Facilitator and Host: Peter Neupert, Corporate Vice President, Health Solutions Group, Microsoft Corporation
Keynotes: Dr. Kiyoshi Kurokawa, Chairman, Health Policy Institute, Japan
Panelists: Prof. Steven Boyages, Chief Executive Officer, Sydney West Area Health Service, Australia
S. Yunkap Kwankam, Coordinator, eHealth, World Health Organization
Li Baoluo, Vice Chairman, Chinese Hospital Information Management Association
Ryuichi Yamamoto, M.D., Ph.D., Associate Professor, Interfaculty Initiative in Information Studies, Graduate School, University of Tokyo, Japan, President, Japanese Association for Medical Informatics
Thursday, May 8, 2008
ANNOUNCER: Ladies and gentlemen, please welcome Corporate Vice President, Health Solutions Group, Microsoft Corporation, Peter Neupert. (Applause.)
PETER NEUPERT: Good afternoon. Now that we’ve all had a healthy lunch, we get to turn our topic to the conversation of health. We all understand and we’ve heard earlier today that health is a pressing need for all governments, rich and poor, developed and developing. I work for Craig Mundie. I rejoined Microsoft in September of 2005 to start the Health Solutions Group. It’s a commitment by Microsoft to invest in intellectual property and advanced capabilities to help bring solutions, and I really mean solutions, to the community that is working hard at trying to solve the challenges and opportunities in health.
We’ve heard earlier this morning about how health touches every citizen, whether they’re sick, whether they’re well, when they’re born. Health is something that is an important sort of human activity, and information technology can really help deliver better solutions, better results, better outcomes when properly used. I think we all also understand that health is a key ingredient. The quality of health, the affordability of health, the access to our health delivery system is a key ingredient to the sustainability and economics of most countries. What I don’t think we understand yet is whether it’s a precondition to a growing economy, or whether it’s a consequence. And I think that is an important conversation.
As Craig talked about in his talk, health is a big, complicated, interrelated topic. It’s an ecosystem between physicians and consumer, between physicians and funders, between the life sciences organizations. It’s impossible to make change happen without recognizing that its ecosystem attributes are key to what information technology, what solutions get deployed, and in terms of what outcomes actually happen. So I think it’s important as we have our conversation this afternoon that we recognize and understand the ecosystem attributes of the health system.
Everybody in the ecosystem understands or has hopes for the potential of information technology to transform and deliver new possibilities for better results in that ecosystem. Clearly in the last decade there’s been huge transformation in the delivery of medicine by the use of information technology, new diagnostic capabilities, new drugs, new possibilities, but we have even higher hopes for the role of information technology in the delivery of care. We all recognize that we can do a better job, and believe that information technology and software in particular is the key ingredient to us doing a better job. So we hope to have an interactive conversation, an illuminating conversation this afternoon to understand how information technology can help solve the problem.
So, with that, I would like to introduce Dr. Kiyoshi Kurokawa, who chairs the Health Policy Institute of Japan, which is an independent think tank, and who has been a distinguished leader in this space for a long time, and who most recently held the Global Health Summit with the Bill and Melinda Gates Foundation and the World Bank.
Dr. Kurokawa. (Applause.)
DR. KIYOSHI KUROKAWA: Thank you. I am honored to be here with you to a conference sponsored by Microsoft, the champion and leading business giant in the age of information technology, the technology which has changed our way of life in the last two decades in the most dramatic way in human history perhaps since the industrial revolution of the late 18th Century. But before I begin this, I would like to say again condolences, and also best wishes for Myanmar for the suffering of the great tsunami, and I just called the office, and the Japanese Government is now immediately going to transfer half-a-million, 50 electric generators already transferred, about 2,000 large tents already sent to Myanmar. But I think they have a cabin meeting today to discuss and also perhaps to decide, I hope, a larger sum for further support to the suffering. Thank you.
Incunabula is a Latin word, incunabula is a specific meaning of printed books between Gutenberg’s first printed Bibles to 1501, the year 1501, there were about 40,000 printed books during that some 50 years time. The reason the basic word for Latin is because it has a big meaning. He printed Bibles which allowed more people to read the Bible, and then what happens is there’s a lot of challenges to the teaching by the church. Enlightenment, and that triggered the end of the dark ages of Europe for many, many centuries, and which eventually led to religious revolution and then lead to the Renaissance, modern Western science.
So that shows you the power of dissemination of information to a greater public domain which becomes a threat and challenge to the establishment of that time. And that is the power of information, and the magnitude and scope of the Internet and the connected world is not comparable to any extent of any previous form of information and communication technology. That is the challenge. Government, whatever the history of each nation may be, and business establishment, or the authorities over the society feels threatened, because the public are empowered, even within the nation, or even across the nation in this connected world. The world has become flat according to Thomas Friedman, and this is a great challenge to the government, the establishment, and nations, and that is all we are discussing about in this flat world.
The healthcare is our common social capital or our common social good. Just like primary and secondary education, everybody needs that. No one wants to become ill, but that may happen any time, and anywhere to anyone. You may not think about disease immediately, but just think about accidents, injuries also require proper medical care, that’s the medical healthcare issue. The critical component of this healthcare, therefore, in any nation, anywhere, at quality, access, and cost, and who pays. What are the current status, issues and possibilities of information technology in healthcare? This is the focus of this session, and some specifics will be discussed by experts later on the panel, thus I shall try to be a bit different.
