Top Ten Technology-Driven Trends in Health Care 2004-2014

1. Top Ten Technology-Driven Trends in Health Care2004-2014 Annual Meeting of the University of California Academic Business Officers Group Century City April 27, 2004

2. Possible Reasons for Interest in my Presentation • Work in an AMC (AHC.) • Work in a unit that’s part of a campus with an AMC. • Have an interest in the future of health. because it has academic interest. • Currently a patient. • Consumer who will some day become a patient.

3. Institute for the Future

4. Forecasting Creating plausible, internally consistent, and possible future scenarios in order to make better decisions today: an invaluable and irreplaceable context for strategic planning.

5. www.healthtech.org 415-537-6974 524 Second Street San Francisco, CA 94107 Translating Research Into Action An independent, non-profit research organization

6. Technologies • Anti-microbial Drugs • Cardiovascular Drugs • Remote Patient Mgmt • Security Technologies • Neuropharmaceuticals • Gene Therapy • Wireless Technologies • Voice Recognition • Clinical Trials • Web Services • Minimally Invasive Surgery • Drug Delivery Devices • Sensors for Monitoring • Organ Assistance and Substitution • Stem Cells • Genetic Testing • Imaging • Tissue and Fluid Bioengineering • PACS and CAD • Point of Care: Mobile Computing • Networking • Cancer Pharmaceuticals and Biologics

7. Framing Issues: 2004-2014 • New Consumers: changing health care and its providers. • Rising expenditures for HC driven by new technologies and consumer demand. • Increasing specialization: a byproduct of advances in medical technology, diffusion of IT, and accessible information on outcomes. • Workforce shortages.

8. 1. One-half of America’s Adults Qualify as New Consumers • College (1 year) Analytical sophistication and confident in making decisions • Cash Disposable household income of $55,000 (2004) • Connected by Computers Ready access to the Internet.

9. 2. Expenditures for Health Care as % GDP • $1.7b rising in 2003 to 15.3% of GDP • Highest among industrialized nations (av. 7.5% for the other 28.) • Arbitrary cap of 15% considered “sustainable”? • But, forecasts for 2011 are: CBO and CMS-17% of GDP Others-20% of GDP

10. 3. GreaterSpecialization • Specialty units and “centers of excellence” within many hospitals. • Free-standing specialty hospitals and ambulatory centers defined by organ system, disease or specialty. • More sharply defined specialization within departments, single specialty groups, and hospital systems. • Regionalization by default

11. 4. Projected Shortages: Physicians Anesthesiology Oncology Gerontology Gastroenterology Cardiology Hematology Pulmonology Intensive Care Psychiatry Urology Nephrology Radiology Pediatric Specialties (an exception to serving a rapidly expanding older population.)

12. And Also, Nurses Technicians Bioengineers Biomedical computer scientists Pharmacists Non-physician clinicians

13. Impact of New Technolgies on the Workforce • Endovascular technologies create new fields • Stents replace angioplasty, add to volume. • DESs replace bare stents: negative impact on cardiac surgeons but expands indications. • New neuropharmaceuticals and devices for stroke create more volume • Computer-controlled magnetic-guided catheters lower the bar for training

14. Shift to Earlier Decision and Intervention #1 • Earlier diagnosis and management • Test selection by sensitivity and specificity to minimize time delay (R/O & R/I) • Efficient: reduces anxiety and return visits • More expensive tests may have lower total “cost” (MRI vs. CT, PET/CT vs. MRI) • Panel or a combination of tests may be preferable (gene micro-array for diagnosis, PET/CT over MRI forstaging)

15. Shift to Earlier Intervention: the Tools #1 • Faster, smaller imaging devices • Point-of-care diagnostic devices • RPM (remote patient monitoring) technologies • Attached and implanted sensors, physiologic and biochemical, that are “smart” and self-reporting and wireless • Molecular imaging (PET)

