DISRUPTION! Relevance, Impact & The Road Ahead for Health Care

THE FUTURE OF Dr. Farzaneh Sabi, Associate Medical Director Mid-Atlantic Permanente Medical Group 1 Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing (ACCME) through the joint providership of Washington Regional Transplant Community (WRTC) and the District of Columbia Association (DCHA). WRTC is accredited by the ACCME to provide continuing medical education for . WRTC is accredited as a provider of continuing education by the California Education.

2 The Future of Hospitals

Education is the passport to the future, for tomorrow belongs to those who prepare for it today.

Malcolm X

3 The History of “Hospitals”/Medical Facilities

Ancient Egypt, Greece, Temples not only served as a place of worship but also as a center for physical healing.

18th Century – “” Voluntary Hospital Movement Royal Infirmary,

19th Century – Public and systems emerge Nightingale Introduction of medical and nursing schools

4 The History of Hospitals – 20th Century

Early 1900’s – the introduction of incubators for premature babies and the beginning of the Neonatal

1960’s – Coronary Intensive Care Units offering continuous cardiac monitoring

1966 – Duke University offers consultation to physicians in developing countries via the radio

1968 – The first “Hospital Information System” The system routed back and forth orders placed by physicians to other departments in the hospital. Monmouth Medical Center, New Jersey 5 The History of Hospitals – 20th Century

1970 First Freestanding Ambulatory Center in Phoenix, Arizona

1980’s and 1990’s – Era of Laparoscopic Surgery

1990’s – Age of the Internet and Electronic Medical Records 2000s “Meaningful Use” of EMRs

2001 Lindbergh Operation – Remote Robotic Cholecystectomy in New York City (French and Canadian Surgeons) – in Strasbourg Civil Hospital in Challenge, time delays between control and operating ends 6 Trends in Total Joint Replacement

From 15 days To 1 day in an in the hospital Ambulatory Surgery Center

Health services research Trends and determinants of length of stay and hospital reimbursement Confidentialfollowing kneeand Privileged and hip Information replacement: evidence from linked primary care and7 NHS hospital records from 1997 to 2014 Vaginal Hysterectomies, Same Day Discharge

The Decreasing Length of Hospital Stay following Vaginal Hysterectomy: 2011–2012 vs. 1996–1997 vs. 1995–1996 Geburtshilfe Frauenheilkd. 2014 May; 74(5): 449–453. Confidential and Privileged Information 8 Advancements in

Surgical Aortic Valve Replacement Transcatheter Aortic Valve Replacement Valve crimped onto balloon and advanced through catheter to heart Valve deployed by dilating balloon to inflate valve in aortic annulus

Inpatient Length of Stay: 6 to 11 days

Length of Stay: 1.4 to 2.3 days

Procedure performed under MAC, no ICU stay. typically ambulating within 4-6 hours after the procedure.

9 Overnight Sleep Studies  at Home Sleep Studies

10 Transformation from Hospitals to Patients as the Center of the Medical Universe

11 Resource Optimization and Venue Management “Care at the Right Time, in the Right Location”

Clinical Hospital Clinic Telemedicine Decision Unit

Outpatient Ambulatory Hospital Procedure Clinic Surgery Center Suite

Confidential and Privileged Information 12 Comparison of Number of Hospitals and Ambulatory Surgery Centers: 1970 to 2016

Source: American Hospital Association Annual Survey 2018; Data through 2016 Confidential and Privileged Information 13 Transition from Hospitals to Medical Office Buildings

Kaiser Permanente’s First Oakland Hospital State of the Art, Technology Based Kaiser Permanente’s South Baltimore County Medical Office Building

Confidential and Privileged Information 14 Urgent Care / Ambulatory Observation Units

Advanced Imaging Clinical Decision Unit Laboratory Services

Pharmacy 15 Ambulatory Surgery Centers

16 Declining Number of Hospital Beds

Source: American Hospital Association Annual Survey 2018; Data through 2016 Confidential and Privileged Information 17 Differing Capacity per Population

