Tag Archives: innovation

Dx + Tx = Ix


Integrated treatment is an important step in service innovation, and it is no less important to see how the convergence of diagnostic technologies and methods with treatment methods will lead to integrated, one-stop encounters.  This is more than an integrated provider, but the development of theranostics (therapy/diagnostics), which combine what in the past have been discreet clinical steps into a single diagnostic and treatment encounter.

We are still developing methods here, but in the image guided surgery is an example. The ability to bring together disparate knowledge, currently spread across different brains (i.e. experts) into a single brain will create new clinical professions, shift knowledge from higher levels of expertise to others who delivery services augmented with machine intelligence embedded in the devices. These sorts of development disintermediate clinical workflow, to use disruptive terminology, but reintegrate the clinical workflow in new ways, this time around the patient, rather than the clinician.

Importantly, the diagnostic bottleneck which health systems find causes waiting and delay is likely to be largely eliminated for a wide range of procedures, as at the point of diagnosis, treatment would also be provided. With improved detection methods, too, this treatment will start sooner — we are still learning of the clinical benefits of bio-conjugated quantum dots, and biosilicon, and other new materials, but they are likely to underpin a new health service delivery paradigm.

The equation in the title simplistically represents the shift toward integrated therapeutics, which in the end may be the biggest next step in medicine since discovering germs as will germs came specialisation and the burgeoning of clinicians and expertise, coupled with the universities in creating specialist bodies of knowledge. Ix, integrated care, builds on integrated knowledge (IKnow?) which is something we are slowly appreciating as the problems we face effectively challenge the narrow disciplinary models we see at university and in clinical practice.

The question though is whether policy and decision makers will be bold enough to face up to these opportunities or will vested legacy interests prevail?

Best technology first

Proton Therapy

An announcement in the past year that the UK’s NHS would be expanding the availability of proton therapy — a 40 year old technology — does make one wonder. Of course, proton therapy is pricey for the underlying technology, but its precision and better beam control adds benefits when one moves beyond a simple cost model (proton therapy suites run around $125 million or so) to whole system thinking.

Isolating the costs of particular pieces of equipment leads to a tiering of diagnostic procedures, use of protocols around narrow areas of diagnostic accuracy, and ensure that patients will experience simpler technologies first before progressively better diagnostic accuracy is needed; in effect the patient is forced to endure uncertainly as the clinical decision system moves to the more certain, but less available technologies.  MRI technologies provide more certain diagnosis, and a quicker diagnosis can lead to starting treatment sooner, or importantly, ruling out further treatment.

My view is that by using the best technology first, the whole systems costs of diagnosis, treatment, patient time, clinical on-costs, and waiting, anxiety, etc. can be bundled more tightly together. This eliminates wasting clinical time through duplication of procedures, but using different technologies each time. The advantage of more advanced technologies like the MRI is also reduced exposure to radiation (which is more likely with combinations of x-ray and CT as steps along the clinical diagnostic pathway.

Hospital as Nexus of Innovation

Alex Kosmas's nexus

Alex Kosmas "nexus"

The ERRIN innovation event, The Hospital of the Future, 2 March 2010, explored the future of the hospital as a recipient of financially and environmentally sustainable investment.

The key outcome for me, as one of the moderators of the event, was the emerging view of the hospital as a major innovator within their local/regional economies.

Hospitals are both producers of knowledge and consumers of it. They in effect sit on two sides of the great chasm that separates a great idea with its commercialisation — this chasm is fondly referred to as the ‘valley of death’, and many good small start-ups go there to disappear and their potential benefits lost to society.

We may not think of hospitals in this particularly entrepreneurial manner, but perhaps within their social mandate to provide healthcare, they may be one of the few institutions that are best suited to be research translators.

There is much concern about the general poor ability of universities to commercialise their research. Perhaps we should focus our efforts elsewhere — universities are not really consumers of what they produce; indeed, they can be seen as some of the least innovative institutions in modern society, reforming slowly, adopting novel approaches to teaching as a leisurely pace, and often quite disconnected from the real challenges facing policy makers and decision-makers on a day to day basis. They were innovative when they were invented, but times change (for a take on this see Louis Menand’s The Marketplace of Ideas, reviewed in The Economist)

For healthcare, it may be more sensible to concentrate on building entrepreneurial capacity with institutions that are heavy consumers of innovation, in effect to pull the bench-side research to the bedside, rather than continue to try to turn academics into real-world entrepreneurs.

