Stanford Medicine 2017 Health Trends Report Harnessing the Power of Data in Health

June 2017 Stanford Medicine Foreword from Dean Minor

Today across the world, enormous to better understand the most important transformations are taking place in trends and gain insight into the health care. future. We interviewed industry experts to better understand those trends and Demographic, economic and technolog- how they envision the future of medicine. ical changes are forcing us to reconsider And we spoke to our own faculty to better everything about health care, from its understand their work and how it fits into delivery to its funding models, from the wider picture. patient’s various personalized education to scientific innovation and monitoring devices, whether they be from the role of the physician to the What has become very clear from wearables or home devices, can now role of pharmaceutical companies, the findings in this paper is that be interpreted to identify trends and payors and patients. the greatest force behind these markers of future disease. trends is data. Like the rest of the world, health care is But that is just the start. Among many becoming increasingly connected but Whether it is health wearables or things, data will change how doctors, also increasingly complex. This poses on-demand testing, better hospital health care teams and institutions like both an opportunity and a challenge to software or algorithms capable of catching Stanford partner together, how cost is institutions like our own whose job it is to disease more effectively, rapid change is rationalized to increase accessibility heal, innovate and educate. taking place because of increased access and, most importantly, how we protect to big data and advanced data analytics. patient privacy and maintain patient That’s why, given all of these forces If this continues – and we firmly believe it trust. We do not expect to provide all shaping health care, I am very pleased to will – doctors will need to learn new skill the answers here. But we do hope it’s introduce Stanford Medicine’s inaugural sets that, in turn, will require changes to the start of a lively debate and, if you Health Trends Report. education and learning. As Kleiner Perkins’ have any feedback or thoughts, I’d be Mary Meeker stated in her recent Internet delighted to hear them. Our aim in producing this Report is to draw Trends Report, “health care is at a digital together the key trends facing the health inflection point.” We couldn’t agree more. I hope you find the inaugural care sector and by doing so inform and But what role will big data play? Health Trends Report valuable. educate patients, doctors, governments and other members of the medical We at Stanford Medicine believe in a vision community about the opportunities and of health care – Precision Health – that is challenges that lie ahead. If there is one more preventive, predictive, personalized thing we can confidently predict about and precise. By leveraging big data and Lloyd B. Minor, MD the future, it’s that the trends we have scientific advancements while maintaining Dean identified in this paper will upend our the important doctor-patient bond, we Stanford University School of Medicine thinking and revolutionize patient care. believe we can create a that will go beyond curing disease after To produce the Report, we undertook a the fact to preventing disease before it comprehensive review and analysis of a strikes by focusing on health and wellness. wide range of existing open-source data For instance, the data gathered from a Stanford Medicine Executive Summary

The future of health care is being Data is permeating every component of When it comes to the road ahead, it will shaped dramatically by a number of the health care ecosystem: be absolutely vital that all players in the significant trends. • : Access to new, di- health care community, in both private verse data and open datasets are fueling and public sectors, come together to With the cost of care on the rise, the drug discovery and making clinical trials overcome several challenges: industry is experiencing a shift toward and research more efficient. • Rising costs: Spiraling costs across the preventive and value-based care. At the • Daily life: Wearable devices, online U.S. health care system could nullify the same time, technology like wearable diagnostic tools and genetic sequencing additive role data plays. devices, at-home testing services and services hold the promise of better • Data sharing and security: Silos and telemedicine are empowering patients informed and engaged patients. roadblocks prevent effective data shar- to be more engaged with and proactive • The patient experience: Health ing but, at the same time, privacy and about their own health. Meanwhile, the systems are investing heavily in security of patient data is paramount. industry is grappling with the tension technology, including machine learning, • Policy and legislation: Data privacy between encouraging data sharing which is proving as effective as or more and interoperability must be addressed to maximize the benefits of data and effective than human diagnosticians. at a legislative level to create a maintaining patient privacy and trust. • Ongoing care: Telemedicine and health regulatory environment that encourages All of these developments are altering apps make it possible for physicians innovation and research while putting the role of physicians and their relation- to see patients virtually, outside of patients first. ships with patients. traditional facilities for increased access • Electronic medical records (EMRs): and tailored care. Frustrations with the design of elec- Behind these trends is one fundamental • Prediction and prevention: Health tronic medical records undermine the force driving health care transformation: data is allowing doctors to build better physician-patient relationship. the power of data. patient profiles and predictive models • Skills and training: Without proper to more effectively anticipate, diagnose infrastructure and a data-literate clinical and treat disease. workforce, health data can only be collected and stored, not leveraged fully. • Encouraging preventive health care: Reliance on reactive health care will hamper physicians’ ability to anticipate, diagnose and treat disease.

A focus on data in the coming years has the potential to make health care more preventive, predictive and personalized, meaningfully reduce health care costs and lead to better patient outcomes. Stanford Medicine Table of Contents

Introduction 1 Data’s Impact on Health Care 2 Medical Research 3 Daily Life 5 The Patient Experience 7 Ongoing Care 9 Prediction and Prevention 11

The Road Ahead 12 Rising Costs 12 Data Sharing and Security 12 Policy and Legislation 14 Electronic Medical Records (EMRs) 14 Skills and Training 15 Encouraging Preventive Health Care 17