Over a millennia our ancestors primarily for survival, that means starvation and diseases. During this many years, they accumulated indigenous knowledge, shared such knowledge within their families, and small communities, and then this sharing becomes larger and larger, particularly since the emergence of so-called civilization in several different parts of the world. And, indeed, for the medical practice, Egyptians, Mesopotamians, Incas, and Chinese all civilizations have substantive knowledge pertinent to their own resources, available, and also with their wisdom and expertise.
But why then Western science and civilization have been so dominant in the modern world in which we live today? Please see perhaps a Pulitzer Prize Winning book by Jared Diamond, my former colleague at UCLA, entitled “Guns, Germs and Steel.” It’s a very insightful, interesting book. The human population therefore rose to 200 million, approximately, 2,000 years ago, and it took another thousand years to increase another 100 million, and then reach 500 million by around 1500. But then all of a sudden it accelerated to reach 1.6 billion a hundred years ago, and over the last 100 years it’s risen to 6.6 billion. It is projected to go to 9 billion by year 2050, amazing, this is a great achievement. Life expectancy, for example, 2,000 years ago was 25 years in most civilized countries, like the Roman Empire, because it had been very difficult to reach survival beyond the age of five because of starvation, nutrition, and diseases, many infectious diseases. It had become then 40 to 45 years old life expectancy. That means to gain 15 years of life expectancy took 2,000 years, and we reached that in many developing countries 100 years ago, the U.S., and the U.K., that was the life expectancy which took 2,000 years. But over the last 100 years, we gained another 40 years all of a sudden, and we’re talking about an aging society. Everybody expects to live 60, or 70, or 80, sometimes 90, so that is the reality of the world. It’s a great achievement.
But what would become of social systems made without regard to such unexpected sudden changes? Most notably, most of the dramatic development and progress has occurred in the last 100. Just think about 1905, that’s the first successful flight by the Wright brothers, over 10 seconds, for 40 meters. Now you are flying from everywhere over hours. Just think about 1905, Einstein thought about E=MC2, but 100 years later we are talking about nuclear power is a great stuff because it doesn’t emit CO2, just 100 years. How about health? Some of the hallmarks of this medical or health issues are, just think about Edward Jenner’s small pox vaccination, just 200 years ago. That’s a disease where once you contact it 50 percent dies, but once you survive, you never get it. He made a clear observation, and implemented.
The discovery then of various infectious disease and bacteria occurred towards the end of the 19th Century and 20th Century, and effective vaccination, and then the discovery of effective drugs, most notably penicillin in 1928, then Polio vaccine in the mid-1950s, and we are very safe from these deadly diseases. The discovery of DNA, double helix was 1953. In less than 50 years we have the human genome. Without any technical inventions, and computers, it would have been impossible.
Various medical and surgical procedures, including open heart surgery, organ transplantation, catheterization, brain surgery, more and more sophisticated lab tests, imaging technologies such as x-ray, CTs, Echo, and MRI, genetic analysis, stem cell research, gene therapy, just to name a few, only in the last maybe few decades. Many test tube babies are born, and even surrogate mothers. There are big challenges for our ethical values, but science and technology continues. The end of life, living will, do not resuscitate, euthanasia, these are some of the major issues. How can IT serve this disparity of this healthcare?
With a further growing human population, we face new challenges, based on energy intensive economies, and conventional capitalism. Global climate change, global climate crisis, water, and food, and natural resources shortage, extreme poverty, and disparity, we know it, because we live in a knowledge-based society, a crisis over human identity that may often lead to violence, and conflict, and on, and on. Even with this progress, that is the reality of the world.
Several millions of children die each year, just simply due to starvation, and many do not have even reasonable quality, or even access to a reasonable quality of water, and they ingest it, and many die of diarrhea, and pneumonia, and other diseases every year, millions die. On the other hand, the affluent community of society talk about obesity and diabetes, do you need doctors to do that, just simply watch your own body in front of the mirror, you know what to do, but simply you cannot do it. Can IT technologies do something about it? This is one of the major health cost burdens.
Fantastic cancer drugs, great, molecular biology, but who can get to them? Even in the United States doctors have to call insurance companies. HIV/AIDS, the first patient was seen in 1981, 25 years later we’ve lost already 20 million, still we have 35 million all over the world, and 70 percent live in sub-Saharan countries. What can we do about it?
A global market economy suddenly over the last 20 years, tends to widen this gap between those who have, and those who have not, and since the mid-’90s the Internet began to spread connecting the already widely disseminated use of tabletop and laptop computers. And Microsoft has been a champion in this new IT age. Then worldwide Web came into our life in 1992, and the rest became history of the connected world.
We live in a very well connected world, if you are not living in the digitally divided other side of the world, and that knowledge society, connected, instant and bilateral communications, verbal and visual. Mobile phones, everywhere, each day 1 million mobile sets are sold worldwide, e-mail, and that’s not going to the library that often anymore. But, the consequence of the rising awareness of human misery, and suffering of extreme poverty, and the inequality everywhere in the world, in the nation, and visual images, real visits, and contact through easier travel throughout the world have a significant impact on grasping the hurt of many. We feel empathy, we begin to see, can we do something about it. Now, that led the world into a new, and different dimension, various international efforts, but with new stakeholders.