That means of course that consumers of research need to be freed up to be more innovative and entrepreneurial in order to accelerate the research translation process. Hospitals seem to me to bring together key elements to achieve that goal better than we may have realised and that therefore, the hospital of the future, starting today, should be a nexus for innovation and entrepreneurial activity.

Entrepreneurs and the invention of the future

Graph of the locations of water on EarthI attended the European Foundation for Management Development conference at Advancia 22-23 February 2010, to meet new colleagues as well as participate in a panel discussion on the challenges facing entrepreneurs. I organised my presentation around the question: “what sort of the future will the entrepreneur invent?”  I used two pictures to start my talk, one a 1530 Utopian painting and the other a poster of Fritz Lang’s dystopian film Metropolis.

Everything around us is invented, discovered, or created by the mind of people making sense of the world, so while it may be too much to see the entrepreneur as a super-human force of nature (as some discussed at the conference), the point is that human ingenuity is behind the world we live in, and our ability to be ingenious drives the

entrepreneurial spirit. I raised these issues in my presentation:

  • crises are really opportunities, especially for entrepreneurs;
  • the growing networking and interconnectedness of the world offers amazing opportunities for entrepreneurs to look at ways to bring people, information and services together; concerns about digital divides, social exclusion etc., in my view are transitional features of the current world, and not defining features, and that in time, these will be replaced with other forms of exclusion; the point being that technologies themselves are not exclusionary, but what people do with them is;
  • rising educational attainment is upon us, and there will be a substantial decline in the percentageof the population globally with only primary education, and doubling in the next decade or so of numbers of people with tertiary education; again, this offers amazing opportunities for learning in new ways, also considering the networking of the planet;
  • agricultural innovation is seriously important as over the next 20 or so growing seasons (years), the planet’s population will rise by about 30%, per capita food consumption will rise by 50%, dietary preferences will change, water and energy demand will also rise; this points to the need to ensure that fresh water is where the people are (right now, the fresh water is located mostly where people are fewer), and that each agriculturally productive hectare can add 50% of productive capacity — in very few growing seasons; with climate change, too, factors such as what grows where comes under stress, as different areas will need to learn to grow non-traditional crops, and other areas will become unproductive;
  • I also showed pictures of intelligent machines such as an autonomous GPS-guided farm tractor, and a similarly autonomous mining truck; the autonomous military robot with its gun on top is a telling reminder of the progress in military science, while the Utopian picture of the smart city of the future offers a different sort of hope;
  • finally, I showed a map of the world 4 degrees warmer, and wondered how we were going to deal with social displacement indicated by the growing numbers of people who will come to live in unihabitable or hostile environments (at risk of flooding, heat stress, and so on).

Having said all that, I am left to wondering though how we bridge the entrepreneurial challenges facing the public sector.  In many cases the challenges entrepreneurs face are caused by governments, and by regulation, as well as by restrictive banking practices which make access to capital so very hard. While we look to the entrepreneurial spirit in the private sector, and feed and encourage creativity, we find the opposite is true in the public sector. Indeed, Martin Lukes, from Prague, presented an excellent paper, with a telling conclusion that public sector people have less organisational support for innovation and entrepreneurial activity than their private sector counterparts. In some respects the elephant in the room is the public sector, consuming huge amounts of taxpayers’ money, yet often failing in two ways, failing to ensure entrepreneurial growth through poorly thought out rules and regulations (red-tape, regulatory burden and so on), and failing to get their own house in order.  Given the current state of affairs in some the world’s major economies, I don’t think the public sector can excuse itself from the need for entrepreneurial reform and effort.

The invention of the future requires all hands on deck, and no one can be spectator any more.

Universities: are they as smart as we all hope they are?


News item in the UK: The sector’s funding body, the Higher Education Funding Council for England (HEFCE), announced (on 1 February 2010) that budgets are to be cut by £449 million for 2010/11.  This includes:

* A 1.6 per cent reduction (£215 million) in teaching funding;

* Research budgets will remain the same as last year;

* A 16.9 per cent cut in capital funding;

* A 7 per cent reduction for funding of special programmes and initiatives.

In a letter to vice-chancellors setting out the budgets, HEFCE said it recognised that the reductions will be “challenging” to institutions.

