Neupert On Health : global health

Learning from Singapore and Switzerland

pnblog — Fri, 23 Oct 2009 17:59:00 GMT

So this week’s question from the Washington Post RX Blog was:

Which country has the best health-care system and why? Can the U.S. follow its model?

My response -- Learning from Singapore, Switzerland -- is below.

To realize the goals of providing increased access while maintaining fiscal responsibility, we have to dramatically change how we 'do health' today -- whether we're doctors, hospitals, or consumers.

Health is complicated no matter where you go in the world, and there are different challenges in every country. There is no 'best' system anywhere, but there are best practices from around the world worth exploring. Two immediately come to mind:

Singapore's system has characteristics that reflect what we'd expect to see in our own system - personal responsibility, competition and choice. Working people are obliged to put money into a personal savings account for out-of-pocket expenses. The money remains completely in each person's control; each decides how to spend it. And there's choice -- at the Raffles Hospital, one can choose a $1,438 luxury suite with a 24-hour nurse and other amenities OR a $99 a night dormitory room with the six other beds. Procedures cost the same, and are transparent (Publication of the cost of hospital procedures is mandatory, turning the purchase of a hip replacement into something similar to buying a pair of shoes), but there's choice. Contrast this to our system where it's difficult to even get a price in advance, let alone make choices.

Switzerland's system also offers interesting models for consideration -- universal access, individual choice from an array of private insurance options, and a higher level of personal accountability (shared costs by individuals). All citizens are required to buy health insurance and private insurers are required to offer coverage to everyone - regardless of age or any previous medical conditions. Insurers offer a basic package on a not-for-profit basis, and supplemental packages on a for-profit basis that consumers can choose for things like home care, alternative medicine, and so on. Competition is basically about price and service. For those who can't afford the basic package, the government offers direct cash subsidies. In addition, the system provides incentives for consumers to avoid unnecessary treatments by requiring them to share some costs at a higher level than in the U.S. It's not perfect, but it is customer-driven.

In a democratic nation where capitalism flourishes, personal accountability and choice ought to be at the heart of the system.

Please feel free to comment with your own thoughts – I’d like to hear from you.

International Travelogue Part Two...

pnblog — Thu, 12 Feb 2009 22:09:00 GMT

Last week, I continued my round the world itinerary visiting customers, partners, and governmental agencies. I took an overnight flight from London to Bangkok on a Saturday—the plane was full, primarily of tourists taking advantage of what Thailand has to offer, despite the political turmoil. My day started with a random act of kindness—receiving a text message from someone who picked up documents I left on the train to London and offering to send them to me—remarkable! What many folks don’t recognize when looking at maps is how large, spread out and diverse Asia Pacific is. After arriving early Sunday morning, I caught up with my team on the ground, many of whom just came from Arab Health—a huge HIT conference. I then spent Monday in Bangkok with customers, Tuesday in Kuala Lumpur departing on an overnight flight to Sydney, and Wednesday to Friday in Sydney departing on an overnight/day flight to U.S. for a brief, but important meeting in Scottsdale, AZ on Friday afternoon before the last leg getting home to Seattle that evening. Amazingly throughout the 13 days, there were no big logistical problems (no lost bags, no delays over an hour, no lines over 30 minutes)—made it much easier to survive!

Here are a few of my observations from Asia Pacific—with more specifics this week to provide context:

Monday morning started with a visit to a large public hospital in Bangkok. They are at the same time very sophisticated from a diagnostic/therapeutic perspective (research lab, surgery center) and very antiquated from a work process perspective. They see a huge number of patients—both with appointments and not. Their “system” is primarily paper-based—the amount of forms and paper they have is overwhelming. Their whole system is based on queues—throughout the hospital, there are people waiting and standing in line. To get a pharmacy or lab item, a patient might go through three separate queues or tellers with an indeterminate wait time at each—identify/submit order, make payment, and draw or receive lab or Rx. I was struck by the incredible opportunity for the use of technology to improve the entire system—in terms of throughput and satisfaction, and ultimately patient care. Hospital management also sees the need and the opportunity— to invest in the information infrastructure as they have invested in the medical equipment infrastructure—but the implementation task seems daunting to all.

I spent the afternoon at Bumrungrad Hospital in Thailand where I have a development organization and key strategic partner. Bumrungrad is an amazing example of excellence—using technology to support clear outcomes—quality, efficiency, and customer satisfaction. Each time I’m there, they show me advances in infrastructure, workflow processes and facilities. It is great to have strategic partners who push the agenda for our products forward. Now they’re moving on to Bumrungrad Version 3.0—a whole new level of service and are again looking to IT to help. While they serve the local population, they serve an even greater number of foreigners—thousands and thousands of “medical tourists” from the US, Middle East, Europe, and Asia. Interestingly one of the key topics was how to leverage HealthVault in supporting the medical tourist and expatriate part of their business…something we have talked about internally but now have prioritized.