In the year 2000, the United Nations launched the Millennium Development Goals, and there are eight goals sets published and reported in 2005, and four out of these eight goals are directly related to health issues. Global health has captured the global attention, recent movement further addresses various underlying, and associated factors like nutrition, and social issues closely linked to global health. Feeding is another challenge, and as you know the recent rises in crop prices are reflecting wider introduction of bio-fuels, hitting poor people hard. The issue can be stated as two Cs and three Fs, climate, change, fuel, food, and fear.
Of course, the national and the international efforts have been there. Many countries provide all ODA, overseas development assistance, and also through many international organizations, most notably the United Nations, and its various agencies, such as WHO, UNESCO, and also the International Monetary Fund, World Bank, Global Fund, regional development banks, and other major players. But, they came to be a top down approach on overseas aid, and often known to be ineffective and inefficient. But, changes have been happening over perhaps a decade or so of a new movement, which is due to a connected world, information technology, which is remember that incunabula. We are connected. More people are aware of these global issues, which I like to call globalization 1.0.
A distinct activity emerges in the developing world that is a civil society movement, with numerous NGOs, and more recently social entrepreneurship. I will call this movement globalization 1.0, and they are bottom up, and often maybe inefficient, but dedicated. It is of note that more than half of this large number of NGOs are led by women on the top. Why? Just think about it. Nobel Peace Prize in 2006 went to Grameen Bank and Mr. Yunus, micro-finance of very poor women, they became independent, and that is a wide recognition of social entrepreneurship. Now, this micro-finance system has been implemented in more than 20 nations. That’s a great achievement.
Another emerging movement is globalization 2.0, let me call it, it’s represented by philanthropy and foundations, most prominently represented by the Gates Foundation. More philanthropies and foundation addressing their focuses on poverty, and global health, and other global disparity issues, often being more effective as business-like, their engagement into these kind of global issues catalyze a top-down national, international policy, also with bottom-up NGO activity to this bottom-up NGO activity movement more effectively towards common goals. That has been a very helpful engagement into this, and also in the global economy. Many new billionaires have emerged in the global marketplace. And I think we are hoping many of them, hopefully, address their interests to those poorest billion, poorest billion, over the world, like the Gates Foundation does.
Another movement is a corporate social responsibility, or corporate global responsibility, which is I like to call globalization 3.0, where underlies intangible assets become one of the core values of a corporation. Stated in another way, corporate is valued not only by its shareholders, but in the global stakeholders of multiple managers. Corporate global responsibility may become a very important issue, again, Microsoft together with many other companies, become a champion of this globalized world.
Then what happens, the next stage of globalization, 4.0, is education. Now, primary and secondary education can be done with different ideas, just as we heard a little bit, or part of it in this morning, but that will be further advanced and spread out throughout the world, but particularly universities become a globalized, international village, for bright, young students throughout the world. And various programs, and courses are built to study this poverty, and global issues, and global health, in fact, I was told there are about 140 FTEs in the entire University of California system addressing global health and these poverty issues, and there are many opportunities to visit different arts of the world, like Africa, and South Asia, where poverty is one of the core issues of that area. And they become the future leaders, recognizing such an issue for them to challenge.
Such a development of a multi-stakeholders movement of the globalization 1.0 to 4.0, over the flattening world, may not have emerged, or developed without Internet, and IT technology, enabling many to see, and feel the reality of the world, encouraging more and more of various civil society movement, and the involvement in many communities, and countries of the world, to provide a better world for all.
Therefore, I’d like to make my sort of brief speech by making one concluding remark. I think this is a very interesting comment, which I found in the book by Lester Brown, who has been really advocating sustainability. And in his book “Plan B 2.0”, he said when I talked to him that this is not his own word, that he quoted it from somebody who said this thing. But, I don’t remember exactly who said that, but this means communism, communism has failed because it did not tell the truth on the economy. But, capitalism may fail, because it does not tell the truth on ecology.
So this ecology becomes one of the big challenges, whatever we want to work on, to enjoy our quality of life, and economic growth, and for the better world. I’d like to see how this social revolution, by information technology, could be utilized to make the world a better world for all, with your leadership, collective wisdom, and it is time for us all, and each to act.
Thank you. (Applause.)
PETER NEUPERT: Thank you, Dr. Kurokawa. That was very thought provoking. You demonstrate clearly the many challenges, and opportunities that we face, trying to think about health and information technology. And while IT might not by itself be the solution to obesity, as a self-proclaimed technology optimist, I actually think that it can make a difference. I do think technology can help change consumer behavior, with notifications, with information, with the ability to see further into the future, maybe we can help solve obesity, among many other things.
I’d like to bring the panel up. We’re going to have a diverse panel of distinguished speakers on this topic. I’d like you to think about your questions. I’m going to introduce them, then make a couple of brief remarks.
First, Dr. Yunkap Kwankam, he’s the E-Health Coordinator of the World Health Organization, and is responsible for the development of the WHO’s E-Health Evidence Base, and monitoring of best practices, please. (Applause.)
Dr. Ryuichi Yamamoto is the Chairman of the Japanese Association for Medical Informatics, a senior physician and academic from Japan, who has a broad view of all the healthcare IT initiatives across his country. Dr. Yamamoto. (Applause.)
Professor Steven Boyages is chief executive officer of the Sydney West Area Health Service, one of Australia’s largest health services, and has done some great work using software to build solutions, and is the king of acronyms, I learned earlier. (Applause.)
And Dr. Baoluo Li is a distinguished member of the Chinese healthcare community, and who has made significant contributions to the field of healthcare IT, and is the head of CHIMA. Dr. Li. (Applause.)