Now what is to be done? Predictably, the higher education sector in the UK is arguing that this will affect perhaps 200,000 students who won’t be able to get a university education. A few weeks ago, the sector argued that the UK’s place as a top tier home of higher learning was at risk — but that came from the elite Russell Group, which represents perhaps the top of the top universities in the UK.

There are a number of possible ways of thinking about this. A few:

  1. Universities already get a lot of money, and they perhaps could reduce their running costs — think of the disorganised structure of the academic year, think of teaching loads or confused performance management (is it teaching quality, research or publications??), and pretty good employment contracts. (I had one once.)
  2. There are too many universities trying to do too much, and perhaps it would not be a bad thing if some either closed or merged with another institution. The loss of the old polytechnics deprived the higher education system of a sensible alternative. Since comparisons to the US are frequently made, it is worth noting that some of the US’s top institutions are not called “university”, anyway, but ‘institute’ and indeed ‘polytechnic’. One could also look for new innovative institutions to emerge to challenge much that universities do. For instance, research institutions without university links, or which are focused on compelling issues — check out the Santa Fe Institute, for instance. Universities are not the only fruit!
  3. Cutting capital funding is not such a bad thing, given the horrendous financing of a state-sponsored capital funding body. Better universities learn how to build collaborative relationships with sources of capital, than expect their funding automatically to come from the state.
  4. Perhaps too much inadequate research is done, poor deployment of intellectual effort at reaching wider learning communities, responding to new ways of structuring learning beyond the rather tired full or part time dichotomy, and so on.

But of course, the key dilemma remains, what is to be done?

I take an optimistic view, but I would put the challenge at the door-step of the universities.

Rather than complain, prove that 800 years of public and private investment hasn’t been wasted, and come up with sensible solutions that would establish a sustainable approach going forward.  I doubt 200,000 or 200 students would be disenfranchised as a result, new ideas would emerge.

A recent book review in the Financial Times of Louis Menand’s The Marketplace of Ideas, would be a good place to begin some fresh thinking. The reviewer, Christopher Caldwell, notes:

Starting in the 1970s, professors, newly alert to injustices in society at large, took aim at credentialism and departmentalisation in every nook and cranny of American life – except, Mr Menand notes pointedly, their own. The professorial hierarchy continued to rest on a system of arduous PhDs (raising high barriers to entry), “disciplinarity” (denying the authority of the non-credentialed to teach or even discuss academic subject matter), and tenure (jobs for life). It was a system well-suited to monopolising bureaucratic power, but less well-suited to the free flow of ideas. Menand cites a 2007 study to show that, in the 2004 presidential elections, 95 per cent of the social science and humanities professors at elite US universities voted for John Kerry and 0 per cent (statistically speaking) for George W. Bush. Monopolies produce smugness and sameness in universities, just as they do anywhere else.

The title of this blog entry takes from a line in the film Independence Day, where the President says to the Geoff Goldblum character, ” And we’ll see if you’re as smart as we all hope you are” It is now time for the universities with their massive subsidised top-tier braintrust put on their thinking caps, stop playing victim and take responsibility for the solution.  The university-based economists let us down quite badly with failing models of our economies, and we are all paying for it in one way or other. Let’s not see two in a row.

What’s a finance minister to do?

With public finances in most countries looking pretty challenged these days, what steps can central jurisdictions take to achieve two key health policy goals:

  1. reduce the overall healthcare expenditure by bending the cost curve down,
  2. improve productivity, value-for-money, health outcomes.

Few in government have much experience with reducing healthcare expenditures.  And ministers are rightfully fearful of voter wrath, so one must wonder where the political courage will come from in the first place. Perhaps the key thing is denial is not an option, neither is blame-fixing. The first rule, therefore, is to fix the problem, not the blame.  True statesmanship is now needed, more so than party political rhetoric; that is, of course if we are right that things are in a really bad way.

Few, too, in healthcare management have the necessary experience with substantial changes needed in healthcare delivery systems especially where resource constraints will need to similarly deliver productivity gains.  We’ve had tremendous growth in healthcare expenditure matched with uptake of new technologies, complex treatments, and greater clinical specialisation. We can simply do more, and it costs. But along with this rise in capability, there has been much less reform of the way healthcare is done. Clinical workflows continue to be clogged with unneeded activity; we still use expensive hospitals when less expensive polyclinics or primary care settings would do. We fail to exploit the full potential of the other health professions, such as nurses and pharmacists. The second rule, is that you cannot continue to fund an unreforming health system.