16. Smarter, Smaller Surgical Devices-MIS #2 Endovascular Technologies (a disruptive technology) • Stents, grafts, coils, balloons, debris baskets • Infusion of chemotherapeutic agents • Implantation of radioactive seeds • Delivery of growth factors, genes, stem cells and antiangiogenic molecules • Portal for chronic drug delivery

17. Percutaneous Mitral Annuloplasty A L crimping the valve P Congestive Heart Failure

18. Annular Ring Implant Explant at 28 days

19. PVT Percutaneous Heart Valve

20. 3D CT Angiography

21. Triple Play • Carotid stent placed to open carotid artery • Concentric (MERCI) retriever used to extract most of the clot • Intra-arterial tPA used to clear smaller arterial branches None of these is an approved therapy.

22. PAS•Port for Vessel Anastomosis Confidential

23. Hand-sewn Automated PAS•Port: Acute Results Confidential

24. Mitral valve repair/replacement CorCap only CABG CorCap Surgical Applications

25. Cerebral Aneurysm

26. Coiled Aneurysm

27. Tipping Point for Endovascular Treatment of Strokes & Aneurysms Barriers to diffusion were referral pattern (vs. coronary angioplasty) and poor early outcomes for balloon aneurysm occlusion Drivers at the tipping point: • Evolution of Neurovascular Stroke Units. • Comparative information on published outcomes and ISAT on surgery vs. coils • Trained # neurovascular interventionalists. • Technologic advances in image-guidance, versatile detachable coils, and stents.

28. Radiosurgery“Radiosurgery for trigeminal neuralgia, epilepsy, vascular malformations, acoustic neuromas, multiple metastases and other benign and malignant brain tumors is drawing patients away from neurosurgery. In less than 10 years, the number of acoustic neuromas treated by radiosurgery will exceed the number removed surgically.”CW, 2003 #2

29. “Bionic Man” #3 Implants and Transplants: Joints • Hip, now evolutionary (MIS) • Knee (disruptive) • Others (shoulder, digits, wrist, intervertebral disc) Stimulators • Cardiac • Nervous system (brain, spinal cord and peripheral nerves)

30. “Bionic Man” # 3 Pumps Cardiac (LVADs, mechanical heart) Drug delivery (insulin, chemotherapy) Nervous system (morphine, spasmolytics, GFs) Grafts, Stents and Coils • Cardiac (coronary artery, valves, other) • Intracranial (stroke, aneurysms, other ) • Peripheral (gut, biliary, vascular)

31. “Bionic Man” the Hattler Catheter # 3 • Organ Assistance and Substitution Devices • Liver dialysis • Artificial kidney • Hattler intravenous membrane oxygenator

32. # 3 “Bionic Man” Newer generations of VADs will diffuse more rapidly as they improve in function, size, and compatibility

33. #3 Micromed DeBakey Axial Flow Pump

34. Cancer #4 • Treatment strategy is changing: No longer a matter of winners and losers at any cost (cytotoxic polychemotherapy) Instead, opt for a negotiated truce by long-term treatment and lengthening quality survival • Accept cancer as a chronic disease. • Containmentthrough vaccines, anti-angiogenesis, serial therapy, and new multimodality approaches

35. #4 Cancer Forecast of Important Technologies • Conjugated monoclonal antibodies • Molecular re-classification of cancer • Molecular treatment based on rational drug design and development • Vaccines: preventive (ID) and therapeutic based on molecular/genetic specificity, e.g., Provenge (Dendreon) for prostate cancer (Jan. 12, 2004) Molecular imaging (cell death)

36. Cancer #4 • Gene therapy: most act through immune mechanisms and by use of RNAi • Anti-angiogenesis and blockers of metastasis as long-term strategies • More effective delivery of radiation therapy with IMRT (radiosurgery) • Improved drug delivery, e.g., lipsomes,, focused US, polymers, nanoparticles • Palliative use of directed energy, e.g., RFA, US, cryosurgery, radiosurgery