Appendix 18 Stanford Medicine Introduction

quality of care and cost of care. At both A number of important trends are On the front lines of this change, the individual and population level, shaping the future of health care. As human capital needs are shifting as data is helping us reach new frontiers the cost of health care continues to technological advancements and in how to treat patients, improve climb, in the U.S. alone health care artificial intelligence transform how outcomes and achieve new solutions. spending has outstripped inflation by care is delivered. Cybersecurity is top a 5:1 ratio over the past 10 years.1 As a of mind in an era of sophisticated In the Report that follows, we’ll share result, we are seeing a shift toward targeted cyberattacks, while industry the key trends in health care and the encouraging preventive care through experts are pushing for more open way in which data is revolutionizing the an increased focus on nutrition, data sharing infrastructure to gain industry and our view on how to best exercise and wellness, and a pivot faster, broader insights into public foster and embrace this change. toward value-based payment models. health. Meanwhile, the rapid increase in corporate partnerships and VC Along with the widespread use of funding in the sector are accelerating online resources such as WebMD change at a powerful pace. that sees 212 million unique monthly visitors,2 the increased use of wearable Behind these key themes lies an devices and at-home genetic testing important common thread: the services are leading to a generation of power of data and its potential to empowered patients who are taking fundamentally transform the future increasing ownership of their health of health care. far beyond the walls of their doctor’s office. And on the horizon, the use of Information is becoming easier to telemedicine is widely expanding collect, analyze and understand, access to, and convenience of care opening the door for major advances across the globe. when it comes to preventive care,

1 Stanford Medicine Data’s Impact on Health Care

The last decade has seen major advances in the production and collection of data, as well our ability to effectively analyze and understand this new information. Big data Daily Life is helping every industry become more efficient and productive – and health care is no exception.

Today, data is a powerful force driving health care forward. The year 2016 reinforced the impact data is having on all The Patient aspects of the health cycle. Notably, the Ongoing Care Medical Chan Zuckerberg Initiative announced a $3 Research Experience billion investment over the next decade to find solutions to cure, manage and prevent diseases. Rather than spending only on scientific research, significant funding is going towards bringing together scientists and engineers. The research and output produced will be open data for physicians Prevention & and researchers. In addition, the initiative Prediction will seek to improve communication chan- nels between key sector stakeholders.

The government has also been involved in data changes in health care. The Center for Medicare and Medicaid Services (CMS) has implemented innovative policies that put data at the center of health care. The of entire health care systems – currently prepared to push the bounds even further implementation of accountable care preventing the medical community from to improve health care faster. organizations seeks to maximize not using data to its full potential. only care quality but also interoperability In this Report, we look at data’s impact and consistent patient records. Further- The growth seen in medical data (by some throughout each step in the health care more, it has released care estimates 48% each year), computing cycle: from medical research, to daily life, ratings to increase transparency power and technical ability are enabling to the patient experience, to ongoing care, for patients and physicians. the medical field to reinvent itself in ways to prediction and prevention. never before possible. Medicine has made In 2017, we see the need to overcome tremendous strides over the past century, existing barriers – whether they be upcom- but with the influx of big data, some ing policy changes or security breaches observers believe the field of medicine is

2 Stanford Medicine Data’s Impact on Health Care

Medical Research Startups, tech companies, universities, hospitals and public institutions are Medical research is among the areas in joining forces to maximize the benefits health care where the power of big data of big data in health. Leaders like IBM has had the most visible impact. We’re bringing together Watson and Memorial Sloan-Kettering are diverse kinds of data that collaborating to develop treatment plans we haven’t had available for cancer patients.6 Meanwhile, Microsoft Today and the University of Pittsburgh Medical to us before that will help Center are partnering to improve the Medical researchers and physicians have us address questions delivery of health care.7 As hospitals face access to vast amounts of data that did about care and about the more data challenges, these partnerships not exist five or 10 years ago, including determinants of health. allow the medical community to leverage socioeconomic, environmental, biomed- - Stanford Faculty the expertise of technology leaders on ical, molecular and genetic information, critical issues like data governance, IT staff along with individual health statuses, and data science. behaviors and outcomes. Recent open data initiatives such as the City Health Case Study: Critical New dashboard3 have dramatically increased Partnerships the types of publicly-accessible data, allowing researchers to pose new ques- Advancements in genomics and Verily-Stanford Medicine-Duke School tions, uncover new findings (such as new gene-sequencing have led to the creation of Medicine: Efforts like Verily’s Project treatments being developed for malaria4) of large volumes of diverse datasets for Baseline are being pursued in an effort to and validate breakthrough hypotheses. drug discovery. In the past few years, we gain a broader understanding of health. have witnessed the successful use of big Spearheaded by Alphabet’s life sciences data across the full drug discovery process, unit Verily, Project Baseline will collect accelerating the rate at which researchers comprehensive health data from 10,000 develop new products. This approach participants over four years in collabora- is currently being used to identify new tion with Stanford and Duke to build a map People are actually treatments for Parkinson’s.5 of human health and disease. thinking about data now. A decade ago most And the findings are not only drawn from Apple: Launched in 2015, Apple’s “traditional” medical data. Experts are ResearchKit is an open-source software of these practices were using new sources to structure clinical framework designed for iOS devices to running on paper, and trials more efficiently, reducing the cost collect genetic data and medical test the fact that there is this and length of time needed to conduct results for use in medical research and data is really interesting, medical research. With advanced analytics diagnostic apps. In aggregate, the data and people will now and accessible databases, researchers gathered from Apple’s vast user base think about, ‘Hey, what seeking participants for clinical trials can makes for a powerful resource for now harness the power of data to identify medical research. else can we measure in patients with specific conditions and the a quantified way that most effective sites for recruiting. hasn’t been measured?’ - Industry Expert