Reform must be a constant feature of healthcare, since it is so dynamic as an area of innovation. If we want to bend the cost curve down, we need to persist in reform, indeed, disruptive reform, creative destruction in healthcare service delivery.  It is not about being nasty as a finance minister, it is all about using the money to unleash creativity to the benefit of all.

The challenge is less how to do that though, than wondering why what is there about healthcare today that seems to keep that from happening in the first place. Now that is really something to wonder about.

Regional innovators, European disruptors, world-class leaders.

adapted from original orthogra...

A good starting place, but not the whole journey

We are all innovators now.  Gone, surely, must be the days of free-riders, of subsidised mediocrity and creative malaise. A new world beckons. But doubts remain.

I had the privilege of moderating an excellent post-Lisbon event on innovation for ERRIN, the European Regions Research and Innovation Network.  What was so exciting was to hear from different EU regions what they are doing to drive innovation forward. We learned of the creative use of foresight, to probe where technological innovation was occurring and scientific breakthroughs likely to be. We learned about how to bring a diverse mix of interests around a common table, of industry of academe and of entrepreneurs.

It was refreshingly different, and further evidence that this European behemoth might actually show itself as the global powerhouse that it has the potential to be.  Perhaps the G2 of the USA and China should be G3, but that will depend on the EU speaking of course with one voice and the post-Lisbon squabbling is only just beginning.

We also heard Commission thinking on where they saw the landmines in the road to economic recovery and hints of structural reform that would be needed in the near term at least.

For innovation and research and development, if regions are the breeder sites where industry, ideas and money mix to produce economic recovery, how will the wider European project benefit?

Two things come to mind. The first is obviously that we need to celebrate and share the excellent work at the regional level, but we must be mindful that narrow national policies of individual member states may pitch regional advantage into the political mix, to trade regional advantage off against national policies.  If regions are to excel and strive for at least European leadership, if not world-class stature, they must be owned but us all in Europe.  This is a call perhaps for more European protection for centres of excellence.

The second is that the regions do need to become world-class, and this means that they will need to increase the originality of their innovation plans to embrace the disruptive, challenging and far-reaching.  This is to ensure that regions don’t keep reinventing the wheel as similar priority setting processes and strategies risk producing similar technological priorities — Europe won’t excel if all the regions come up with similar priorities. This can be exacerbated by excessive reliance on public sector funding, in part, as this puts the regional process into one which risk narrowing the priorities chosen to ones which meet local/regional political goals, and not necessary the wider interests of Europe.  While public funding can be a help, it must not restrict the ability of regions for forge strategies that may not meet the needs of their localities but serve a wider interest. (see Philip Cooke, Regional Innovation Systems, Clusters and the Knowledge Economy, Industrial and Corporate Change, 10-4(2001):945-971)

This means that we need wide coordination of innovation activities and strategies, to share priorities through a clearinghouse arrangement, and to identify emerging innovation area that have not been prioritised by a region. What, indeed, are the Grand Challenges facing Europe, and how can these stimulate regional innovation, for instance.

We also need to see much closer working between private equity and venture capital and the work of the regions. Where are the venture capitalists when regional innovators meet?

In the year 2109…

THE YEAR 2109, a hundred years from now.

This image shows the Sun as viewed by the Soft...
The future may be warmer, and not just the climate

The average life expectancy is around 150 years for most people born in the early part of the 21st century. The life expectancy of a child born in 2109 is in excess of 500 years.

Cars? All electric using ultra-capacitor storage systems.  There are no vehicles with internal combustion engines. Fusion power is the main power source. Broadcast power widespread.

Cities are pedestrianised. People work from home or small community hubs, large corporate office complexes were pretty passée by 2050; the last hospital was built in 2025.

The tallest structure in the world is in Qatar and is a space elevator. There are 10 of them in the world.

The average wage is 800,000 euros (dollars? heard of them but not widely used), but its all e-money anyway, haven’t seen folding money in years and coinage is quaint.  Gold is worth 125,000 euros an ounce (what’s an ounce daddy?)

Robots don’t get paid to work.

More than 95 percent of all births take place at home.

Ninety percent of all doctors are robotic artificial intelligence systems.