The good news is, as the only one who is not a doctor on the panel, I get to ask the questions, I don’t have to answer them. But, please, I hope you also prepare your questions.
Just a few brief remarks, since I’ve got my distinguished panel up here. I’ve spent the last 10 days in Australia, Singapore, Thailand, talking to hospitals, doctors, scientists, patients, government leaders, and I’ve seen a few common themes emerge. One of the common themes is the desire to leverage information technology, to connect communities, to connect physicians with patients, to empower physicians. Another common theme is a real desire to get more out of their investments in information technology, that there have been many investments that actually haven’t brought the value that people expected. So one of the topics that we want to talk about is how do we get more value out of the investments in information technology.
I saw a recognition, or I saw on the part of the people I was talking to a recognition that they need to move from custom environments, there are a lot of custom solutions in health, to more off the shelf environments, where we can share the learnings across communities, and across nations by investing in commercial software the way other industries have.
There’s a strong theme to empower consumers that, as Craig talked about, consumers may be the agent of change that will help us get control of healthcare costs, healthcare behavior. In each country, Australia, Singapore, Japan, Thailand, they all have efforts underway to build consumer health records.
Another theme I saw that was really, really insightful is that those successful hospitals, those that are delivering the best quality care are those that have done the best job deploying and implementing information technology. The ones that have learned to practically leverage information systems, they’re not all digital. Hospitals aren’t going to be all digital for a long time. But, they’re the ones that learn how to use today’s information technology in smart ways, to get real value out of it.
The last theme is, the leaders have learned that it’s not just about the hospitals where they have to leverage their technology, it’s investments, it’s how do they go beyond the walls of the hospitals. Each system is a little bit different, but hospitals are an important part of the care delivery system, but they’re just a part, they’re not the whole of it. So how do they leverage information technology, scale information technology to go beyond the hospital walls.
Kurokawa-san described the huge advances in the last decades that have been the result of information technology, the huge increase in lifespan, and yet the challenges that exist. But one challenge I wanted to highlight is frequently quoted by Dr. Lee Hartwell, who is the head of the Fred Hutchison Cancer Center in Seattle, and he’s made the point multiple times that it takes on average 17 years for science to be deployed as best practice in the health delivery system. This is in a time when we are accelerating our knowledge in health by big factors, and yet it takes us 17 years on average to deploy that and deliver quality care. We have to do better, and we hope that the kind of scale information systems can allow us to do better, not only in the developed world, but beyond.
Many see the potential for information systems to empower the physician, to empower the scientist, the citizen, but as Dr. Surin said, we need new paradigms of thinking. This potential of information systems has existed for a long time, and we haven’t gotten the benefits that we like. So it takes new leadership. It takes the combination of leadership at the ward level, at the hospital level, at the government level to really understand how to practically deploy information technology to get value, and that’s an important thing. So it’s about new paradigms, new thinking, so that we can get the benefits that information technology promises.
I think it’s important to think about why is it so hard to realize this potential, what are the factors that get in the way in the health ecosystem of getting the benefits of information technology that may or may not exist in other industries? One, it’s a hard problem at the clinical level, heterogeneous data, big data sets, lack of process. Another is that it’s fragmented, health data is scattered all over the place, most often on paper, which makes it hard to automate. Workflow processes aren’t consistent, aren’t standard. But I would argue some of it is cultural, some of it is institutional, how health is funded, how it’s delivered, how we have a history and a teaching profession that talks about really the independent practice of the physician, their ability to do it on their own.
In the United States, let me give you one example, in the United States we spend on the order of $40 to $50 billion a year between the NIH and the pharmaceutical companies trying to find new cures, new medical devices, new drugs, new ways to extend our lives. We spend less than a billion dollars on the science of how we deliver medicine, how we deliver healthcare. For most industries, that would be reversed. Most industries spend way more money on the application of intelligence in an engineering process than on core research, and in health we have it just the reverse, and we need to bring some of that thinking of science and engineering to the delivery of medicine to improve the outcomes, and really leverage today’s technology.
And so the challenge that I would like to turn to my panel is, is to find the right places to invest, the right ways to get value, the right ways to practically leverage in this hard problem, in this hard ecosystem, the way to get value out of information technology, and hopefully have an illuminating conversation. With that, let me turn to our distinguished panelists to talk about the opportunities and challenges, and places to start that they see. And Dr. Yunkap is going to be the first speaker. Please.
S. YUNKAP KWANKAM: Thank you very much, Peter. I deeply, truly appreciate this opportunity to be here today at this meeting organized by a valued partner like Microsoft. You all saw the video, which talked about making biomedical information accessible to clinicians and researchers in the underserved parts of the world. That’s a major program, indeed.
My job is to help the organization help countries bring ICTs to bear on the challenges that they face, and I really believe ICT is the third pillar of the health industry. The first was chemistry in the 19th Century, led to the pharmaceuticals industry; in the 20th Century we had physics, which lead to imaging systems and equipment. I believe ICT is the foundation of the knowledge-based health system. And you’ve heard many important things said here today about the value of ICT. So I will not repeat some of them. Let me just point out a few application areas, and I’ll end with a few challenges which can also be seen as opportunities for the IT industry.
