2013 saw an accelerated crumbling of borders and boundaries in health care, fueled by technological and scientific advances. Boundaries between high-tech Western medicine and global health practices have begun blurring in interesting ways, as are those between home and hospital, patient and doctor and even a patient’s own body and the treatment used for her disease.
Last year also saw a fierce political fight over the Affordable Care Act (ACA)—aka Obamacare—ending in some six million people crossing the boundary from uninsured to insured, according to HMS, if you count Medicaid and Children’s Health Insurance Program eligibles.
What does all this portend for 2014? This year, Vector asked leaders from all walks of life at Boston Children’s Hospital to weigh in with their predictions.
1. ACA’s aftermath
2013 will be remembered for the never-ending arguments about ACA, including the substantial problems associated with the initial rollout of online health care exchanges around the U.S. My expectation for 2014 is that ACA supporters will be able to declare partial success by the end of the year. There will be a substantially greater number of people covered through new health care options, with the initial wave coming through existing and expanded Medicaid programs. As online products begin to sort themselves out, I believe a new wave of challenges and concerns (some of which we are already reading about) will emerge. In particular, new insurance products with restrictive provider networks will proliferate nationally and may be especially problematic for pediatric patients requiring highly specialized care.I do not expect major changes in health reform policy this year given the mid-term elections in November, but will be interested to see whether Democratic candidates choose to embrace the law or try to avoid talking about it. On the Republican side, it appears that the game plan will be to continue to raise concerns without offering much in the way of solutions. As more people enroll in the new health plans, it will become increasingly difficult to undo significant portions of the law. I have been wrong before, but I expect that those states trying to drag their heels on implementation will face increased pressure to engage (especially around expanding their Medicaid programs) when they realize that other states have been successful and have attracted significant additional federal funding for their Medicaid programs. —Joshua Greenberg, JD, Vice President, Government Relations & Public Policy, Boston Children’s Hospital
2. Clinician revolt against federal health IT deadlines
Although implementation of technology has helped streamline some tasks in health care, it has equally added new ones. The pressures of regulatory mandates, including Meaningful Use Stage 2 requirements for electronic health records (EHRs) and transition to the ICD-10 diagnostic coding system, will continue to push clinicians toward the brink. As detailed thoroughly in this recent blog post, there is just too much “peripheral” work for clinicians to do, in addition to actually examining and treating their patients.Clunky and complex interfaces used in the clinic have not yet given way to the streamlined ones people are now accustomed to on their mobile devices. The industry is changing and trying to adopt these improvements—but not quickly enough. The scope of what clinicians have to absorb will lead to more proposals to lengthen the national health care IT timeline. —Daniel Nigrin, MD, Chief Information Officer and Senior Vice President, Information Services, Boston Children’s Hospital
3. New health care innovation centers and Lean business modelsUntil now, there has been more talk than action about the importance of fostering innovation. In 2014, health care organizations that wish to maintain their leadership positions will need to not only talk the talk but also walk the walk. Expect to see a flurry of new corporate health care innovation and innovation acceleration programs (the American Association of Medical Colleges has even produced a primer). Many of the new programs will focus on mobile apps and health IT innovations to exploit the digital health care transformation currently underway. Also keep an eye out for the launch of new innovation centers similar to our FastTrack Innovation in Technology program, as well as more health care hackathons. —Naomi Fried, PhD, Chief Innovation Officer and Director, Innovation Acceleration Program, Boston Children’s Hospital In contrast to the way traditional academic ventures are pursued, technology is being taken over by a nimbler Lean methodology. With events like Hacking Pediatrics and other opportunities for crowd-sourced, rapid innovation, there is increasing opportunity for start-ups to come out of academic medical institutions much like what is happening at UCSF, Mount Sinai, UPMC and Intermountain Healthcare. Rapid prototyping technologies such as 3D printing have dramatically reduced the time and cost to reach market or test an idea. Similarly, the explosion of mobile health and software development within the health care space has led to a boon in medical entrepreneurship. —Michael Docktor, MD, director of clinical mobile solutions at Boston Children’s Hospital and a co-founder of Hacking Pediatrics
4. Fueling life sciences: the rise of corporate venture capitalAs traditional venture capital firms have moved away from funding life sciences start-ups—especially those around early-stage technologies—corporate venture capital has emerged as a powerful force and will continue to increase its presence in the investment space in 2014. There is a growing need for capital, but also for corporate savvy in spinning out promising technologies from academic institutions—like Claritas Genomics, launched by Boston Children’s in 2013 in partnership with Life Technologies. Our office alone is currently working on about 20 separate start-up opportunities. Corporate venture capital is at the top of the list of potential partners in these “NewCos,” in particular because they bring, in addition to capital, direct expertise to help commercialize products. —Maude Tessier, PhD, Assistant Director, Business Development and Strategic Initiatives, Technology and Innovation Development Office, Boston Children’s Hospital
5. The first digital health IPO
Today, the digital health industry is ripe with investment and entrepreneurs. A growing number of new products are entering accelerators like Rock Health, HealthBox, Blueprint Health and many more. Over the past five years, the industry has grown with new companies and increasing investments from venture capital, but most investor exits (or divesting of investments for a return on capital) have been through acquisition, such as Aetna’s purchase of iTriage, a nonprofit offering resources to help patients manage their health.2014 is when we will see the first digital health Initial Public Offering (IPO) for a patient engagement product or service. The digital health industry has seen IPOs in the areas of healthcare process optimization and consumer wellness, but patient engagement is where the true opportunity lies. The industry needs an IPO to continue fueling the financing of digital health start-ups and ultimately to maintain energy in this space, seed and mature good ideas and build confidence for new investors to get involved in this market.
