lack of affordability of the existing model is forcing us to rethink care delivery. The US spends about $10,200 per person per year on care while Australia spends about $5,400.1 Some countries spend far less. India, for example, spends an average of $63 per person.2 Every government is grappling with how it can afford to deliver health services to an ageing and chronically ill population.
  2. Scientific breakthroughs such as genomic, metabolomic & micro-biomic analysis are helping clinicians select treatment options specifically tailored to each patient. This, coupled with behavioral economics that incentivize the most appropriate behavior, means personalized medicine and personalized experiences in health care are possible.
  3. The advent of 5G and always-on sensors (in our homes and workplaces, wearables, and ingestibles) will help us connect data in real time. This will likely lead to proactive insights into our state of well-being and enable us to make choices and take actions in the moment—when it matters—rather than waiting until we become sick.

These forces or catalysts of change are founded on the capabilities offered by the 4th industrial revolution.

Welcome to the fourth industrial revolution

Klaus Schwab, executive chairman of the World Economic Forum, describes three previous industrial revolutions where new forms of “energy” were created that enabled people to do new and different things.3

In the first industrial revolution, we discovered coal and steam power. The steam-powered train opened new trade routes for the transportation of goods and services. In the second industrial revolution, we discovered the oil and electricity that powered factories and opened the door to the mass production of things like automobiles. The third industrial revolution signaled a move away from mechanical and analogue technologies to computers, the internet, and digitized communication. We are now in the midst of the fourth industrial revolution where technologies are elegantly integrated.

The new power driving this revolution is exponential technologies including the internet of things (IoT), fifth-generation technology (5G), robotics, virtual reality, and artificial intelligence (AI). These technologies are changing the way we work and live. By clicking on a calendar invite on a smartphone, we can get directions to our destination, an anticipated ETA, real-time transport options, and voice-activated guidance. Unlike the three previous revolutions (which were constricted to geographies), the fourth industrial revolution knows no boundaries. With an estimated 71 percent of the world’s population connected to mobile devices by 2025,4 the impact and opportunity will be much greater.

Here’s how I see the fourth industrial revolution playing out in health care: Imagine a pre-diabetic consumer walks into a pharmacy and picks up a candy bar. Immediately, that person’s smart watch, which has automatically connected to the store’s computer system, sends a signal warning against the unhealthy snack. When that person picks up a bag of almonds instead, a message reinforces the healthier choice by offering a 20 percent discount, for example. The ability to encourage well-being in real-time could be enabled by the emerging technology, interoperable data, and personalized medicine in the future. This is all part of the fourth industrial revolution. It is no longer the technologies themselves that are important, but rather what the technologies allow you to do and the velocity at which change occurs.

The future of the digital health record

Paper patient records were digitized during the third industrial revolution. In many countries, this digitized record is not accessible outside of the hospital or available to patients. Moving all of a patient’s information to a single location—and matching digital records to the correct patient—is a challenge that is not unique to any one country.

During the fourth industrial revolution, interoperability can remove these obstacles. Digital records might combine traditional clinical and pharmaceutical information with previously unavailable data to create a highly personalized overview of someone’s health. Data from a smart bathroom scale, smart medical devices, and wearable fitness trackers could automatically flow into each person’s digital record and be automatically integrated with other data sets. A history of food purchases from the grocery store might be used to nudge consumers toward healthier food choices. Financial data might help identify stress issues related to money, or erratic spending habits that could flag possible mental health issues.

As the data infrastructure evolves, real-time collection, integration, and analyses of patient data will likely become more common. Insights from these data can strengthen our understanding of health and help us answer the questions we couldn’t in the past.

It’s worth noting that while a government might require patient data to be stored in a single location, there is sometimes a distrust of government and its ability to safeguard information. In some countries, there is greater cultural acceptance when it comes to the idea of storing and even sharing health information. This acceptance occurs when consumers see value in a comprehensive patient record where their entire health history exists in one place.