3 Stanford Medicine

The Future Experts point out that true progress can only take place with a proper biomedical Experts agree that over time, big data Data is fundamentally research infrastructure in place, and will become even more essential for changing the research moreover, one focused on collaboration, medical breakthroughs. Many envision enterprise and creating interoperability and data governance. a future of ongoing data collection via multiple sources. For example, a patient’s new extraordinary So how will data circulate in the future? electronic medical records (EMRs) will opportunities to learn Experts foresee a loop of data generation be combined with data captured from things that were either with two potential outcomes. A closed- wearables and genetic testing. un-learnable or would loop process is already taking place today, have taken generations. in which information passes through a two-way channel between the patient - Stanford Faculty and the company capturing the data. This Consumer-Level system gives the patient information about Genetic Data their health while simultaneously affording the company data to analyze. EMR Data Wearables The sheer volume of health care data Data is growing at an astronomical rate: 153 In the future, experts aspire to an exabytes (one exabyte = one billion open loop system that allows the data gigabytes) were produced in 2013 and an generated to feed directly into medical estimated 2,314 exabytes will be produced research and fuel new discoveries. With in 2020, translating to an overall rate of the potential to replace many studies increase at least 48 percent annually.8 typically conducted in labs, big data will be positioned to revolutionize the process of medical research as we know it. Holistic Image Growth in Health Care Data of Patient

2,314 Exabytes By gathering and analyzing all of this data, [Tech companies are] researchers will be able to replace some collectively envisioning traditional studies conducted in labs. a closed-loop system in which information from a health system combined with information from the patient, all their wearable Those troves of information, digitalized information become the images, their genome foundation for biomed- and millions of other tests ical research… We are 153 that they’ve had, can be beginning to reconstruct Exabytes combined with brilliant the relationship between informatics algorithms to 2013 2020 genes and life and health produce right back at the in ways that are likely to bedside highly important be transformative. Source: International Data Corporation (IDC) clinical advice. - Stanford Faculty - Stanford Faculty 4 Stanford Medicine

Estimated growth in direct to Daily Life Today consumer testing market

Long before patients enter their The popularity of wearable devices, such $350M doctors’ offices, data is connecting as pedometers and heart rate monitors, their day-to-day lives and behaviors is exploding. Experts predict that health to tangible health outcomes. In three and fitness technology will see record U.S. primary areas, the health care sector sales in 2017, with 35 million units in sales.9 is already making noticeable strides Global sales were estimated to be as high outside of the doctor’s office: as 274 million devices in 2016.10 Among • Wearable devices continuously collect consumers, fitness bands are the most patient health care data popular type of wearable, and people cite $15M • Direct-to-consumer testing, including health as a top motivator for using the new genetic tests wearable technologies.11 2010 2020 • Access to online research and medical informational websites Source: Kalorama Information

ExpectedParents Impactbelieve an of incr Wearableease in we Technologyarable technology can improve their: This market growth reflects a desire for Health 85% on-demand care at more affordable prices. As with wearables, the increased demand Tech Proficiency 80% for at-home testing demonstrates that Parenting 77% patients are deliberately choosing to be Productivity 77% more actively engaged and empowered by E iciency 70% taking greater ownership of their health. Relationships 64% The internet continues to empower Stress Level 61% patients by providing easy access to health information. Traffic patterns on sites like Source: PwC, “The Wearable Life 2.0” MayoClinic.com and WebMD.com show that patients are curious and eager to The desire to understand individual health better understand and take control of Top reasons to have and take control of it is already prevalent. their health. According to the Department a wearable device As consumers continue to experiment with of Health and Human Services, as of 2003 new technologies, they will be more likely “over a third of U.S. adults would [have] to adopt innovative iterations of wearables difficulty with common health tasks, such 83% that link the data produced directly to as following directions on a prescription medical professionals, including doctors drug label or adhering to a childhood and researchers. immunization schedule.”13 However, Thermoelectric pulses to heat, cool, and consumers are now seeking to change soothe your body via a bracelet that senses Various types of testing, including digitized that. According to analytics company temperature, pain, and stress glucose tests, blood pressure and genetic Quantcast, WebMD sees over 25 million testing, are allowing individuals to take daily visitors, and the site is among the control of their health without requiring 50 most-visited sites in the country. While interaction with doctors, insurance health literacy remains an important issue % 82 companies or pharmacies. According to address, experts agree: in today’s world, to a report from Kalorama Information, individuals begin their personal health the direct-to-consumer testing market is journeys through at-home online research The ability to track your child’s health, expected to grow from $15 million in 2010 rather than a visit to the doctor’s office. safety, or location via wearables to $350 million by 2020.12

Source: PwC, “The Wearable Life 2.0” 5 Stanford Medicine

The Future A majority of people would be While the market is currently dominated excited to experience wearable by recreational technology and fitness As current trends continue, health care technology from the following: companies, there’s a market opportunity data will eventually permeate many for health care organizations to enter the aspects of a person’s life, where activities wearable market by delivering FDA-com- and behaviors are constantly tracked and pliant, HIPAA-compliant devices producing linked back to the medical community. medically robust and relevant data.

Some experts suggest that invisible or While experts are optimistic about a implanted wearables will become the future of empowered patients, it will be norm and will create continuous streams incumbent on patients to prioritize their of data and health tracking, while at-home 65% own health literacy. As consumers are testing will help detect diseases in a more doctors given access to more health data, it will targeted way. For instance, research become part of the physician’s role to from Stanford Medicine has shown that help interpret the troves of information wearable devices can use biosensors to at their fingertips. detect symptoms of possible illness, such as Lyme disease.14 In a future of wearables and testing, patients will no longer need to feel physical illness to prompt them to seek medical attention. The promise of wearables is in the ability to detect and therefore treat illness at an earlier stage.