In Kuala Lumpur, I visited two private hospital groups, each of which is part of a larger conglomerate. They view healthcare as a growth portion of their portfolio and they have money. I enjoyed learning from them about their goals and approach, and explaining our strategy to them. The perceptions of what Microsoft is as a brand are so prevalent and ingrained—consequently, I have learned my most important objective is to communicate with folks that HSG is a serious and thoughtful player in health information technology. These private hospitals want technology partners to help them do a lot; —streamline their clinical and business processes, use clinical workflow tools to put guardrails on clinical processes, provide sophisticated BI tools and to stay on the leading edge. While they are focused on their enterprise needs first—our Health connected strategy—of connecting consumers to physicians to facilities—really resonated with them for their future business needs.

In Sydney, I met a very diverse group of folks—shadow ministers, MDs, CEOs of hospitals, members of the Clinical Excellence Commission, and members of the NSW health service. Australia has been pursuing leveraging HIT for several years. Some states are pursuing standardized Cerner implementations for hospitals and there is an institution named NEHTA that has been exploring the policy issues/standards around community or personal ehealth records. As I’ve noted before, the challenges in Australia are similar to the U.S. and Europe—leveraging information across the continuum of care, getting more out of their existing departmental systems, improving performance at the enterprise and system level and engaging consumers. The health of the healthcare system is a hot media and political topic—everyone is talking about the Garling report and what it means, physician concerns about the Cerner implementation in emergency departments and other specific bad ED incidents the media have publicized. While I get the scale benefits of standard software and standard rollouts by centralized and skilled service organizations—they frequently run into challenges in the healthcare domain.

I concluded my trip in Scottsdale, AZ, where I had the opportunity to address a small group of CEOs at the Health Management Academy. It was a great interaction about how technology has changed many industries. I had the opportunity to use my personal history to tell the story of how connecting vision, technology folks and domain experts has powered positive and sustainable change—which I have had the good fortune of doing at Microsoft, at MSNBC and at drugstore.com. It was fitting to conclude the trip back in the U.S with leaders dealing with the challenges in their organizations and the economic climate. Increasingly I see the local market separating into two segments—while all are focused on cost containment—some are primarily hunkering down and others are seeing the current climate as an opportunity to invest in transformation. Obviously I believe the right technology is critical to both groups.

Let me wrap with a side comment. I’m over 50 years old and have been traveling internationally for nearly 40 years. Even though there have been many articles and books written about how the world is flat, it is remarkable to me how much the world has changed in this relatively short period of time...and yet, in some respects I believe the change is just starting. From the ease of staying in touch (my kids could call/text me anytime—didn’t need to know where I was at all)—to the ability to stay connected to important events in the U.S. (Superbowl started at 6am local time in Bangkok with Thai announcers and a pre-game show)—to physically getting from place to place—it is all steadily improving and becoming part of the norm. In the same 13 day time frame, I worked out on four separate continents—ran in the cold in London’s Hyde Park and in the heat around the Sydney Opera House—and collected all the workout information on my HealthVault compatible Polar heart rate monitor and watch.

International Travelogue

pnblog — Mon, 02 Feb 2009 00:50:00 GMT

After my visit to Washington D.C. and the U.S. Senate, I thought it might be instructive to visit other parts of the world to gain additional perspective on the challenges the global economic crisis is posing to health systems. For the last five days, I have been in Western Europe visiting four different countries and interacting with health system CEOs and CIOs, ministers of health, leading social service bureaucrats and members of the Microsoft health ecosystem.

Here are some observations worth sharing:

Everywhere there is a deep interest in personally controlled health records - more than I anticipated, and despite the fact that some early projects in the category have performed poorly and have low adoption. Stakeholders recognize that citizens/consumers need to be actively engaged in their health in order to improve the results and economics of the health system. They view personally controlled health records as an important tool to motivate and engage them. They don't see other options that can accomplish this goal.
Privacy is a major issue surrounding the sharing of health data -- either in the professional arena (insurance, provider to provider, provider to pharma) or in the case of professional to consumer. Many have concluded (as we have in the design of HealthVault) that personally controlled health records are the best solution (but not the only one).
Health systems and their funders are looking for ways to connect the health delivery system across institutional boundaries -- from GP systems to hospitals and specialists. No one is doing it well yet. They see it as critical to delivering better outcomes and containing costs, and they acknowledge that seamless data sharing is critical to enable new work flows. Unfortunately there remain many barriers to this seamless data sharing -- some technical, but mostly economic fear of existing stakeholders around loss of revenue or the implications of transparency on business practice/quality of delivery.
The payment systems inhibit innovation in many cases or drive it in others. In some markets, governments are pinning their hopes on private insurance as a vehicle for innovation and focus on wellness/prevention while in other markets the government is directly trying to tinker with the payment schemes to encourage new behaviors by the provider organizations. From an economics perspective -- what strikes me as the real problem and challenge with these approaches is that the feedback loops are long and indirect, and consequently the cycle time of improvement will be incredibly slow. This is why price mechanisms in the capitalist system are so important - real time feedback mechanisms with the ability to self adjust.
The people with whom I met had an informed interest in what was going on in the U.S., particularly around the stimulus bill for health IT and about the prospects for health reform. They are watching to see the impact. What surprised me was the low esteem in which most regarded the U.S. health system...based on the statistics around health spend as a % of total GDP spend and reported health outcomes. I acknowledge that the U.S. system has many flaws, is broken in many ways, and has lots of waste that should be eliminated. But I have always been a bit of a skeptic that the statistics on outcomes really tell the full and complete story around quality of care delivered across different societies. I am not sure that the perception of others really matters in this case in terms of the U.S. needing to fix the problems regardless -- but it bothered me enough to flag it and put in my "think about it later" list.