37. #5 Surgical Procedures Move Out of Hospital • General Hospital : what’s left? serious trauma, complex surgical operations (CA, NS, Ortho,..) • Surgical Hospital-cardiac, spine, total joint • Ambulatory Surgical Center– short term stay: laparoscopic, spine, oncology, cath lab • Ambulatory Surgical Center—same day: hand, some spine, ENT, arthroscopy, oncology, cosmetic, hip (?) • Clinic/Office: urology, ophthalmology, oral surgery, cosmetic, G.I., dermatology, oncology

38. #6 Access to Healthcare 24X7 • Driven by demands for improved patient safety, efficacy of care and communication • Finally gaining agreement on standards for data sets, medical record vocabulary and format, record storage, and retrieval. • Development of regional information systems that can be accessed from secure Web portals,pulling in information from disparate sources, and displaying images.

39. IT will Revolutionize Healthcare

40. #7 Personalized Medicine • Reliance on genetic testing, proteomics pharacogenomics, and molecular specificity • Identification of diagnostic and therapeutic targets for sub-groups of patients using cancer markers (genomic and proteomic). • Defining homogeneous but much smaller target populations (Gleevec and EGFR’s) • For Pharma, a new business model: greater risk and higher margins, but with better outcomes for patients (Genasense—untreated advanced melanoma : antisense)

41. Theranostics Theranostic applications fall into three general categories: • Genetic predisposition diagnostics. • Theranostics that aid physicians in selecting the proper drug and dosing of that drug. • Clinical trials diagnostics.

42. # 8 Use of IT in Healthcare: Expanding and Wireless • Wireless technologies enable information access and data entry at any site • Clinical data entry by voice, tablet, keyboard or some combination widens acceptance among physicians • End to lost wheel chairs, infusion pumps and patients (RFID) • provides rapid access to clinicians and staff

43. #9 Compensating for Workforce Shortages Supporting Technologies • Wireless and networked systems • Integrated medical records • Web-based systems • Access anywhere, anytime • Sensor-based devices for home care • External sensors, e.g., vest, pouch, wrist • Algorithm-based chronic and post-acute care monitoring

44. #10 Inpatient Cardiac Services Causes of lower operating margins for inpatient cardiac procedures 1. Payor push-back: employers and CMS hold down costs 2. Image of hospital and physician/patient expectations require painful choices to use technologies with negative margins (DESs, LVADs) 3. Rising salaries of nurses and techs

45. #10 Inpatient Cardiac ServicesShrinking • Competition from ambulatory cath labs, short-stay heart hospitals, and full-service heart hospitals • POC screening and imaging of patients with acute cardiac events in the ED avoids admission to observation or inpatient units • Improved cardiovascular pharmaceuticals • Catheter-based procedures replacing open operations for CAD, valves, ablations, etc.

46. Inpatient Cardiac Services # 10 Patients kept out of hospital by: • Implanted devices that avoid hospital admission: pacemakers, implanted cardioverter defibrillators (ICDs), LVADs, • New approaches to prevention: better treatment of diabetes, genetic predisposition testing, employer-based prevention and public education, premium discount • Effective disease management programs enabled by RPM, wireless transmission of information, personal robots, smart homes

47. Domestic Robots in the Home Intouch Health www.intouch-health.com

48. Inpatient Cardiac Services #10 Patients no longer admitted because of: • Non-implanted devices that allow treatment outside of hospital settings: extracorporeal ultrafiltration for CHF • Technologies to eliminate or modify unhealthy behavior: gastric banding, nicotine vaccines, liposuction • 30% of current CABG caseloads will migrate to PCI with drug-eluting stents and 90% of PTCAs stents will be drug-eluting

49. Inpatient Cardiac Services Shrinking #10

50. Incidence of Heart Disease ? Recent advances and trends: • BNP as treatment of CHF • Importance of inflammation, e.g. statins (Lipitor won this head-to-head study) • Potential of ApoA-1 Milano (now Pfizer’s for $2b) mimics function of HDL, dissolves plaque • Emphasis on pharmacogenomics • Greater use of generic drugs • Combination pills (Pfizer):Novasc/Lipitor, Lipitor/CTEP