One promising company, HealthTap, just received a new financing round of $24 million and has great potential to change consumer participation in health care. Another company, Scanadu, is probably further from an IPO—having just completed early production of its devices and still needing to complete the FDA approval process—but is a company to watch in the digital health space. As the health care industry transforms under ACA, the investor community already sees potential in digital health, but an IPO will be an important milestone to unlock the full potential. —Alex Pelletier, MBA, Digital Health Program Manager, Innovation Acceleration Program and manager of the FastTrack Innovation in Technology Award
“Stem cell and gene therapy will explode with new opportunities for treating rare diseases in children.” —Sandra Fenwick, CEO, Boston Children’s Hospital
6. Genome sequencing at birthThe coming year will see increased focus on genome sequencing of sick babies as an aid to their medical diagnosis and management. In 2013, the NIH funded four grantees across the U.S. to explore the use of genome sequencing in newborn health care for a period of five years, including a joint project from Boston Children’s and Brigham and Women’s Hospital. In the future, genomic sequencing may expand to all newborns as sequencing technologies get more affordable and sequence data get more interpretable. This may not only help improve care for those babies but also guide their families in making future decisions. —Pankaj Agrawal, MD, MMSC, Newborn Medicine Research Center, Boston Children’s Hospital
7. Gene therapy comes of ageSuccess at developing tools to correct single-gene diseases will continue in 2014. Boston Children’s, in collaboration with leading centers around the world, has active protocols treating patients with severe combined immunodeficiency, Wiskott Aldrich syndrome and childhood cerebral adrenoleukodystrophy, a storage disease involving the brain. The technology utilizes genetically engineered viruses to carry correcting gene sequences into patients’ blood stem cells, which are then engrafted into the bone marrow. Patients are showing promising results, and gene therapy for several other diseases is in the works. —David Williams, MD, Chief, Division of Hematology/Oncology; Director of Translational Research, Boston Children’s Hospital
8. Cell-based therapiesEfforts will intensify this year to bring therapies based on mesenchymal stem cells (MSCs) closer to clinical trials in newborns. Clinicians are focusing on two devastating ailments—bronchopulmonary dysplasia (BPD), the most common pulmonary complication of preterm birth, and hypoxic-ischemic encephalopathy (HIE), a leading cause of brain injury in term or near-term infants. In preclinical animal models of BPD, MSCs derived from banked cord blood, placenta or cord stroma have been shown to arrest lung inflammation and enhance lung repair (see here, here and here). Other animal evidence (see here and here) suggests that autologous umbilical cord blood cells, given as adjunct therapy, could help reduce neurologic injury and preserve neuronal pathways in infants with HIE. Several clinical trials in adults have already demonstrated the safety and feasibility MSC-based therapies delivering live cells, and in the near future, we will see an explosion of phase I/II trials targeting neonatal diseases—using not only MSCs but MSC products such as secreted microvesicles, bypassing the need for live cells. —Stella Kourembanas, MD, Chief, Newborn Medicine, Boston Children’s Hospital
Can patients’ own cells be turned into cancer drugs? Together with scientists at the Memorial Sloan-Kettering Cancer Center, we are opening a trial in which we take immune cells from children with high-risk leukemia, bioengineer them genetically to attack the cancer and return them to the patients as “designer drugs.” This approach has shown promise in other types of leukemias and lymphomas and could be extended into some types of pediatric solid tumors in the future. —David Williams, MD, Chief, Division of Hematology/Oncology; Director of Translational Research, Boston Children’s Hospital
9. EHRs will become more intelligently designed and mobile
Doctors and other clinicians currently spend, on average, 40 percent of their time in stuffy workrooms documenting patient encounters. In 2014, these activities will be taking place more often at the point of care. Cerner Corporation and many other IT companies have realized the value of mobile health and the importance of getting doctors out of the workroom and into face-to-face contact with their patients—where they truly want to be and belong.
