Draft of Speech for United Nations Rio + 20 Pre-Conference
Stanford University Campus, 2/3/2012
By Eric Dishman

I am very honored to be here today on behalf of Intel Corporation and our joint venture with GE, Care Innovations, to help celebrate the 20-year anniversary of the Rio conference and to help plan for the next 20 years of sustainable development and innovation. I realized as I prepared for today that my own career as a social scientist in high tech, focused on home health and independent living, has paralleled those 20 years. In fact, it was the summer of 1992 while working for Paul Allen, the co-founder of Microsoft, at his think-tank in Silicon Valley when I designed my first remote patient monitoring prototype to help monitor the heart rate and blood pressure of seniors who found it too challenging to get to a doctor’s office for a check-up.  What was vision back then is a much-needed reality today. If you take only one message away from my comments here this morning, it should be this: if we are to develop sustainable, worldwide healthcare systems, we must build a workforce, a business model, and a technology infrastructure to take healthcare home.

For a moment, I ask you to visualize in your imagination the oldest person you have ever known. It could be a parent, a grandparent, a neighbor, a former boss. Just capture their image in your mind, when they were at their oldest. What did they look like? Their clothes? Their hair? (Or lack thereof?) What surprised you about what they could still do at their age? And what depressed you that they had lost? Now look around this auditorium and imagine a fifth of the people here sharing the same looks, needs, and capabilities of that oldest person you can remember. Now you will begin to have a sense, thanks to so many advances in healthcare, agriculture, and technology, that we have a “longevity challenge” ahead of us. It is most striking when you realize that back in 1950, there were only 3000 centenarians on our planet but, by 2050, demographers believe there will be more than 6 million people over age 100! It is, indeed, a swiftly graying planet.

The Rio conference in 1992 served as a wakeup call about Global Warming and helped to energize innovation and investment in climate change sciences and industries. But Global Aging, by comparison and with every bit as much impact on our global economy and lifestyle as Global Warming, has received inadequate attention and investment. Thus, Intel, a company whose history and heart is about trying to solve big, audacious societal challenges through computing, started about 12 years ago to study Global Aging. Over this time, our social scientists, engineers, and designers have observed over 1000 elderly households and 250 care facilities in 20 countries. This body of work has helped to fuel everything from new products and businesses like those in Care Innovations to policy work in the U.S. and the European Union to our current work with China on “Age Friendly Cities” as they strive to move 90% of their care for older people to the home by 2020.

As part of that fieldwork, almost a decade ago, I spent time studying rural villages throughout Europe to try to figure out how to deliver healthcare to those resource-limited communities. In one town in particular, the local leader—sort of the unofficial mayor—drove me out a few miles from the center of the town to show me an empty lot that he and others in the community were attempting to buy to build a hospital. He proclaimed to me: “If you have a hospital, then you have arrived as a community…you have made it!” They were doing everything from bake sale fund raisers to major capital campaigns to try to build a hospital for their isolated region.

About a year ago, I checked in on their “progress,” and it was a sad story. The unofficial mayor had died of emphysema, and the group of investors in that community had never been able to raise the money for such an expensive endeavor as a hospital. They had lost their down-payment money (and, in some cases, their retirement nest eggs) in the midst of the financial mayhem of the European debt crisis. And the lot, to this day, sits empty, with nothing but a gravel parking lot and bushes and trees poking up through a lone, crumbling sidewalk to nowhere.  Perhaps most tragic to me is the lost decade—two decades, really, from when they had first started—of having no care available for the local people of that town in the interim.

Herein lies some of the thinking about healthcare development that I want to try to “un-do” today. The notion of a hospital as a symbol of “having arrived”—of economic and technological progress—is not surprising, but also not very healthy in the long run. I ask you to consider the idea that real progress—truly successful innovation—would be to use hospitals only as a last resort and to build out a 21^st century healthcare infrastructure that shifts care to the home and community, that focuses more on prevention and early detection, and that is accessible and affordable for everyone. As a global society, we need to accept the idea that the hospital as the end goal—as the marker of medical progress—no longer fits our needs. In the midst of Global Aging, a hospital-centric model must somehow begin to give way to a home-centric model for the future.

So how might we begin to get there—how do we begin to take healthcare home? I’m somewhat notorious at Intel for coming up with alliterative phrases, and today will be no different. As you break out into workgroups this afternoon at the conference—and as you prepare your national strategies back home for the Rio conference in June—I urge you to think about the following “3Cs”: Connectivity, Careforce, and Community.