Soon, medical centers, rather than tech 62% and fitness companies, will become the hospitals de facto providers of wearables. In fact, a majority of people already agree that they would be excited to experience wearable technology from a doctor (65%), from a hospital (62%) or a health insurance company (62%).15

62% health insurance companies

Source: PwC, “The Wearable Life 2.0”

6 Stanford Medicine

The Patient The Future

Experience More and more providers EMR Technology: As EMR technology are spending hours becomes even more ubiquitous, experts What happens once a patient walks into dealing with things to hope that the industry continues to the doctor’s office? Today, patient visits champion interoperability to expedite the stereotypically involve long wait times, get all the data into the potential for better patient outcomes. scant physician face time and inaccessi- system, so the extent to ble personal health records. All of these which we can make the Case Study: Kaiser Permanente’s challenges are interconnected and are data collection easier and Investment experiencing change today. the speed in which the provider gets that data Kaiser Permanente has created a program called HealthConnect that unifies health turned around to them is Today records across its system. Since 2013, the an issue. program is already credited with $1 billion We have already seen significant invest- - Industry Expert in cost reduction across the system. ments in technology to optimize physician data usage: nearly all (96%) hospitals in Changing the Diagnostics: Algorithms the U.S. have traded paper records for with machine learning capabilities are online portals16 designed to help the proving as effective as or more effective doctor track testing, imaging and visits than human diagnosticians, including and give patients access to information Physician Time Distribution cases such as spotting cancers in without necessitating a call or fax to the During Office Hours 18 test results.19 In fact, recent research doctor’s office. conducted by Stanford Medicine found that algorithms can “match the perfor- Although the technology is generally mance of dermatologists” at detecting viewed favorably, there are significant skin cancer.20 There is significant potential challenges and the technology imple- % for catching more diseases at earlier mentation has not been as successful as 49 stages, thus increasing the likelihood of expected. While some medical systems successful treatment. are already realizing cost efficiencies 33% of electronic medical records (EMRs), Industry experts say medical decisions a recent study found that physicians are now being based on more robust spend more time on desk work than with statistics. For a growing number of people, patients. This suggests that, in fact, EMR 21% there is now sufficient longitudinal data technology is not reducing paperwork and from their entire lives, which allows providing more time with patients,17 but medical experts to answer questions merely changing the type of desk work that about a patient’s health based on more physicians are responsible for. than just global or national statistical averages. In time, physicians will be able to identify benchmarks that are defined by a EMR and Other Clinical patient’s specific health history, as well as Desk Work Face Time community health standards. 49% 21% 33%

Source: American Medical Association and Dartmouth-Hitchcock health system

7 Stanford Medicine

Case Study: IBM Watson New Health Care Roles: Not only will National governments are also increasing doctors require stronger data analysis their investments in personalized IBM is developing an interface that would skills, but the physician’s office will need medicine, with France recently committing allow Watson to analyze existing medical to add new roles to its roster. As machine €670 million to personalized medicine and research on any given topic, then synthe- learning becomes a growing component genomics research.24 size and summarize the information for of health care, specialists in data science, the doctor. The intention is to help doctors governance and IT infrastructure will quickly determine the best treatment become vital to the practice or health options for an individual based on the vast system. Industry analysts predict that 30 amounts of data available. percent of providers will use cognitive analytics to interpret patient data by The reason for which The New Doctor: As data continues to 2018,22 which will require specialists to personalized medicine define the health care space, physicians help implement these new technologies. is possible is because will be required to understand technology you have access to that to properly take advantage of new tools Personalized Medicine: In the near massive data that is being at their disposal to make data analysis future, the doctor may also choose to use analyzed; and as you more useful. Many predict educational personalized medicine as a treatment programs will be designed to better train option by tailoring medication regimens analyze it, you therefore doctors in quantitative skills, statistics and to a person’s unique genetic makeup. This understand what is likely data analysis. This is already taking place is done by integrating a person’s genetic to be the medical profile with increased interest among medical blueprint with data on their lifestyle and of a certain individual students studying the field of public environment, and evaluating it alongside and are able to dig much health, who are focused on connecting an array of patient blueprints to predict deeper into what are his health policy with data. illness and determine the best course of treatment. Some analysts estimate risks and what are his Stanford Medicine has responded to this the current of size of the personalized ideal treatments if he’s need to better understand datasets by medicine market to be at $1 billion, with already suffering. investing in its Biomedical Data Science expectations that it will reach more than - Industry Expert Initiative,21 which provides formal support $2 billion by 2022.23 to the study of complex datasets.

Global personalized medicine market by product 2012 - 2022 (USD Billion)

Many of the medical students are getting Masters of Public Health, in fact, some of them 1,007.88 instead of PhDs. You have concrete evidence that datasets are now considered ripe for 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 evaluations. PM Diagnostics PM Therapeutics - Industry Expert Personalized Medical Care Personalized Nutrition & Wellness