Now we’re all aware that there’s a strong correlation between health worker density, the number of health workers per thousand population, and improvements in many of the indicators, including the Millennium Development Goals. Yet, the world today faces a major challenge. There’s a shortage of 4.3 million health workers around the world, a global shortage, 57 countries do not have a health worker density sufficient to deliver basic services. In other words, we will not meet the Millennium Development Goals if we do not do something about the dearth of health workers. Nine of those countries are in this region. In Africa alone, there are 36 such countries. The needs in each of those countries are for 3,800 new health workers per year for the next 20 years to be able to make up the deficit.
It’s clear that traditional means of educational delivery are grossly inadequate to meet these needs. We must be creative, and there are some promising experiences where ICT mediated forms of instruction have been used to try and make up this deficit. One example is in Brazil. In four years Brazil was about to train 324,000 nurse auxiliaries using e-learning. In Kenya, the skills of 22,000 enrolled nurses are being improved so they could become registered nurses. This is scheduled to take seven years using e-learning on the job so that their skills and services are still available to the clinics and hospitals in which they work. It’s going to cost somewhere around $2-1/2 million. By comparison using traditional means of educational delivery it would cost around $50 million. And this is the kicker, given the current capacity of that country, using traditional methods, it would take over 200 years to upgrade the skills of those 22,000 nurses.
In a country like the Seychelles, an archipelago of 120-plus islands, they have produced their first cohort of nursing school graduates without a brick-and-mortar nursing school by using distance e-learning in collaboration with an Indian institution. This just illustrates some of the potential that ICT and e-learning in particular have to improve the health workforce, the pre-service training that was mentioned earlier and, of course, it’s potential for in-service training as well.
That’s an infrastructure which you can use to train health workers, and can also be used to address the issue of health education for the public. If you look at the projections on what we’re going to be dying of through 2030, the first four is heart disease, stroke, HIV/AIDS, et cetera, these are remediable or amenable to interventions which are based on behavior modification of the individuals, and that infrastructure which you can use to train professionals can also be used to educate the public so that they take care of themselves.
So ICT is fueling the paradigm shift. Craig Mundie called it a Copernican shift that moves towards patient-centric, or citizen-centric health. It’s also a shift from narrowly focusing on curing diseases in health facilities by professionals to arming citizens with information and knowledge so they can help take care of themselves wherever they may be. So that’s just one of the potential areas.
The second area I would like to talk about is the area of the electronic health records. We all know the value of accurate, electronic health records, up-to-date information on patients when they come into a clinic. Now, this is not a luxury that’s only good for the advanced economies. Experiences around the world show that these have worked in places like Africa, in Latin America, in poor countries, Latin America, in Asia, this is something that we need to invest in, and it will reap significant benefits. Imagine that we can now, the technology exists, to create longitudinal conception to death records of individual’s health. Imagine the goal, the kind of knowledge mine that that represents if we could analyze this, and reap new information from this so that in the future when a child is born, we can determine what predispositions they have from the genetic background to what diseases, what conditions they’re subject, and try to do something about these. But that’s the good news, the great potential of ICT.
I would like to end with a number of challenges which also are opportunities for this technology. If you look at health as a production function, what determines good health? Well, it’s basic things, I think Dr. Kurokawa mentioned some, water and sanitation, food and nutrition, housing and shelter, education, and healthcare. Yet the large emphasis on the use of ICT is in that tiny sliver which is healthcare. It’s understandable in certain economies because the other conditions have been taken care of, there are no mass problems of water and sanitation issues, but in many parts of the world still there are issues of basic water and sanitation. Now, I challenge this audience to do something in using this technology to address these other influence pathways to good health.
The second area is equity. The world is only as healthy as the most unhealthy people. In terms of the outbreaks that could occur and rapidly spread throughout the world. So there is a great need for this technology to address the most under-served areas. Technology is a strange animal in that sense that while it raises entire averages, and I think the Secretary General of the ASEAN said this morning it also has real increasing disparities because the rich have a greater aptitude to absorb and use technology than the poor do. So we must address certain interventions to the poor to level that playing field, because we are only as healthy, as I aid, as the most unhealthy among us, or we’re only as healthy as the least healthy among us.
Finally, I would like to address another issue, that of prediction. Health systems like any physical systems have built in lags. Today’s interventions, for example, are in response to yesterday’s challenges, and will not show effects until tomorrow. And so we have to be able to predict where the next biggest challenge is going to come from in the health system, where the next outbreak is coming from. We must be able to do that so that we’re not acting as pathologists who do everything correctly, but a little bit too late. We need to be able to be pro active in the interventions that we have. I believe that accurately gathering information, and providing the solutions that help us analyze such information, structured information, using norms and standards, we will be in a position to be able to predict what health systems are going to be faced with in the near future, and start to put those interventions in place before they actually happen.
I think the future is bright, as I said, ICTs are the future. I believe we need to address these challenges. I thank you. (Applause.)
PETER NEUPERT: Thank you.
DR. RYUICHI YAMAMOTO: Now I introduce a short history of healthcare ICT in Japan. It begins at the end of the 1960s as the insurance claim maker. All Japanese people have more and more public healthcare insurance. Claim policies are summing up each healthcare action, such as suture, intramuscular injection, drip infusion, and so on. Healthcare providers much calculate many small amounts of claims for each patient. But these simple calculations, and simple if and else little judgment is nothing that the computer can’t do so well. And this kind of reductive simple computer system developed so quickly over 98 percent of all the clinics and the hospitals have this kind of system now.