By “connectivity,” I mean many of the connection technologies already discussed here at the conference today. In particular, how do we insure we build a broadband infrastructure that is ready for 21^st century healthcare delivery all the way to the home? So many countries are rightfully investing in fiber or wireless of many types and flavors, but they have done little to define requirements for the kinds of healthcare needs we will have in a graying world. We can’t let digital movies and music be the only source for driving our requirements for broadband networks. Healthcare requirements—for a virtual visit with a doctor, vital signs capture from the home, a sensor network for helping to prevent falls, a security solution that protects patient data from the bedside to “the cloud” and all points between—should also be part of the mix. We must come to ask: Do we have the right speed, security, network redundancy, packet prioritization, and other capabilities to make the home a plausible, affordable, and safe node of care?

Connectivity technologies and innovations for a 21^st century healthcare “grid” abound. For example, Intel has recently worked with doctors and officials in Mexico to build a solution called “Medicina a Distancia” to bring hospital quality expertise to remote and rural parts of the country. I know many of you here have been working on similar telehealth initiatives to bring the access and expertise of the city to rural areas, which is an amazing beginning. But we still treat such telehealth encounters as the exception to a face-to-face visit instead of the norm. We have to make the face-to-face visit the rare exception. And to do so, we have to carry the “last mile” of that connection all the way to the patient’s home, workplace, and community for some rather creative applications that drive prevention, wellness, behavior change, and adherence to a care plan.

For example, years ago, researchers in Intel Labs in Ireland took off-the-shelf GPS technologies and an internet connection to prototype an online service that allowed senior citizens who still could drive their cars to share their weekly routing information online with frail, home-bound seniors who could no longer drive. Pretty soon, they were carpooling and sharing rides all around town, getting people out of the house, and offloading the local healthcare authorities who didn’t have time or money to check in on each homebound elder. The connective power of the internet can unleash amazing social support systems that we have only begun to tap into as a society; we must leverage this connectivity if we are to give everyone access to high quality care.

The “second C” I ask you to think about is what I call “careforce.” That is, how do we use information and communication technologies to help skill-shift care to increasingly informed and empowered patients, friends, neighbors, and community health workers? In the era of Global Aging, we simply cannot train enough doctors and nurses to catch up with the demographic realities of the age wave, so we must come up with creative ways to better leverage the family caregivers and community workers who already provide the bulk of daily care anyway. Online training and time banking tools for volunteers, social support networks, decision support tools…all of these can be key enablers for a 21^st century careforce that must learn to assist and complement the hard work of increasingly scarce doctors, nurses, and highly trained medical specialists.

To help achieve this end, we recently launched the “Intel Skoool Healthcare Education Platform” for multimedia content and assessment on mobile computers in Sri Lanka. (Intel World Ahead Program)  This program seeks to expand and to give technology training to 1 million healthcare workers in developing countries by 2015. This will also entail delivering basic electronic health records to children in 5000 schools by that same year. Furthermore, Intel social scientists have continued to study “team based care models” around the world to help figure out what new tools and workflow training is needed to do virtual, coordinated care between general practice doctors, nurses, medical assistants, volunteer community health workers, and patients themselves. We believe developing a tech-savvy careforce—and the coordination tools to support them—is crucial for a sustainable healthcare system in the long run.

The third and final “C” I ask you to consider is “community.” I opened this talk with the call to “take healthcare home.” While I sometimes mean specifically building care capacity in the actual homes of citizens—and that is certainly a focus for our Care Innovations joint venture—I also more broadly mean that we have to move beyond hospital-and-clinic-centric models to home-and-community-centric models. In short, we must learn how to place-shift care to these more inexpensive, accessible settings—for diagnosis, treatment, and prevention. And we must learn how to design buildings and neighborhoods where care-at-home is a priority, instead of an after-thought or a panicked, expensive retrofit for our parents’ homes after they have already become ill or injured.

This may involve putting a telehealth unit—like our Care Innovations “Guide” technology—into the actual homes of chronic disease patients, who can remotely collect their vital signs, get just-in-time video coaching or content, or hear reminders for medication and other behavioral supports. Or it may mean using a health kiosk at the workplace or library or grocery store for a quick checkup, instead of an often un-necessary, expensive pilgrimage to the clinic. Our social science team has been studying models like the Veteran’s Administration Home-Base Primary Care program in the U.S. and various “hospital at home” models in Europe to understand just how much care can safely and effectively be done in the home. As a result, we have come to believe that each nation should be exploring how to achieve the goal of shifting at least 50% of care done in hospitals or clinics today to the home or community by 2020, as a starting point for building a sustainable healthcare economy!