Source: Grand View Research

8 Stanford Medicine

Ongoing Care both convenience and customer service in an increasingly time-constrained industry After a doctor visit, health care continues. and society. Moreover, telemedicine is Telemedicine is an Patients must cope with diagnoses, tack- increasing access to health care for under- example of a system that le prescriptions and develop new health served communities. Given the high costs really works… That’s an care habits. Technological innovation is of building hospitals and health centers, enabling new types of care beyond the telemedicine is being used to alleviate some example where modern traditional patient experience, leading to of the demands for access to physicians in technology has made a novel types of data creation. rural areas with no proper health facilities. huge difference. - Industry Expert Today The rapid adoption of telemedicine as a service shows the value of the technology:26 Telemedicine, or the remote delivery of health care through technology, is being used today in a variety of ways Growth of Telemedicine Case Study: Stanford Medicine’s and for a variety of reasons. Already, Technology ClickWell Program Google, Verizon and AT&T have ventures in the telemedicine space, along with a Through Stanford Medicine’s telemedicine rising number of insurers and startups program, called ClickWell Care, patients in the space. According to research firm 2016 can choose when and where they meet IHS, the market is expected 1.2 million with their health care providers, whether to grow from $240 million in 2013 to virtual2016 visits in-person, over the phone or via video 25 1.2 million $1.9 billion by 2018. virtual visits conferencing. A year after the program started, an estimated 55-60% of clinic Providers withHospit Programsals visits were handled virtually.27 Expected Growth in Hospitals Telehealth Market Case Study: Novartis Foundation 72% $1.9B 72% The Novartis Foundation uses telemed- icine to reach patients who do not have Physician groups access to traditional health care facilities. They connect with patients remotely Physician groups in sub-Saharan Africa to treat cases of 52% hypertension. Their work has expanded to the point where they now provide 52% telemedicine services to an area with an estimated population side of 1.5 million.28 The percentage of large employers o ering telemedicine benefits $240M The percentage of large employers o ering telemedicine benefits 2013 2018 48% 74% Source: IHS Technology 48% 74% 2015 2016 Telemedicine has recently been accelerat- ed by new technologies. For one, it allows 2015 2016 for a more continuous “concierge” style of virtual care. This level of care solves for Source: American Telemedicine Association

9 Stanford Medicine

The Future However, with fewer barriers to medical support, patients may be more proactive Experts expect that technology and in seeking health care, which would in It’s very expensive infrastructure enabling telemedicine turn result in healthier communities. to expand a hospital will continue to improve, and tech Experts acknowledge limitations to system – there’s a lot of companies will help make these systems telemedicine technology and recognize increasingly user-friendly and effective. that many studies of telemedicine effec- infrastructure, personnel, Telehealth is also expected to take tiveness remain inconclusive, particularly etc. But if you do it advantage of the global adoption of as it relate to the ability for doctors to through telemedicine, smartphones, with some estimates collect sufficient patient information via you increase the reach of anticipating half of the global population digital meetings. However, all agree on your referral base, that’s 29 to have smartphones by 2019. the inevitability of the technology and a fairly inexpensive way see great potential in this service. Among those with steady access to to go. There are economic health care, ongoing care will mean fibers to telemedicine. on-demand access to professional - Industry Expert opinions without the inconvenience of travel or time. The average American will only see their doctor four times a year, less than many other OECD countries.30

Annual Average Doctor Visits Per Person in Select Countries

Japan 13.0 Telemedicine is going to be really important Germany 9.7 in terms of how doctors relate with patients in a Canada 7.4 way that is more efficient France 6.8 and doesn’t require them necessarily to come into Australia 6.7 the office as often. UK 5.0 - Stanford Faculty USA 4.1

Source: Statistia

10 Stanford Medicine

Prediction and Case Study: Chan-Zuckerberg more data on healthy people (rather than Initiative exclusively on the sick) allowing for earlier Prevention detection of disease. In September 2016, Mark Zuckerberg and How can we better harness data to Priscilla Chan announced their decision Emerging technologies make it possible to predict and prevent disease before it to donate $600 million to form a new, routinely evaluate risks for each individual strikes? Experts agree that health care as independent research organization: the patient based on their genomics. Currently, we know it is primarily reactive in nature Chan Zuckerberg Biohub. This ambitious this is reserved for select cases, but as – people tend to seek care, get tests and collaboration between Stanford, UC San genetic testing technology becomes more monitor their health only in response Francisco and UC Berkeley aims to engage common and affordable, experts predict to a problem. However, the medical in research projects with the goal of testing will become routine for all patients. community is trying to shift from reactive developing and applying the technologies In addition, innovative wearable technol- care to proactive and preventive care. that will enable doctors to prevent, cure or ogies currently in development will ensure manage all diseases during our children’s that detection will take place beyond lifetime. formal testing. While most “smart clothing” Today today is fitness oriented, innovators in Case Study: Stanford Byers Center the sector are working on applying the An effort to prioritize prevention is on for Biodesign technology to early detection of diseases. the rise, with universities, startups and For example, the “smart bra” by Cyrcadia non-profits participating in the effort. The Stanford Byers Center for Biodesign is Health uses photoacoustic imaging to At-home genetic testing companies developing a number of predictive devices detect early breast cancer. such as Color Genomics and 23andMe to prevent disease before it strikes. These are contributing to this effort with their innovations include a monitoring device genetic testing kits that allow individuals that predicts pediatric asthma attacks to better understand their genetic days before they occur, a cost-effective predispositions. Non-profits such as the test for the genetic causes of heart disease Foundation for Health in Aging and the and a rapid non-invasive test for potential Giving people the tools Preventive Medicine Research Institute heart-transplant rejection. to enable them to make are increasingly focused on educating and changes in their screening preventing disease, rather than simply Since 2011, nearly $2 billion has been combatting them after they have already invested to fund health care companies and health care and hit. Companies like IBM, Google, Medtronic that use predictive analytics in health prevention approach is and Merck are developing predictive care,31 and we expect to see this trend one of the highest return devices to be integrated into daily life. continue in the coming years. impacts you can have in This thriving ecosystem is contributing public health today. to a future that is more preventive, predictive and personalized. The Future - Industry Expert

Experts expect it won’t be long before health data allows doctors to build more accurate patient profiles and predictive models to more effectively anticipate, diagnose and treat disease. Another outcome of increased monitoring will be