As all other countries, because the cost of healthcare increased year by year, and the tax per illness is increased. Nationalization of healthcare, suppressing the administrative costs becomes an urgent matter for large hospitals in the 1980s, and the old entry system was developed. It was characterized as action point entry system. Insurance claim maker computer system is a backend system, so a patient usually is not aware of the system, but in case of the old entry system the computer came into the physician’s office. And medical staffs have to watch display, touch keyboard, and rolling mouse. But all that stuff, all the entry systems are only a transaction system, and replace paper requisition to electronic data, but that’s all. About 50 percent or more of doctors in Japan have old entry systems.
Two factors of ICT in healthcare in Japan, 1990s, one is the computer came to have more and more power; two is that the healthcare community needed more communication. Lab science advanced rapidly, day by day, and one healthcare professional could not manage a patient by himself only. Collaboration of intra and inter healthcare institutes was urgently needed. Paper-based data, or images are not suitable for faster communication. And developing an EMR, electronic medical record, began in the 1990s in Japan, but I think already you noticed it was not the easy way.
In 1999 the Ministry of Health and Welfare of the Japanese Government determined the requirement for paperless EMR. In 2001, also the Ministry of Health, Labor, and Welfare of the Japanese Government made a grand design for health ICT in Japan. And in 2006 the Japanese Government made a new IT reform strategy.
In January of 2006 the Government of Japan made a new IT reform strategy realizing a ubiquitous and universal networked society where everyone enjoys the benefit of IT. This strategy has several parts, and the first part is the structural reform of healthcare through IT. In June of 2006 the Government of Japan made the Action Plan 2006, and this action plan contains: Make new grand design for health ICT, which is emphasized in constructing the Japanese PHR; build a common infrastructure, introducing the healthcare PKI, secure networks, and healthcare smart cards; an ICT-based healthcare network, regional and inter-regional healthcare network gathering nationwide health data, and developing healthcare technology, and ontology; and finally, full online handling of insurance claims, which is the main target of the IT strategy.
I think full online handling of insurance claims is not the easy way, because the Japanese Insurance Claim Code is far too complex to build an online insurance claim system and, of course, there must be a secure and reliable network, which covers entire healthcare providers. Now, locally speaking, the new IT reform strategy of the health field is a kind of paradigm change, which is from healthcare institute-centered to people-centered. And this year three ministries collaborated on a project to try building a PHR infrastructure. The three ministries are the Ministry of Health, Labor, and Welfare, and the Ministry of Economy, Trading, and Industry, the Ministry of International Internal Affairs, and Communications.
In Japan ministries are so independent, and this collaboration was something miraculous, I think. This is a short history of Japanese ICT in the healthcare field. Thank you. (Applause.)
PETER NEUPERT: Thank you.
STEVEN BOYAGES: Thank you, Peter, and thank you for the opportunity of speaking here this afternoon. We are all leaders in this room, and the importance of leadership is to act. And a little bit of background about myself, I was an endocrinologist. Some of you, or many of you won’t know what an endocrinologist is. In fact, it’s actually a hormone specialist. And the hormone system is a great example of an ecosystem. It has stimulating factors, it has inhibitory factors, it has target glands, it has receptors, in other words receivers of information, it’s a very complex information system. But, its governing rules are simplicity.
Simple systems, or simple rules govern complex systems. That’s one of the key messages that we need to take away from this meeting over the next two days. What can we do to change the healthcare ecosystem that Peter talked about, because it is an organic system. One of the reasons that led me from being an endocrinologist, which I still am, to being a bureaucrat leading a large organization is I was tired of the industrial models, or the linear production models that were being applied to healthcare. It’s a complex, organic, ecosystem, and we need to understand that. To continue the metaphor, the ecosystem is under pressure. It is suffering its own climate change. How do we make it sustainable? How do we use ICT as a vehicle for that sustainability?
For example, in our own state of about 6 to 7 million people we spent 28 percent of the state’s budget on healthcare. If we do nothing we will spend the entire budget within 10 to 15 years on healthcare services. That is clearly unsustainable. So the question to all of us is not why we should be adopting ICT, or even what, there is a lot of what, the question is, what is the how, how do we go from today to a future tomorrow that has value for money, and that our politicians understand that value for money, and the value for that investment. That’s the challenge for all of us. So how do we transform, which is the theme for this conference.
I’ll put to you there are four key attributes to the success of a future ecosystem in health. The first is connectivity. By connectivity I mean connecting across settings of care, primary care, hospital-based care, baby care centers, primary healthcare centers, every setting of care, whether it’s the traditional setting of care, or big institutions, should be connected. We should have a man on the moon vision, or mission, of trying to connect each one of our healthcare settings within 5 to 10 years. That should be achieved, both in terms of space, geography, as well as in time. That’s one of the things that we’ve stressed, in terms of moving towards what we call real-time, or near real-time reporting.
The second plank that we should focus on, and a point that the as the first speaker raised, is in relation to our limited healthcare workforce. And that’s one of our key constraints. If we don’t address the issue of mobility in the healthcare workforce, and this is where technology can greatly assist, mobility within our facilities, as well as mobility across the different settings of care, and how we extract value for money out of mobility, then we won’t be doing our job properly. And that raises the issues of portability, user interface, connectivity though broadband, and wireless, and other technologies. So it’s a key issue, first around connectivity, second around mobility.