We have seen exponential growth of mobile devices and their nearly ubiquitous adoption by clinicians. iPhones, iPads and other mobile operating systems offer everything from search tools to the ability to take photographs and, ultimately, to access patient records at the point of care via the EHR. In the coming months, I will be fortunate to help pilot PowerChart touch, an iPad-specific version of our EHR system.
Technology, such as voice recognition from companies like Nuance, will allow capture of further elements recently dubbed the para-EHR—elements like phone calls, emails and texts that currently don’t make their way into the EHR. Through an iPad app, clinicians will be able to dictate directly into the EHR and readily capture snippets of communication—from phone conversations to chance meetings in the hospital lobby. —Michael Docktor, MD, director of clinical mobile solutions at Boston Children’s Hospital and a co-founder of Hacking Pediatrics
10. Wearable technology reaches the tipping point
In 2014, wearable consumer health-tracking devices—from the Jawbone UP to Fitbit, Nike FuelBand and the Misfit Shine—will become commonplace, along with an increasing groundswell of software apps that will democratize and mobilize medicine and empower patients. We will see a tremendous and rapid rise in the number of individuals tracking their health metrics.
Many start-ups, employers, insurance companies and even EHR companies are vying to be part of these software and hardware ecosystems. With the launch of the Apple iWatch, expected in 2014, the barrier to entry for wearable devices will be lowered dramatically. While none of the tracking technologies are particularly novel, they will be increasingly common in many forms, from Google Glass to clothing with integrated sensors. Patients will hopefully use their data to communicate better with their physicians and take part in their own care. —Michael Docktor, MD, director of clinical mobile solutions at Boston Children’s Hospital and a co-founder of Hacking Pediatrics
THINKING GLOBALLY, ACTING LOCALLY
“The use of technology to educate, train and support clinicians will grow in application and spread worldwide. Capturing massive amounts of data as clinicians use these tools will allow for quality improvement and will serve to develop the predictive analytical capability to better diagnose and treat patients.” —Sandra Fenwick, CEO, Boston Children’s Hospital
11. Evolution in global healthMobile technologies are innovating global health, just as they are domestically. Community Health Workers, for example, are using cell phones to monitor and treat children, obtain instant information on recommended medications or therapies, wire money, arrange transportation for individuals needing emergency or hospital care and upload information into a database for monitoring and evaluation.
We also are seeing increasing interest globally in non-communicable diseases like diabetes, sickle cell, seizures and congenital anomalies. This is due in part to the progress being made with communicable diseases and in part to a new ability to obtain remote consults regarding chronic diseases. Expect to see two other very unfortunate trends related to “lifestyle” illnesses: Obesity is increasing ferociously around the world (including in countries like China and India) and childhood tobacco use is on the rise. —Judith Palfrey, MD, Children’s Hospital Primary Care Center; Director, International Pediatric Center; Past President, American Academy of PediatricsWith the Millennium Development Goals (MDGs) maturing in 2015, the drive to reduce newborn deaths will become increasingly urgent this year. The fourth MDG, agreed upon by all the world’s countries and leading development institutions, calls for reducing mortality in children under age 5 by two-thirds between 1990 and 2015. It has galvanized unprecedented effort to meet the needs of the world’s poorest countries, where the vast majority of newborns die from lack of simple, low-technology interventions such as neonatal resuscitation, naso-gastric feedings, intravenous fluids, antibiotics and the provision of warmth. —Anne Hansen, MD, MPH, Medical Director, Neonatal Intensive Care Unit, Boston Children’s Hospital
12. Global partnerships: it’s a small world after all
We are fortunate in Boston to have the largest biotech/pharma industry cluster alongside world leading academic institutions. This cluster grows every year as new companies form and as established international companies open new satellite locations. In 2014, there will be increasing momentum for members of our health care ecosystem to reach out to partners on a global scale. OPENPediatrics, an interactive, cloud-based clinician education platform created by Boston Children’s and IBM, is one example that is promoting exchange of knowledge between health care providers around the world who care for critically ill children. International scientific consortia also are moving forward across geographic borders to address some of the world’s toughest medical challenges. —Maude Tessier, PhD, Assistant Director, Business Development and Strategic Initiatives, Technology and Innovation Development Office, Boston Children’s Hospital