11 Stanford Medicine The Road Ahead

The opportunities presented by data The U.S. faces health care costs that the number of hospital readmissions, in health care are immense, but so continue to increase year over year, for instance. Data must be leveraged to are the obstacles the sector faces as it outpacing inflation.33 Experts fear that identify areas that can lead to significant evolves. To move forward, the following increasing costs will continue to crowd out cost reductions, and experts must trans- challenges must be addressed: budgets at all levels, from state and federal late that data into actionable solutions governments to the private sector. that yield healthier outcomes and lower • Rising costs overall health care costs. Moreover, if we continue to promote an open, collabo- • Data sharing and security rative data environment, the financial burden associated with medical research • Policy and legislation and development can lessen significantly The premiums for resulting in industry-wide savings. • Electronic medical records (EMRs) employer-based insurance are going Skills and training • up. The copays and Data Sharing and deductibles have gone • Encouraging preventive health care Security up faster than salaries. The private and public sectors must You are finding families How can data sharing be encouraged work closely together to overcome these struggling, businesses across the health care sector to facili- challenges, listening to and engaging struggling, state, local tate medical research and pharmaceu- with a range of voices across stakeholder and federal governments tical research and development? At the groups to ensure the solutions consider same time, how can we improve data all individuals and communities who struggling. If health care security and protect patient privacy? will be affected. costs continue unabated, they will bankrupt A tension lies at the heart of the new age potentially families and of health care. On one hand experts agree Rising Costs some governmental that infrastructure and policies encour- aging the sharing of data are essential institutions, or crowd How can payors, medical systems, and to maximize the benefits of big data. On the technology sector combat the rising out many other kinds the other hand, the health care sector cost of health care? of spending. has become a target for cybersecurity - Stanford Faculty attacks and concerns exist when it comes Experts recognize the cost of health care to protecting patient privacy. The industry in the U.S. is a unique challenge. Among must resolve how to harness the full industrialized nations, the U.S. spends a Managing health care costs will require potential of big data by sharing it to benefit disproportionately high amount of money collaboration from all sector stakeholders. public health, while still ensuring patient on health care – in fact, more than twice While government may be able to subsi- information remains safe and secure. the OECD average. 32 dize drug prices, it cannot directly impact

12 Stanford Medicine

Willingness to Share Data New Threats to Privacy and Security Individuals are willing to share personal information to increase the While patients’ willingness to share data The U.S. Department of Health and Human amount of data in the health care space. is encouraging, the medical community Services reports that three in four (75%) Surveys show that patient willingness must focus on patient privacy and security of all the health care breaches involving to share data is particularly high when in order to maintain trust and access to 500 or more individuals are the result of it comes to information from passive voluntary patient data. deliberate hacking.35 monitoring devices:34

Patient Willingness to Healthcare Breaches Reported to HHS Share Data Involving 500 or more Individuals Cause of Breach by Number of Affected Individuals

vital statistics like % blood pressure or 84 basic lab tests 75%

14% 1%1% Hacking/IT information from a 5% 75% special monitor that’s been 4% 75% swallowed to track internal organ health Theft 14%

Loss 5% health information collected % from a “smart toilet” 70 Unauthorized Access/Disclosure 4%

Unknown 1%

47% health records Other 1%

Source: Intel Health Barometer Source: US Department of Health and Human Services 13 Stanford Medicine

The threat to privacy and data security However, there is a consensus that policy fact, EMRs were at the top of a recent list has grown more pronounced since the interventions are necessary to confront of ideas to transform health care in a STAT “WannaCry” malware attacks in May 2017, many of the health care challenges we face news survey of 425 practicing physicians which targeted the British National Health today and to realize the promise of data and health care leaders.36 Service and medical device companies in and new technologies. the United States. Policy often does not move fast enough Best Ways to Transform Health Care Experts agree that striking a balance to keep up with innovation. Legislative between effectively sharing and protecting bodies will need to address data privacy, medical data will be challenging – but that interoperability and collaboration to achieving this is critical to maximizing the create a regulatory environment that 1. Improving electronic health records and related technologies to enhance future of care. Finding the optimal solutions encourages innovation and research, while the experience of patients and will require private and public sectors, protecting patients and accounting for their clinicians payors and patients to collaborate. other stakeholders’ best interests.

2. Restructuring physician work-life to promote better self-care and work-life balance, especially for physician parents in dual-career families While we’re mindful of [In] our country and most security and privacy, other countries, the pol- 3. Reorganizing the funding of medical education to diminish burdensome debt we need to leave open icymakers are struggling for early-career physicians systems that can link with and have prioritized different pieces of data so the question, of ‘How do 4. Placing more emphasis on identifying we can learn from them. you deliver great care for emotional intelligence in medical school Anyone who imagines a lower amount of annual admissions that we can have both health care spending?’ It’s perfect privacy and great a universal aspiration. 5. Modifying systemic factors (e.g. science just doesn’t get it, - Stanford Faculty reimbursement, medical malpractice) because we won’t. that impede genuine, multidisciplinary team-based care that will unburden - Stanford Faculty physicians

Electronic Medical 6. Rebalancing the funding and focus of graduate medical education to produce Records (EMRs) more primary care physicians and fewer Policy and Legislation hospital-based specialists How can the current EMR systems be What are the policy or legislative made more user-friendly, clinically solutions that will help to facilitate useful and interoperable? What are the 7. Enhancing the reimbursement of solutions to these challenges? roadblocks to improvement? physicians who focus on health maintenance and primary care A significant level of uncertainty permeates EMRs are one of the most visible aspects of the health care policy landscape, with the the increasing proliferation of data in health 8. Accelerating migration away from final composition of health care legislation care. Unfortunately, their potential has yet utilization-driven fee-for-service care not yet fully determined. As a result, experts to be fully realized and many experts that to so-called “value-based care” are cautious about making predictions have used EMRs express frustration with about the future of health care policy. the systems that have been designed. In Source: STAT News survey