Three countries, three approaches to digital records

Here’s a look at how three countries are combining technology and data to bring patient records into the fourth industrial revolution:

  • Australia: The My Health Record (MHR) is an example of a single digital-health record for the Australian population. Nearly all of us have one. At the moment, it can store data from hospitals, primary-health visits, pharmacy data, and vaccination history. Some pathology groups are already uploading scans onto MHRs. As of April, 83 percent of pharmacies were registered with the system—up from just 33 percent a year earlier, according to the Australian Digital Health Agency. More than 250,000 Australians are hospitalized each year due to medical errors, inappropriate use, or interactions, according to the Pharmaceutical Society of Australia. A single database for pharmaceutical information could help reduce those errors. The MHR could be the foundation for a significant transformation in Australia where data from hospitals, physician offices, and dentists is combined into one electronic record. While the MHR has tremendous potential, it is still in its infancy.
  • Estonia: With a population of just 1.3 million, Estonia was able to build its e-health system from the ground up beginning in the early 2000s—providers had not yet invested in their own electronic systems. To protect patient information, Estonia relies on blockchain technology and authentication with ID-cards, digital signatures, separation of personal data from medical data, encryption of data, and monitoring of actions allowing users to know who accessed their health data. The system has integrated a decision-support system with an e-prescription database, which provides drug-interaction warnings to physicians. An estimated 15–17 percent of prescriptions are changed in response to these warnings.5 In the future, other databases could be connected to the centralized e-health system—including the Estonian genome center—which could lead to more personalized treatment. By the end of 2019, 20 percent of Estonians are expected to get genetic screening.6 The e-health system might also be integrated with environmental data that impacts public health.
  • Netherlands: A nationwide digital infrastructure for the secure and reliable exchange of medical data among providers was completed in 2011. As of 2016, 92 percent of health care providers were connected to AORTA, and about 11 million Dutch people (almost two-thirds of the population) have agreed to let their data be shared among providers.7 The population, however, has been slow to embrace the system. As of 2018, only 2 percent of the population had online access to the patient records kept by their general practitioner. The government has determined changes in culture and care processes might be needed to accelerate adoption of e-health.8 In the future, the Dutch government wants 40 percent of all people (and 80 percent of the chronically ill) to have electronic access to their own medical records. The government has also set a goal of connecting 75 percent of chronically ill people and vulnerable elderly so they can monitor things like blood pressure and cholesterol and share data with their provider.

As with any major transformation, we expect the fourth industrial revolution will lead to greater efficiencies in the health ecosystem, new opportunities for health stakeholders and governments, and better health for individuals and populations. As Klaus Schwab might say, it’s not the technologies in and of themselves that are significant—it is the way that we elegantly integrate them to do new and different things.

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1 How does health spending in the US compare to other countries?, Kaiser Family Foundation, December 7, 2018
2 Global Health Expenditure Database, World Health Organization based on 2015 data. (World Health Organization's Global Health Expenditure Database.)
3 The Fourth Industrial Revolution, by Klaus Schwab, January 11, 2016
4 Smartphone ownership is growing rapidly around the world, but not always equally, Pew Research Center, February 5, 2019
5 Learning from the Estonian e-health system, Health Europa, January 11, 2019
6 Healthcare in Estonia, The Medical Futurist, May 16, 2019
7 What about LSP? Patients want control of their medical data, Computable, September 21, 2016
8 E-health in verschillende snelheden, e-health monitor, November 2018


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In the News

CMS expects lower premiums, increased enrollment in exchange-based plans

Consumers who purchase health coverage through a public insurance exchange this fall could see lower premiums and more health plans. In its annual report, the US Centers for Medicare and Medicaid Services (CMS) projected that 2020 premiums for benchmark health plans (the second-lowest-cost silver plan sold through an exchange) would drop by four percent for a typical 27-year-old enrollee. CMS expects 175 health plans will sell coverage through this fall—20 more plans than a year ago, and up from 132 health plans in 2018. The federally run exchange operates in 38 states.

While premium rates appear to have stabilized, they remain high for consumers who do not qualify for federal premium tax subsidies, which are available through the exchanges. For example, a typical 27-year old who earns 150 percent of the federal poverty level would spend an average of $52 a month for a subsidized policy, compared to $374 for a 27-year-old who does not qualify for a subsidy under the Affordable Care Act (ACA).

(Source: CMS, Premiums for plans are down 4 percent but remain unaffordable to non-subsidized consumers, October 22, 2019)

Judge denies CMS’s request to preserve site-neutrality for Medicare

On October 21, a US District Court judge rejected CMS’s request to continue in its site-neutral policy while addressing some of the issues raised in the case. The policy calls for Medicare to pay lower rates for clinic visits at certain off-campus facilities. Last month, the judge sided with the American Hospital Association (AHA) and other provider groups that challenged the rule.