13. The ramp-up in “reverse innovation”As the U.S. faces the challenge of reducing health care costs while increasing quality of care, affordable, effective solutions may well come from innovations in global health. “Reverse innovation” is the term coined for the spread of a solution created for a low-resource area to wealthier, more industrialized countries. We have already seen movement in this direction from some large multinational corporations. For example, GE Healthcare’s MAC 800 portable, battery operable ECG system was initially designed for doctors in rural India and China, but its affordability and portability allow any physician, according to the company’s website, “to reach patients wherever they are: in an urban physician’s office, at a regional health center, in a rural clinic or in remote locations nearly anywhere in the world.” Many of our top universities are leading the way, along with a more globally minded generation of young innovators emerging through programs such as MIT’s D-Lab and Stanford University’s C-IDEA. These programs are creating solutions that could improve health care everywhere. —Donna Brezinksi, MD, Division of Newborn Medicine, Boston Children’s Hospital; Founder and CEO, Little Sparrows Technologies
14. Family-friendly care models will mature
The concept of patient-centered medicine almost seems redundant: shouldn’t all of medicine center on the patient? Yet typically, we elicit a story, perform an exam, run tests, get x-rays, talk amongst ourselves, come up with a diagnosis, write a prescription and send the patient on his way. And we are shocked to discover that prescriptions go unfilled, pills are not taken, referrals don’t occur, exercise and nutrition regimens aren’t followed, health disparities grow and our patients, all too often, do not get better.That is changing. The Patient-Centered Outcomes Research Institute (PCORI), founded in 2010 as part of ACA, is leading the march forward in patient-centered care. Its award funding has grown to $650 million annually for fiscal years 2014-2019. Recipients at Boston Children’s include Christopher Landrigan, MD, MPH, Kenneth Mandl, MD, MPH, Jennifer Mack, MD, MPH, and Sarah de Ferranti, MD, MPH. A just-announced PCORI grant is supporting a nationwide pediatric data-sharing network.
Patient-centered care initiatives also are being enabled through technology: examples at our hospital include HelpSteps.com, a web-based system that helps families connect to social services, and ICISS Health, a web platform for evaluating patients’ response to therapy and quality of life over time that connects patients, parents, teachers and others and integrates their reports for clinicians. —Eric Fleegler, MD, MPH, Department of Emergency Medicine, Boston Children’s HospitalDuring 2014, care coordination will be broadly recognized as a key component of high-value health care for children and adults. With support from ACA, care coordination will begin to close the “quality chasm” highlighted by the Institute of Medicine in 2001. Several states, including Alaska, Michigan, Florida, Massachusetts and Oregon, are developing care coordination workforce capacity and curricula. Training programs for care coordinators will be launched in several places across the U.S. A textbook, just released by the American Nurses Association, aptly calls care coordination a “game changer.”
Family engagement in care coordination will be a critical component of high-value care delivery, and national efforts to measure patient-reported outcomes are proceeding robustly, as evidenced by PCORI’s efforts. —Richard Antonelli, MD, Medical Director, Integrated Care and Strategic Partnerships, Boston Children’s Hospital2014 will see an explosion of home visits—with a 21st century twist. The virtual telehealth visit will make up a rapidly increasing percentage of total outpatient visits. A number of converging forces are driving telehealth: new health care payment models, tech-savvy patients and the rollout of ACA, adding millions of new patients to the health care system amid a shortage of primary care doctors, specialists and other care providers.
Companies like American Well, Teladoc, MDLive and RingMD finally found traction in 2013, and are poised for massive growth in 2014. These companies leverage web technologies that enable patients and clinicians to communicate securely using the most appropriate modality (text, email, chat, phone or video) at the most convenient time and place. Large EHR companies like Epic are beginning to incorporate these features into their own products. Insurance health companies like Aetna, Wellpoint, Cigna and Highmark are jumping on the bandwagon.
The pace of development of virtual visit technologies will also accelerate, as evidenced by the American Telemedicine Association’s partnership with X-Prize, a contest to develop a “tricorder-like” handheld device for consumers that can diagnose 15 different conditions and capture five vital biometric assessments. —Shawn Farrell, MBA, Telemedicine and Telehealth Program Manager, Boston Children’s Hospital
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