14 Stanford Medicine

Individuals who use EMRs report many Skills and Training different frustrations, including complaints about the effectiveness of the user The biggest problem with How can university systems and interface, as well as interoperability them is that they don’t continuing physician education evolve issues.37 In particular, EMRs undermine talk to each other and their approach to train a more tech-sav- the doctor-patient relationship and the they’re almost useless for vy and data-literate clinical workforce? personalized attention that patients need. In their current form, they are time the patients. That is, if I’m Maximizing the potential of data in health consuming, prioritize billing codes over in California and I’m in a care will require two key components. patient care and function more as a tool car accident, nobody can First, it will require a data-literate for legal record-keeping than a means for get my [EMR] without my workforce that can understand how to doctors to glean meaningful insights. giving permission. manage, analyze and interpret complex data. This will be especially critical - Industry Expert as efforts to facilitate and manage interoperability continue. Secondly, organizations must make investments in infrastructure, analytical tools and data People are spending For one, EMRs could incorporate basic governance solutions. Today, organiza- more time with the box diagnostic support functions that simplify tions can collect vast amounts of data, and less time with the physicians’ jobs, enabling them to focus but insights cannot be drawn if they lack more acutely on treating the whole the technical expertise to interpret it or patients… They’re talking patient. They could also be redesigned proper tools to analyze it. to the patient, but facing in new ways that serve both patients and the box, because they doctors, for example, by making effective feel they’ve got to get use of voice recognition software. EMRs Talent this information into the could also benefit from adjustments to computer. other steps in the process. For instance, Experts have identified a talent gap in employing a medical technician who the health care sector. Today, there is a - Industry Expert accompanies the doctor during clinic shortage within the system of profession- visits and inputs data into the EMR, which als with expertise in data analysis or is what Stanford Medicine’s new Primary data science. Care 2.0 program does. Experts also express frustration with EMRs’ failure to deliver on a core purpose: EMRs are central to the increasing use of the ability to connect one patient’s data data in health care, but more needs to be seamlessly across different clinics and done for technology to realize its potential hospitals. Platforms not only need to otherwise the one-size-fits-all approach We don’t have the talent be smarter and more doctor-friendly, will continue to cause frustrations for to be able to keep up with but organizations must agree to create doctors and patients alike. the rapid changes that platforms with similar data infrastructures that will make combining datasets easier. are occurring in machine learning and artificial intelligence… there’s a whole new set of jobs emerging around a health care tech skillset that is very different than it was even just 5 years ago. - Industry Expert 15 Stanford Medicine

The job market has recognized the Infrastructure and Tools Organizations that lack the tools to need to attract data-savvy talent. analyze data will only be able to collect According to Glassdoor,38 the “Best Job” In addition to staff, experts believe that and store it, but they will not be equipped for 2017 is “Data Scientist,” with “Data health care organizations will need to interpret the data to improve patient Engineer” and “Analytics Manager” also to invest in the appropriate tools and outcomes or influence public health. among the site’s top five. infrastructure to effectively manage data.

Best Jobs in America It’s very easy now to buy st Data Data doesn’t do you any a toy that will convert Scientist good until you can turn it everything you do all day 1 into information, and that into one or another bit is really our challenge. of data, and it’s easy to nd DevOps - Stanford Faculty download that data into Engineer little apps that you can 2 look at … But has any of it been subject to the kind The health care sector lags when it comes of analysis that would rd Data to infrastructure and analysis. Research 3 Engineer from Deloitte identifies several ways that change your behavior? the health care sector has failed to adopt Not yet. effective data management strategies:40 - Stanford Faculty th Tax 4 Manager Lack of Effective Data Management Strategies th Analytics 5 Manager

Source: Best Jobs in America in in in The sector must adapt and find ways 4 5 1 3 1 4 to incorporate these roles into health care organizations. organizations surveyed health systems report health systems report This shift in the health care sector will do not have an that they do not know that they do not have create growing pains. Almost a third of integrated strategy for their organization’s total a data governance health care IT providers report that they using analytics spending on analytics model in place have been negatively impacted by staffing challenges, and that those challenges relate to difficulties recruiting qualified staff and the development of their skills.39 Source: Deloitte

16 Stanford Medicine

Encouraging A study published in the Journal of General Internal Medicine found similar findings: Preventive The issue is not that you the research showed a cost reduction of Health Care don’t know that you over $3,700 for patients that experienced should lead a healthy the care transition intervention. 44 How can patients be encouraged to lifestyle and maintain an change their behavior to reduce health care costs over the long-term? ideal body weight and Healthcare Costs per not drink too much or Person in the 6 Months A greater focus on preventive care could smoke… it’s how do you After Discharge, Adjusted* potentially reduce the overall cost of get people to actually health care and positively impact many of do that? That is going to Inpatient the other underlying issues that result in Readmission poor health care outcomes. continue to be a central Costs challenge. How do you While a preventive, proactive care change health behaviors? Control $11,671.00 approach is not a cure-all to reducing - Stanford Faculty Group health care costs,41 experts have identified certain areas where early interventions can reduce costs over the long term, including HIV treatments and programs to prevent With $8,011.00 42 Preventitive the onset of diabetes. Intervention Already, there is a notable rise in case Effective behavioral changes will be manager roles, non-medical employees paramount to realize the potential of who help patients – particularly senior Gross $3,660.00 preventive care. Experts can identify patients – take medication, make Savings potential uses of large datasets to design and attend appointments and refill preventive health care strategies (such as prescriptions. Aetna is one company using socioeconomic data to identify links proving the benefits of new health Source: Journal of General Internal Medicine between economic conditions and health care roles. Through a program that care outcomes) but these links will mean “embeds” nurse case managers in little if the behaviors they identify cannot physician offices, Aetna saw 45% fewer As accountability continues to be a weak be changed in patients. hospital admissions, and per-member point,45 these case manager roles will cost reduction between 16.5% and extend beyond the elderly to help ensure 33% for members in the program.43 better adherence to health programs.