These 3Cs provoke us to ask questions—and to challenge long-standing assumptions—about who delivers care, where it gets done, and how it is funded. And they ignite possibilities for connectivity and computing technologies that we have only begun to explore. In no way do I mean to suggest that we should become “anti hospital” or that clinics and hospitals will go away completely. But we should build and use fewer of them—so that we reduce our dependency on those expensive settings that require more and more of society’s resources to maintain. And we should focus our energy and investment, instead, on building out this “healthcare grid” to the home and community, thus offloading our overburdened mainframe medical systems. At an individual level, these questions can also help us to think about how each of us might reduce our “clinical footprint”—much as we have our carbon footprint—by taking ownership of our own health, wellness, and prevention in a proactive way to reduce our impact on the medical system.

Thanks to the ripples of innovation and policy change coming out of Rio 20 years ago, all of us in this room now know “Global Warming” as a megatrend to contend with. We all now know that there is an international race to be at the front of the pack for developing “green technologies” and “green jobs.” And we now know that, in many cases, developing countries may well leap ahead of developed countries in innovating eco-technology because they do not have the “old way of doing things” to maintain and defend. Their historical lack becomes their potential future gain.

I suggest to you that Global Aging is no less urgent or impactful than Global Warming—it is the other inconvenient truth which has been too long ignored or glosses over. Longevity is a societal “success catastrophe” that requires new thinking and new investment by all of us. Thus, perhaps together, here today, we can move towards making Rio 2012 the beginning of the wakeup call for Global Aging. So too, developing economies may well achieve a 21^st century healthcare system faster than the developed world because there is no old, hospital-centric way of delivering care to protect. Many of you have the chance to move straight to a home-and-community-based care model. I hope these 3Cs help you to think about that possibility. I hope they help ignite your country’s efforts to develop “gray technologies” and “gray jobs” to address the global needs of the more than two billion people aged 60 and above who will share this planet—who will inhabit this room with us—in the not so distant future of 2050.

So, in closing…let’s have no more empty lots waiting for enough cash to build the mega hospital complex that says our community “has arrived.” Let’s use the widely available, increasingly affordable connection technologies that are already here in our midst to build a new kind of healthcare system—a 21^st century healthcare grid—that is available and affordable for everyone….in their workplaces, their communities, and their homes. Let’s build a society in which aging-in-place—in which independence—is a reality, even for those who celebrate more than 100 birthdays.

Thank you. And I look forward to joining you in the breakout sessions and in this noble human endeavor!

To paraphrase Mark Twain, rumors of the demise of healthcare innovation at Intel are greatly exaggerated. Given that many of the world’s healthcare information systems run on Intel technologies, I would go so far as to say that it would be almost impossible for a company as large and as global as Intel not to be working on healthcare innovation, even if we wanted to stop. Yet, because of a birthday I will talk about in a second, there are sometimes perceptions out there that Intel has stopped all healthcare activities. We have changed how we are organized but have not stopped healthcare innovation! And why would we? 

Healthcare is poised to be one of the largest growth opportunities for computing over the next decade. It is already the largest sector of the global economy–and the largest percentage of GNP for almost every nation–even before Global Aging swells the ranks of retirees and reduces the rolls of doctors and nurses available to care for our swiftly aging planet. Globally, we spend more human capital on caring for our health than any other human endeavor. More than 25 countries have recently passed healthcare reform laws with many–like the U.S., China, and Australia to name a few–making massive investments in health IT to “future proof” their healthcare infrastructure for the 21st century. And as computing becomes more powerful, ubiquitous, affordable, connected, and secure, healthcare is finally becoming more automated and algorithmic, from medical devices and equipment to clinical systems running on desktops, laptops, tablets, and smart phones to cloud-based and “big data” servers that enable population analytics and genomics unimaginable even a couple of years ago. In short, the era of Personalized Medicine is upon us, and it will require a transformation of computing as we know it, even as we transform healthcare as we know it.

So why do I bring this up now?