The low lying countries have all but disappeared and the massive relocation of whole populations between 2050 and 2070 created whole new countries with renewed economic fortunes. 80 million Bangladeshi were relocated to Northern Canada.  The flooding of the Sahara desert in 2030 to create habitable land was needed to relocate other stranded populations; this also unlocked the resources under the sand.

The population of Nevada in the US is 41 million, having taken on the displaced population of the whole west coast, following both the rising sea level and the Great Quake of 2030. There is some fine beach front property in Idaho. Alberta has a similar population when BC was inundated and the Sunshine Coast disappeared.  Other regions of the world were not spared either.  London was relocated 50 km north, and much of the Netherlands and northern Belgium are gone.

Pneumonia and Influenza, Tuberculosis, Diarrhoea, Heart disease, Stroke used to be big killers, but now through molecular medicine by 2050, organ replication by 2030 and head transplants by 2060 all this has changed. Since 2060, some people have opted to have their brains embedded in robots.

Five leading causes of death are:

  1. ?
  2. Suicide
  3. ?
  4. H23N24, equine spider fever
  5. B348C90, Martian sand virus

The dominant languages are Chineglish, Spanglish and Arabasque.

There is Mother’s Day, Father’s Day and Children’s day, plus Robot Appreciation Day.  The major global day of reflection is called 350 Day as is held on December 16 (the 350th day of the year), the day that CO2 breached that level and never went below.

Marijuana, heroin, and morphine are all available over the counter at local corner drugstores having been denatured to provide the psychological benefits without the addictive properties. The local medicines dispensary owner said to me, ‘Heroin clears the complexion, gives buoyancy to the mind, regulates the stomach and bowels, and is, in fact, a perfect guardian of health’.   Coca-Cola is still going strong.

Eighteen percent of households have at least one full-time robot servant or domestic help.

Professions that don’t exist anymore: train engineer (robots), mail delivery person (robots for home delivery), bank teller (banks?).

You are receiving this message courtesy of the world wide cog, the cognitive intelligence that links all people through cognitive implants and remote sensors.

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What’s an EHR for, anyway?

Sample patient record view from VistA Imaging
Example of EHR (VISTA)

There is trouble in e-health land, at least in Ontario’s funny notion of what they might mean.  EHealth Ontario has been subject to an emergency audit of its procurement or not of an electronic health record [EHR] by the Auditor General of the province.  Apparently, somewhere approaching C$1 billion has been spent with virtually nothing to show for it.  The problems lie in a bad ehealth strategy, and inappropriate use of consultants.

There are lessons here for other jurisdictions, as they seek to embrace the benefits of EHRs, and ehealth more widely, in particular. Of course, what is an EHR for, is the core question.

One of my alma maters, McMaster University, has sprung into the fray saying it has an EHR called OSCAR that could be implemented for perhaps 2% of the estimated cost of a provincial EHR.  Their argument being that a lot of doctors are using it.

EHRs are not a tool for doctors, though.

EHRs are an integrated information repository to facilitate better healthcare.  Doctors are not the only oranges, and nurses, physios, social workers, pharmacists, OTs, oh, yes patients and parents, informal carers, too, need access to health records. In my view, patients should own and hold their own health record, to ensure high audit standards (would you let an error remain on your health record if you knew about it?).

Servicing the specific needs of doctors alone is not an EHR strategy worth having, and doctors themselves should be the first to say this. It is time they showed leadership within the wider healthcare system, and rejected self-serving models, such as McMaster’s, which automate obsolete information models. McMaster, too, should have known better.

The Ontario Ministry of Health has wisely rejected OSCAR’s offer, but for the wrong reasons.  Citing the need for doctors to choose their own systems, just shows their continuing logic of catering to the needs of a particular health profession, rather than addressing the systematic provision of patient information within an integrated decision-support system.

All this is being driven by beleagured officials who really need to think again about their priorities and why they really need an EHR.  Perhaps they are afraid to admit to having made a mistake.  Such hubris.

Clearly more work is needed to define the purpose of the EHR and the goals for an ehealth strategy in Ontario (and other jurisdictions of course), before more taxpayers’ money is spent on ehealth.

Oh yes, apparently Ontario are going for a tender on a diabetes registry. NYC has one. I fear the worst.

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Smart Hospitals

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Hospital Universitario Marqués de Valdecilla, ...
Hospital Complex, Spain

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

  1. their capabilities and
  2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.