17 Stanford Medicine Appendix

1 “Medical Cost Trend: Behind the Numbers 15 “The Wearable Life 2.0: Connected living in a 30 “Americans Visit Their Doctor 4 Times A Year. 2017,” PwC, 2016. wearable world,” PWC Consumer Intelligence People in Japan Visit 13 Times A Year,” Forbes, Series, 2016. September 2014. “Inflation, consumer prices for the United States,” Federal Reserve Bank of 16 “Adoption of 31 “The Future of Personalized Health Care: St. Louis, 2017. Systems among U.S. Non-Federal Acute Predictive Analytics,” Rock Health, October Care Hospitals: 2008-2015,” ONC/American 2014. 2 “WebMD focuses on content, social media as Hospital Association Annual Survey Informa- users flock to mobile,” MobiHealth News, tion Technology Supplement, May 2016. 32 “Health Costs: How the U.S. Compares With August 2015. Other Countries,” PBS, 2012. 17 “Allocation of Physician Time in Ambulatory 3 “Visualization Takes Open Data to the Next Practice: A Time and Motion Study in 4 33 “Medical Cost Trend, Behind the Numbers Level,” Government Technology, June 2017. Specialties,” Annals of Internal Medicine, 2017,” PwC Health Research Institute, June December 2016. 2016. 4 “Open data in drug discovery and development: lessons from malaria,” Nature, 18 “Study: Physicians spend nearly twice as much 34 “Intel Healthcare Innovation Barometer,” Intel, August 2016. time on EHR/desk work as patients,” AHA December 2013. 5 “New technologies are accelerating drug News Now, September 2016. 35 “Health Care Breach Charts,” Davis Wright development, bringing hope to patients,” 19 “How Big Data Keeps Transforming Health- Tremaine LLP Privacy and Security Law Blog, Elesevier, June 2016. care,” LinkedIn, May 2017. March 2017. 6 “Memorial Sloan Kettering’s Expertise 20 “Deep learning algorithm does as well as 36 “Why are doctors burned out? Our health care Combined With the Power of IBM Watson dermatologists in identifying skin cancer, ” system is a complicated mess,” Stat News, is Poised to Help Doctors Make Better Stanford News, January 2017 December 2016. Treatment Choices,” Memorial Sloan Kettering

Cancer Center, January 2014. 37 21 “Biomedical Data Science Initiative,” Stanford “We asked people how to fix EMRs, and boy Health care IT News, 7 news, July 2015. did they have answers,” “Microsoft partners with UPMC, launches May 2017. patient engagement, population health 22 “Worldwide Semiannual Cognitive/Artificial initiatives,” Healthcare IT News, February 2017. 38 Intelligence Systems Spending Guide,” IDC, “Big Data Experts in Big Demand,” Data Center September 2016. Knowledge, May 2017 8 “The Digital Universe of Opportunities: Rich Data and the Increasing Value of the Internet 39 23 “Personalized Medicine (PM) Market Analysis “2017 HIMSS Leadership and Workforce Sur- of Things,” EMC Digital Universe with Research By Product (PM Diagnostics, PM Therapeutics, vey,” Healthcare Information and Management and Analysis by IDC, April 2014. Personalized Medical Care, Personalized Systems Society, February 2017.

9 Nutrition & Wellness) And Segment Forecasts “U.S. Consumer Technology & Sales Forecasts 40 To 2022,” Grandview Research, June 2016. “Health System Analytics: The missing key to 2012-2017,” Consumer Technology Association, unlock value-based care,” Deloitte, September May 2016. 24 “France Plans to Invest €670M in Genomics, 2015.

10 Personalized Medicine,” GenomeWeb, June “Gartner Says Worldwide Wearable Devices 41 2016. “Does Preventive Care Save Money? Health Sales to Grow 18.4 Percent in 2016,” Gartner, Economics and the Presidential Candidates,” February 2016. 25 “World Market for Telehealth – 2014 Edition,” New England Journal of Medicine, February HIS, January 2014. 2008. 11 “The Wearable Life 2.0: Connected living in a wearable world,” PWC Consumer Intelligence 42 26 “How Telemedicine Is Transforming Health “Economic Benefits of Preventing Disease,” Series, 2016. Care,” The Wall Street Journal, June 2016. United States Surgeon General, January 2015.

12 “We Can Improve At-Home Lab Tests - Here are 43 27 “How Stanford achieved 60% telehealth “Payer-Provider Collaboration in Accountable 3 ways direct-to-consumer testing can better adoption at a primary care clinic,” The Care Reduced Used and Improved Quality U.S. News & serve consumers’ health needs,” Advisory Board, March 2016. in Medicare Advantage Plan,” Aetna, Health World Report, June 2016. Affairs, 2012. 28 Novartis Founda- 13 “Telemedicine Factsheet,” “The Health Literacy of America’s Adults: tion, 2016. 44 “Is Implementation of the Care Transitions Results from the 2003 National Assessment of Intervention Associated with Cost Avoidance Adult Literacy,” U.S. Department of Health and 29 “Google designed Android Go to win over After Hospital Discharge?” Journal of General Human Services, 2003. the next billion smartphone users in the Internal Medicine, March 2014. Quartz, May 2017. 14 developing world,” “Wearable sensors can tell when you are 45 “How Doctors Rate Patients,” The Wall Street getting sick,” Stanford Medicine, January 2017. Journal, May 2014.

18 med.stanford.edu/healthtrends