This month marks the first birthday of Care Innovations, the Intel GE joint venture focused on personal health technologies and new care models for the home and community. It has been an amazing year watching Care Innovations launch new products, build its own culture, and move into great new offices near Sacramento, Portland, and New York City! As a small company that inherited great assets from our parent companies, Care Innovations also gained the freedom and responsibility to blaze our own trail. Led by former Intel VP, Louis Burns, Care Innovations is delivering telehealth, independent living, remote patient monitoring, and assistive technologies–and working with care providers around the country to transform their care models using these technologies. As the director of public policy for Care Innovations, I am proud to be part of this venture and will cover many policy issues about shifting care to the home in this blog in the coming months, particularly during this healthcare-contentious election year in the United States.

But I also serve as director of health innovation and policy for Intel, and I want to clear up any misconception about the status of other healthcare innovation efforts at Intel. A year into this, I sometimes am asked whether Intel has ended all other healthcare work and/or spun everything out with Care Innovations. While it is true that there is no longer a single, dedicated business unit at Intel focused on healthcare–what was formerly called the “Intel Digital Health Group” led by Louis Burns did spin out for the most part–there are still well over a dozen Intel teams globally driving a wide range of innovative projects. This website highlights many of the health IT related efforts we are focused on. And below is a sample of some of the activities currently happening at Intel–many of which I will be blogging about in the coming months:

- Intel sales and marketing experts continue to partner with healthcare organizations worldwide on the implementation of health IT, especially around cloud computing, security, and clinician mobility.

- Our Intelligent Systems Group continues to deliver Intel technologies into a wide range of medical customers and devices, from MRI machines to fitness equipment.

- The Intel “World Ahead” program just launched the “Skoool Healthcare Education” platform in Sri Lanka with a goal to help educate 1 million health workers by 2015.

- Various R&D groups inside Intel have explorations ranging from ubiquitous healthapplications on smart phones to the future of biosilicon and artificial organs.

 - Intel architects and engineers have been invited in many countries to help design secure cloud architectures for EHRs, insurance exchanges, and regional health information networks.

- An Intel team is working on the challenge of delivering high performance computing to help usher in next generation genomics for personalized medicine.

- Our global public policy organization continues to work with governments worldwide on health innovation, from broadband plans to changing reimbursement models for virtual care.

- Our team of clinicians, social scientists, and engineers are working on next generation tablet designs for doctors and nurses, building upon the Mobile Clinical Assistant (MCA) reference design.

- Intel recently helped to pilot a telemedicine network in rural Mexico that may well expand to the entire country to help connect patients and medical experts.

- We began work in China–and other countries–on the development of a blueprint on how to build “Age Friendly Cities” that use technology to drive better healthcare quality, access, & costs.

- Our social science team has been conducting ethnographic studies to inform the future of primary care/general practice using coordinated care teams and collaboration technologies.

And the list above continues to grow, not surprisingly, as so many countries and companies invest in the healthcare sector. Each quarter, I bring together Intel teams who are working in some way, shape, or form on healthcare innovation, and I continue to be amazed to find out where Intel’s people and our technologies touch as our compute continuum meets the care continuum from hospital to home. 

So, a “Happy Birthday” goes out to our partner and sister company, Care Innovations! And to all of our Intel collaborators, customers, and colleagues out there, I add: “Healthcare innovation is alive and well at Intel!” Please be sure to continue to reach out to your Intel contacts to find out about the many amazing ways in which we are working on the future of healthcare. After all, Intel’s audacious corporate vision reads: “This decade we will create and extend computing technology to connect and enrich the lives of every person on earth.” If this decade is also the beginning of the era of personalized medicine, it follows that these two visions are well intertwined. There are many of us still painted “Intel blue” who are determined to deliver upon that vision for healthcare. It’s hard to imagine a more exciting business opportunity for our company; it’s hard to imagine a more important calling for our world.

A year ago, I blogged a new year’s resolution that I would blog more in 2011 about what was happening in healthcare reform, innovation, and information technology efforts that Intel is involved in around the world. I knew then that I should have stuck to my prior decade-long resolution not to make new year’s resolutions (or annual predictions, for that matter!) because I didn’t get to blog as often as I had hoped. You would think I would know better by now: best intentions are nice, but you shouldn’t make promises that you can’t keep. So I won’t promise to blog more in 2012–only to do the best that I can.