Under the final rule, which went into effect in January, CMS proposed a site-neutral payment rate for clinic services provided in off-campus, provider-based departments (PBDs) paid under OPPS. According to CMS, this policy would have saved money for Medicare and lowered copayments for beneficiaries. Medicare savings were estimated at $380 million for 2019 (see the November 6, 2018 Health Care Current). The judge determined that CMS lacks authority to pay less for off-site clinic visits and said the site-neutral payment reductions were not implemented in a budget-neutral manner.

CMS announces new five-pillar strategy to reduce fraud and waste in Medicare

On October 22, CMS launched a five-pillar strategy aimed at reducing fraud and waste in the Medicare program. According to the agency, this strategy would also allow it to adopt new payment models and expand coverage to new provider groups. The five pillars outlined in CMS’s new strategy are:

  1. Stopping bad actors quickly 
  2. Preventing fraud through policy changes 
  3. Tracking “new and emerging” risks
  4. Easing provider burdens by streamlining administrative processes 
  5. Taking advantage of new technology to modernize program integrity

CMS has asked for comments on two requests for information (RFIs) regarding the new five-pillar strategy and will gather feedback through November 20.

(Source: Fierce Healthcare, CMS unveils 5 ‘pillars’ to curbing fraud, waste in Medicare, October 22, 2019)

Payments to APMs requiring providers to bear risk increased in 2018, survey finds

More than one-third of health care payments in 2018 went toward advanced payment models (APMs) that require some financial accountability from providers, which is up from the prior year, according to an October 24 report released by public-private partnership Health Care Payment Learning & Action Network (LAN). The report analyzed survey responses from 62 commercial health plans, seven fee-for-service (FFS) state Medicaid programs, and the Medicare program—representing 77 percent of covered patients, or 226.5 million Americans—in 2018.

The report included results of a survey that asked participants their views on how value-based payment models would affect health care. According to the results, 97 percent of respondents expect APM adoption will improve care quality, 95 percent agree APMs could improve care coordination, and 88 percent expect APMs will make care more affordable.

LAN said it aims to move all Medicare beneficiaries into value-based payment models by 2025. The group seeks to tie 30 percent of Medicare Advantage (MA) and traditional Medicare payments to APMs by the year 2020, and 50 percent of payments to APMs by 2022.

(Source: HCPLAN, 2019 APM Progress Press Release, October 24, 2019)

Breaking Boundaries

AI-powered app can detect eye disease much earlier than physicians

Sophisticated diagnostic tools that incorporate artificial intelligence (AI) could offer consumers faster and more accurate diagnoses than their doctors. A study published in the journal Science Advances describes a smartphone app that monitors personal photos to detect eye diseases more than a year before doctors can detect them.

The app uses machine learning to search pictures for signs of leukocoria (identified by a white reflection in the pupil of the eye). Leukocoria, or “white eye,” looks similar to red eye—the red reflection in the eye that often appears with flash photography. But while a red reflection is a sign of a healthy eye, a white reflection can indicate retinoblastoma, a type of childhood cancer of the retina, or a small number of other eye disorders. These include retinopathy of prematurity, cataracts, or Coats Disease. Catching these disorders early can save eyesight or even save a life. With a condition like retinoblastoma, the faster the diagnosis, the better the outcome. Tumors grow rapidly and once white eye appears—it typically takes six to 12 months before the tumor starts to metastasize down the optic nerve to the brain.

The study includes results of a tool called the White Eye Detector, which can scan all the photos in a person’s phone. The research team developed a novel set of neural networks and trained it to spot white eye in family photos of babies and children. The team tested the system on nearly 53,000 photos of 40 young children, half of whom had healthy eyes while the others had been diagnosed with a leukocoria-related eye disease.

In 16 of the 20 children who had the disease, the app spotted leukocoria in photographs that had been taken an average of 1.3 years before a doctor had diagnosed the child. Among the subset of children with unilateral retinoblastoma, the app caught white eye more than nine months, on average, before medical diagnosis. This timeframe could be the difference between losing an eye and saving it, according to specialists. While the tool also works for adults, it is most helpful for children who might be too young to notice or talk about a problem. Retinoblastoma only occurs in young children.

Pediatricians typically screen for leukocoria by shining a red light into a child’s eye, but the exam is not considered especially effective. A 2003 study found that 80 percent of the time, it’s the parents who typically spot retinoblastoma—typically through photographs. The app is free. The developer did not have to seek regulatory approval because the app includes a disclaimer that it can detect white eye in photographs but cannot diagnose any medical condition.

(Source: Emily Waltz, App detects eye disease in personal photos, IEEE Spectrum, October 2, 2019)

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