Beds per 1000 by State, Comparison 2015 to 2016 State 2015 2016 District of Columbia 5.34 5.06 South Dakota 4.66 4.71 North Dakota 4.21 4.30 West Virginia 3.72 3.72 Pennsylvania 2.92 2.90 New York 2.67 2.66 Florida 2.62 2.61 New Jersey 2.23 2.33 Delaware 2.23 2.16 Virginia 2.13 2.13 Maryland 1.96 1.92 California 1.79 1.79 Hawaii 1.85 1.74 Washington 1.67 1.66 Oregon 1.68 1.63

Source: American Hospital Association AnnualConfidential Survey and Privileged 2018; Information Data through 2016 18 Consolidation of Hospitals in Health Systems

Source: American Hospital Association Annual Survey 2018; Data through 2016 Confidential and Privileged Information 19 Consolidation of Hospitals into Health Systems

20 National Health Expenditure Trends $3.3 Trillion in 2016 $10,348 per person 17.9% of Gross Domestic Product

Projected to grow at an average rate of 5.5% per year, and reach $5.7 trillion by 2026.

Confidential and Privileged Information 21 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2016.zip Health Care Out of Pocket Expenses Mirrors Exponential Growth in Overall Health Expenditures in the United States

Confidential and Privileged Information 22 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2016.zip Growing Out of Pocket Costs for Health Care Health care expenses account for anywhere from 6% to 16% of a household’s expenditures on an annual basis. Not surprisingly, the impact is greater with older Americans.

Household Expenses Household Expenses Household Expenses 18 – 51 Years Old 52 to 70 Years Old 71 + Years Old 6% on Health Care 9% on Health Care 16% on Health Care

Confidential and Privileged Information 23 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2016.zip If we as an industry don’t find a solution, others will.

Confidential and Privileged Information 24 Mergers and Acquisitions

Dr. Atul Gawande

25 Rise of the Consumer Voice

26 Care in the Right Place at the Right Time

Respite care, guardianship, long term care

27 “People in the United States spend a lot of money at the end of life. In fact, about one quarter of all Medicare spending goes toward care for people during their last year of life. Beyond this shockingly high number, we know that end-of-life care patterns and spending vary widely across hospitals and communities. For example, although about 1 in 8 elderly persons living in Utah die in the hospital, the number is nearly 3 times higher for those who live in New York.”

Innovation and Technology

Confidential and Privileged Information 30 31 The Future of Hospitals 1. State of the art, technology based centers for high intensity and high acuity care. Fewer, but better. Care in the Right Place, at the Right Time, in the RIGHT location. A center of the ICU’s – neonatal, pediatric, medical, surgical 2. Same level of services 7 days a week. 3. Integrated system of image, lab, and information sharing among all hospitals and systems. 4. Non-hospital based solution for long term care. 5. Regulations catching up with the industry Recognition of Telemedicine Support for appropriate venue of care (surgical or medical)

32 Musical “Rooms”

Emergency Department Intensive Care Unit Med-Surg Room

Telemetry equipped rooms, move supplies and services to the patient and their family rather than the patient and their family to the room.

33 Labor & Delivery & Recovery & Postpartum ☺

34 Confidential and Privileged Information 35 Same Level of Services Seven Days a Week

Confidential and Privileged Information 36 Data Sharing Platforms

37 Network Adequacy?

Confidential and Privileged Information 38 How do we fit into our patients lives, rather than make them fit into our schedules?

Brick and Mortar

Next available appointment

Waiting Rooms

Confidential and Privileged Information 39 Regulations

40 The best way to predict your future is to create it! Abraham Lincoln

Our Time, Our Responsibility Thank you 41 History of Hospitals: https://www.electricscotland.com/history/medical/medicine8.pdf "The eighteenth century voluntary hospital movement" (PDF). Retrieved 23 September 2016. Porter, Roy (1999) [1997]. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. New York: W. W. Norton & Company. pp. 316–17. ISBN 978-0-393-31980-4. • Neonatal Intensive Care Unit; Autor: k1026a • November 7, 2012 • Essay • 545 Words (3 Pages) • Duke University Medical Center Archives- Project MED-AID https://archives.mc.duke.edu/blog/project-med-aid • https://www.hcsinteractant.com/about-hcs/health-care-software-history/ • Collen M.F., Miller R.A. (2015) The Early History of Hospital Information Systems for Inpatient Care in the United States. In: Collen M., Ball M. (eds) The History of Medical Informatics in the United States. . Springer,

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