I used to make these same impossible promises to myself each January about “getting in shape.” Given the number of neon gym membership ads shoved under my windshield wiper while parked at the grocery store, I suspect it is the same for many people. January is about the “I-ate-so-much-over-the-holidays-but-am-now-going-to-eat-right-and-exercise” resolution—to promise ourselves to do better in the nutrition and fitness departments. Thus, we buy not only gym memberships but all kinds of diet “solutions” and home exercise equipment each new year. We buy into these grand promises to ourselves that we will lose 40 pounds or run a marathon. We sell everyone around us on the concept that this is the “new me.” And for most of us, the intent to do the right thing lasts through the first quarter, the energy to do so through mid February, and the commitment just until the stores have sold the last leftover holiday wrapping paper and candy that no one bought at full price.

About three years ago, I finally got off this endless cycle of unfulfilled, self-made promises and set a different course that has produced far better results in terms of my health. I achieved this (and other positive side effects like losing 35 pounds and preparing for a 10k run) first and foremost by firing my doctor. I also fired myself as a “passive patient”–and rehired myself as a key “owner” of my own health and wellness. Many people are shocked when I tell them this, as if they could never imagine switching to a new physician. But it is preposterous that the idea of firing your personal doctor is so preposterous! Many of us demand the best possible service, expertise, and attention when we get our cars repaired, our vacations planned, or the health of our children or parents dealt with, but we somehow will just keep going to the same doctor year after year for ourselves, even when we feel like the relationship is lackluster at best.

In my case, I had gone to the same primary care doc–the one I had sort of stumbled into because he was “accepting new patients” in the brochure I was given when enrolling in benefits at my “new” Intel job–for TEN years! It was not that he was a bad doctor. He routinely saw me once a year. He was friendly enough (though he could never remember that I go by my middle name “Eric,” not my first name “James”). And he dolled out the obligatory drugs for my multiple chronic conditions, small injuries, and the occasional flu as required. The problem was that he was, well, just another passive primary care physician…and I was, well, just another passive patient…caught up in the typical treadmill of reactive medicine as we each waited for the next “problem” to warrant a clinic visit. Over the last five years that I saw him (and I know this because I tracked it in my journal), he literally did not physically touch me during any of my visits. It got so bad that I even joked with friends that “my doctor seems to be afraid of touching his patients” because he simply interviewed me and placed check-marks on a form. But, still, I tolerated and maintained this mediocrity for years: I got my prescriptions; he got his reimbursement from my insurer; our interaction was simply a transaction that neither of us paid much attention to.

I finally got tired of this treadmill going nowhere and decided to look for a physician I loved, not just one I tolerated. I started asking around for recommendations from friends and colleagues, and while most everyone thought their doctor was “fine,” almost no one seemed to love their physician as much as they did their easy-to-recommend babysitter or mechanic or financial planner. Which was strange to me, because people seemed incredibly loyal to their primary care physician and loathe to change to a new one, but unwilling to recommend one. Finally, a colleague at work gave me a passionate recommendation–she said I had to join GreenField Health because she loved all of their doctors and staff whom she had interacted with. I got on their website where they described themselves as “a completely different doctor’s office.” Three years into this relationship, I readily admit that GreenField lives up to the hype: it was a game-changing move for me, and I am someone who loves my doctor, the staff, and the entire setup.

Now, I happily write a $500 check to GreenField each January as an annual resolution and investment in myself and a contract with them that I am very happy to make. This money enables them to provide me with a service–a doctor patient relationship–that I really need. There is no waiting room. I can get an appointment any time. We interact online through secure email when appropriate. I have a physician champion who oversees the complexities of my care across all the specialists I see. They take the time to help me–whether it is a 5 minute call or two hour exam. But most importantly, my doctor there starts with a very different question when we meet. He starts each “visit” by asking, “What should we work on together this year?” instead of the ubiquitous “What’s wrong?” or “What seems to be the problem [for me to fix] today?” This is such an important, radical act to begin with a different question. He immediately enlists me as a partner with him on whatever health and wellness project I want to embark on. In my case, it was getting off the New Year’s diet fad and onto a more ongoing, proactive, preventive, healthy lifestyle. The GreenField philosophy–embodied in that opening question–moves beyond the fix-what-is-broken mentality that governs so much of reactive medicine today to a proactive partnership for better health (and better “cost, quality, and access” as today’s health reform mantra goes). Each year–and I am looking forward to my upcoming January meeting with him–we work on a plan together for my health for the year, and because he can afford through such a financial arrangement to spend time to help me deliver upon that plan, we actually make it happen.