The third issue that you’ve heard about today, both in education and healthcare, is really about health information. This is the glue that actually binds the ecosystem. And traditionally as doctors we felt that we owned that glue, and we’ve heard about the Copernican shift in terms of moving that control, or ownership, or empowerment, or as I like to call it patient democracy, back to the patient. It will start to address many of the issues of privacy, security. There are still issues around authentication and access to the information, but we need to move down that pathway. And there are many parallels we heard from our first speaker about 500 years ago to the world of accounting.
The science of accounting as I understand it came into play because we wanted to document financial transactions. Similarly, we need a system to be able to codify and document clinical transactions in a very similar manner that was achieved 500 years ago, in terms of health information. The first point is connectivity, second point is mobility, third point is health information, and the issues of electronic medical records, electronic health records, personal health records, then arise.
The fourth issue for all of us is the transition, and how we manage that transition, and the points that you raised, Peter, around understanding how we do our work. And to our clinicians, although they’re very good technically, very few actually understand how they do their work, in other words, how we actually do our work, day-to-day, at the ward level, at the clinical level, at the hospital level, and how we bring it together. And the barriers to that are really people, understanding the culture, and how those issues can be addressed, understanding process, then how we actually understand partnership in that regard.
I think it’s a really important point to stress in terms of understanding those cultural barriers, to moving away from the analog world that we work in today, to a future digital information conceptual world. And Thomas Friedman has been quoted lots. The book that I like to quote from Thomas Friedman is “The Lexus and the Olive Tree,” which is really the Lexus representing globalization, and the Olive Tree is people’s attachment to place, and that they will fight over their place. That’s a really important lesson for healthcare that I see with our clinicians all the time. Yes, they love all the technology, they love all the information, but it’s potentially threatening, as well as disempowering.
So I might stop there, Peter.
PETER NEUPERT: Very good. Appreciate those comments.
LI BAOLUO: Thank you, Peter, and thank you Microsoft for providing the opportunity to introduce some of the general environment, and institution in China.
I come from China, and I have been working in the IT industry for more than 25 years. The IT applications in China actually, I’m the fourth generation maybe in China, it is a long story how to develop the applications in the hospitals, and as a part of the health industry to utilize IT.
I just want to introduce some general situations in China. I think the Chinese government faces very serious challenges for the healthcare delivery system. It’s so difficult to provide the healthcare delivery for the common population, especially for the rural and the poor populations, and the second is the too high cost of the healthcare service for the population. So I think it’s not just for the developing country’s problems, China is the biggest developing country, but it’s the same even in the developed countries, the United States, Japan, or Korea. So by now the hot topic is whether we can use the information technology to help the government to solve this hard problem.
In the past 20 years in China we believe we already got very great achievement in the IT applications. And each year the CHIMA, I’m the Vice Chairman of CHIMA, Chinese Hospital Information System Association, it’s very like the HIMSS in the United States. Each year we do our annual survey for the IT applications. Last year we got the responses from more than 1,000 hospitals. And I can give you some reports, the final reports, the final indicators from our survey. And how to understand and recognize Chinese IT environment, I think the key point, the keyword is unbalanced. Unbalanced means in China we have some very different areas, the economically developed area, and the developing area, the rich area, and the poor area. So the only hospitals providing responses to our survey yearly is hospitals located in the rich areas.
So far, the top-level hospitals already deploy the integrated management information system, for the third grade hospitals. We separate the total hospitals into three grades. The third grade is the top-level. And the total hospital number in China is about 18,000 hospitals above the country level. In the top-level hospital they already deploy the billing and accounting system in more than 90 percent, and the drug inventory control more than 92, in the ADT management system more than 72. So for the management information systems, the top-level, they already have very successfully installed applications.
In the top-level hospitals the big challenge is how to develop applications of the clinical information systems. But, for the low-level hospitals, they are trying to learn from the top-level hospitals how to deploy and implement their integrated management and information systems. For the clinical system, for the top-level hospitals, according to our annual survey, more than 20 hospitals have already installed the physician workstation systems, about 29 percent of the hospitals, they’ve already installed the live information systems.
We call it the physician workstation, in the United States they’re called the CPOE system. They’re a little bit different in all countries. Physician workstations includes the medical support systems. But, in the United States usually they include the alert system, reminder system, and other functionality of physician support. I can give you some simple, in China the top-level hospital, I have been working for this hospital, Peking Union Medical College Hospital as a CIO for more than 25 years, and three years ago this hospital already developed a mobile system, we call it the PDA nursing workstation system. So some sophisticated IT technologies have already been deployed in the top level of hospitals.
Using this mobile system, we can indicate several benefits the hospital can get. One is optimizing the work processes, improving work efficiency and service quality. And the second is preventing mistakes, and ensuring the patient’s safety better. The third is the two transmission modes sharing the information in the mobile situation, increasing real-time communication between the doctor and the nurses. And the fourth is the strengthening performance evaluation of the medical workers.
About the performance, you know, the doctor can save about the 60 percent of time, and to save looking for the doctor and the nurse, they can save 20 percent of time, they can save the collecting physicians’ signatures on information about 5 percent. To save the repeated information record saves totally about 40 minutes. So it’s a very successful application for a hospital. IT applications can promote the efficiency and the quality of healthcare definitely.
PETER NEUPERT: Thank you very much, Dr. Li.
So we have about 10 minutes left, and I would like to make sure that we get some time for questions. I see one question in the back, if we can get a microphone over there.