Some I visited are surprised to learn that Microsoft is investing in health specific software and services solutions. Others are challenging us to do even more to bring ease of use, effective application integration and user interface innovation to the health worker desktop today! Most are hopeful that the next round of technology and software investments really help improve the working environment on the front lines of health delivery and health outcomes.

Next stop -- Asia Pacific. Given our ambitious goals, I often tell my team that time is our enemy when it comes to success. Ironically, I have turned the motivational saying into a concrete reality as my itinerary has three of the next six nights aboard planes. whoops

Three Seattle Health Conferences in One Week!

pnblog — Thu, 19 Jun 2008 04:46:00 GMT

Last week was the HealthVault Solutions conference held by my team. The metrics were great -- lots of new applications launched and partners signed, attendance oversold, 600 people, 285 different organizations etc. -- but the story is not in the numbers. What excited me was the energy in the room -- the passion of the people who work in health and want to be part of doing better for consumers. Many participants came up to me at the end of the first day (after 2 hour demo session) and said they were really starting to get it -- the benefits of a personal health data platform -- with multiple applications sharing data as determined by the user. Getting it is a good sign. Dr. Mehmet Oz, who was the keynote speaker the next morning, took the energy level up a notch and raised the stakes. Dr. Oz shared his sweeping vision of empowering consumers (YOU) to improve health -- but the key learning for me was -- to truly engage consumers you must connect with them emotionally. Reason by itself -- don't smoke you will get cancer, don't eat too much you will get fat -- simply is not enough to change behavior. Personalization, connectivity are key -- but we have to be able to connect at the emotional level with users - -this is a new set of challenges. We also announced the winners of our innovation fund - the HealthVault Be Well Fund. We were astonished by the diversity and quality of responses -- and excited to inform the winners, so we can get started on the 15 exciting projects.

Yesterday, Microsoft hosted the Center for Health Transformation (CHT) meeting on our campus. CHT is led by Newt Gingrich -- he is a tireless champion for change and for raising our expectations for results from the health delivery system. CHT does good work stimulating ideas, motivating policy makers to learn and be thoughtful when approaching health and creating connections between their members who are doing good work. Newt was a judge on the HealthVault Be Well Fund panel. Many U.S. ecosystem players participated and exchanged ideas -- sharing ways that IT plus leadership can improve overall results in the health delivery system -- like Gary Kaplan CEO at Virginia Mason, an integrated delivery system in Seattle that has utilized the "Toyota Lean" for system improvement. Given the fragmented nature of the health ecosystem -- these stories of best practices and improved results -- need to be told and retold and retold -- to motivate additional champions how to change and give practical examples of how to make progress.

The last two days I have been participating in the 4th annual Pacific Health Summit. The mission of the PHS is to bring leading scientists together with policy makers and industry to tackle hard problems in Global Health. It is a fascinating conference because of the mix of people (scientists, ministers, NGOs, industrialists) -- all of whom bring a real passion to helping "improve" Global Health -- but start from very different perspectives and world views. This years theme (selected a year ago) was around nutrition and the twin challenges of under nutrition (hunger, nutrient deficiencies and their impact on health status) and over nutrition (obesity, diabetes and the impact on health status and costs). The timeliness of the topic -- given current events -- only raised the level of urgency and passion behind the conversation. I won't even attempt to do justice to the theme in a brief blog -- given the complexity and interdependencies of the key threads -- I'm sure a final report will be published. I can report a few surprising data points for the benefit of others:

despite the lowest incidence of obesity -- Japan implemented a national policy in April to focus on prevention because of current costs and the need to change trend lines. This means that all people in Japan ages 40-74 are required to get an annual checkup. One panelist -- Takemi-san a former vice-minister of health -- described how he had made a public promise to lose 10 kilos - -and this became a big and frequent media event (waist measurement and weigh in). But he achieved the goal!
China too has started a new program to prevent obesity -- as part of an overall approach to public health. The program's essence is its simplicity -- healthy weight and healthy blood pressure. They determined that if they could motivate everyone to eat 40kcals less/day -- they could dramatically change future trend lines. So they ask people to eat 2 less bites off of their dinner plate.
India -- while being a food exporting nation -- has roughly 40% of children under 5 being under-weight. This data point was used to demonstrate that "point solutions" or "simple programs" don't work -- that behavior change at either the national or individual level require comprehensive approaches (education, training, incentives, etc) that also take into account culture and traditions.

The role of nutrition in Global Health is clearly important -- and impacts costs and outcomes throughout the system -- from childhood development through to the management or prevention of chronic conditions. One key takeaway for me is that it will require leadership (at multiple levels) and new forms of collaboration between the private sector and the public sector to sustainability address this issue.