QUESTION: Hong Kong is experimenting with a healthcare system that will connect the private had public sectors. For example, we try to exchange patients’ records from the public health hospitals so that the private practice doctors can actually retrieve the patient’s record on a voluntary basis. That means it’s definitely authorized by the patient himself or herself. So in light of this, do you guys have any successful experience from other parts of the world?
PETER NEUPERT: Steven?
STEVEN BOYAGES: In New South Wales, we’ve been piloting an electronic health record which links private general practice with public sector hospital-based practice. It works, it’s an event summary. It’s a Web layer that sits on top of the actual content systems that contain most of the information. So it has information such as emergency information and basic clinical event summaries and contact information. The problem has been to date around the issues of privacy, whether it’s an opt-in or opt-out system. Seeking permission from the general practice private groups to participate in the system, and this is where I believe, like many others, that if we move towards a system where the patient holds their record or event summaries, then we can move away from some of that issue of demarcation and dispute. So that’s where we’re at at the moment in New South Wales.
PETER NEUPERT: And if I could just add to that, I’ve seen many of these both in the United States, and Australia, and other parts of the world. They are largely not so much a technical problem, as Steven was just describing, it’s more of a policy question, a business model question, who is going to pay for the community repositories. It’s sometimes the question who owns the data? It’s sometimes the question what privacy rules are in place for the benefit of the patient? And these policy questions are one that I’ve observed everybody recreates the wheel. There’s 50 different stats in the United States, I would say there’s 70 different community health exchanges going on, and each one of them is creating their own set of data sharing principles. They try to share, but because of sort of the provincial nature that Steven described, it’s very hard to copy the rules, if you will, from one institution to the next. So I think one of the things a Leadership Forum could do is to prevent the reinvention of the wheel of the types of policies for community sharing of health information, or perhaps ore accurately health data.
Are there other questions out there? There’s one coming, we’ll get the mike to him.
QUESTION: From the Ministry of Public Health, Thailand. What is the appropriate strategy for managing the national health information system in a country, because we have thousands of hospitals in the country with different applications, so do you have a suggestion for the appropriate strategy for dealing with the national health information management?
PETER NEUPERT: I let some of those that are actually doing it, and then I’ll follow up with some ideas.
S. YUNKAP KWANKAM: You might be familiar with a program called the Health Metrics Network, it’s published a framework that it urges countries to adopt. Basically that framework includes a data architecture which basically promotes the idea of local management of information, whatever you generate you use yourself, but also the idea of authorized access to that information by other instances within the health system. For example, the district level, the provincial level, the national level, and the development of tools which allow aggregation of this basic information. So this speaks to quality, because if you simply collection information among HMIS to be submitted to the central level, experience has shown that the quality is really poor. But if people actually use the information they collect for their own healthcare and local administration of health facilities, then the quality goes up. However, we lose, if we don’t allow access to other institutions, we lose that value which comes from being able to aggregate information from various sources.
PETER NEUPERT: And I would like to add, I think aggregated information is really valuable. Sometimes the concept of aggregated information or the concept thereof gets in the way of people’s belief and security in the system. And so you always have to balance the needs of getting the near-term product done, i.e., solving the short-term problem, and the benefits of the aggregate information. I frequently talk to folks and say, build the systems first that give confidence to citizens that their aggregate information isn’t going to get misused, that they actually have control over it, before you deal with the public health issues. That if we think about trying to get to just the public health issues first, that we may never get the system deployed. But if we take a step-wise, phase-wise approach, and build confidence as we have these community sharing records, then we can really get to the dream position of having these large aggregate databases for cancer research, for epidemiological research, for all other kinds of things. So I think that’s an important thing to keep in mind is that we need a phased approach, and a confidence building approach is probably the first phase along the way.
A second comment I would like to make just real quickly is, in a national health information approach, you have to recognize and deal with the facts of the matter, which are all your systems are different, and they’re going to be different for a period of time. And so you need an information architecture that deals with those differences as a fact as opposed to trying to wait for standards, and the deployment of standard software to begin getting started. And so I think there are information architectures that allow you to start with the facts, and do what Steven described doing, which is, oh, we can share patient identity and demographics, and we can share these data types, even if they come from fundamentally different systems, there is technology today to allow that sharing in a very cost effective way, and I think there’s a high value in doing that.
I think we have time for one last question. Any more questions out there? Then I will try to wrap up so that we can stay on time. It’s a long day of interesting conversations. I would like to point out something that I heard from all of the panelists, and from Kurokawa-san’s speech, and that is really the need, there’s the stress on this ecosystem, but the fundamental need that seems to come out, whether you’re trying to solve the health worker density I’ve never heard the health worker density problem, that’s a great way to put it and the need to improve the productivity as Dr. Li talked about, the productivity of our existing health workers as one way to increase the health worker density, and the ability to not only increase individual productivity, or increase individual training ability, or increase individual consumer, we need an approach that increases the system’s capabilities.
As Steven was talking about, it’s about how do we think about it as a system so that there are repeatable processes, and that’s what other industries have done. I think it’s this leadership shift that takes a paradigm change of how do we build a repeatable process, whether it’s in training, whether it’s in the actual delivery of healthcare in a complicated system, or whether it’s how do we build systems of care between hospitals and clinicians, and chronic disease management, or population aggregate disease management that we can build these systems to get those benefits. And that’s both the opportunity and the challenge.
I would like to thank my distinguished panelists, and for your audience participation. Thank you. (Applause.)