I realize full well that not everyone is in a position to be able to fire their doctor or to pay $500 a year for this kind of personalized service. But each of us can demand more from our doctor and can step up as a partner to own more responsibility for our health. We can begin to get off the reactive medicine treadmill that is premised upon (and financed around) pharmacological fix-its rather than tackling more fundamental health issues. What my GreenField experience has helped me to realize is that we, as patients, have to be active members of a coordinated team and that we need a physician champion to help oversee all the other meds we take, specialists we see, and complex health needs that we have. I’ve been fortunate enough through GreenField to have a taste of the future of healthcare now: a true partnership, a prevention orientation, and a care team who takes the appropriate time to teach and enlist me in my own care and behavior change.

All around the world these days, we hear healthcare experts abuzz with catch phrases like “medical homes” or “patient centered medical homes” or “next generation primary care” or “coordinated, collaborative care teams.” And against the backdrop of these many discussions of electronic health records, meaningful use criteria, quality measurement, telehealth, clinician workflow, change management, age friendly cities, payment reform, cloud computing for clinics, data security, predictive analytics, and personalized medicine–many of which are topics I will end up blogging about in 2012 to some degree–it is important to remember that, at the end of the day, real reform–real innovation in healthcare–has to be about building better relationships between patients and doctors. (Or perhaps there will be better words for these staid, traditional roles, such as “providers” and “partners.”) If all our efforts in reform and healthcare IT come to fruition successfully, then this kind of care I fallen in love with at GreenField shouldn’t be the “boutique” or “concierge” exception for only a few….it should become the norm and standard in care for everyone.

Last week I had the honor of speaking to the American Academy of Home Care Physicians at their annual scientific meeting. I think of these clinicians as both the history and future of healthcare in the United States. They continue to make “house calls” to some of the sickest of the sick in our society–to those who are often too frail to send to a hospital where the stress of dislocation or the risk of infection could have deadly consequences. Thus, these doctors, nurses, and nurse practitioners maintain a tradition of personalized, in-home care that is centuries old. But these clinicians also may be a harbinger of what is to come. They represent what has to happen for healthcare reform to be effective: they deliver contextualized, personalized, compassionate, and collaborative care to individuals at home, often at lower costs and higher quality than institutional settings can afford.

What was most interesting to me is that the entire event was standing room only. It was so crowded that they had to remove the hotel room walls in the middle of the event to expand the venue so we didn’t all pass out from heat stroke or lack of oxygen!  The AAHCP conference is held in association with the much larger American Geriatrics Society conference, and I don’t think anyone ever imagined there would be so much sudden interest in home-based care. Let’s be honest: home care has often been ignored or maligned while our national attention has focused so much on optimizing care in hospitals and clinics. But health reform–in the U.S. and around the world–is finally creating economic incentives to deliver care to people at home, at work, on-the-go, and electronically instead of just “filling beds,” which has been the economic engine of reactive, volume-driven healthcare for a long, long time.

Perhaps equally revealing as to the importance of home-based care to our national economic interests was the fact that I came home with no less than a dozen business cards from venture capitalists, private equity investors, and other business leaders who attended the AAHCP conference because they believe home-based care is poised for significant investment and growth. This is a sea change from the past, where, because of reductions and changes to the ways in which home care has been reimbursed, many investors have treated this industry as an economic backwater. But suddenly, having a well-trained work force of clinicians who can deliver high-quality, highly-coordinated care to people in the community becomes a strategic and all-too-rare asset in a world of ACOs, bundled payments, and risk sharing.

As I prepared for my talk to AAHCP last week, I had an “ah hah” moment–at least for me. And I shared this thought with the audience there at our nation’s capital. While it is hard to argue against one of the major quality goals of U.S. health reform being to reduce hospital readmission rates, why are we satisfied with that as an end goal? I mean, of course it makes sense to get rid of unnecessary suffering and expense by helping patients who leave the hospital to recover quickly and safely within their own homes instead of being rushed back to a hospital with complications after some surgery, accident, or major illness.

But something about hospital readmission rates becoming a major coin of the realm for health reform–an uber quality metric by which many hospitals and health plans will be measured in the future–really disappoints me. First off, why “readmissions”? Why not just focus on reducing hospital admissions in the first place–get rid of the “re”–through prevention, earlier detection of problems, or better triage and delegation to less invasive and expensive care settings? To some degree, focusing on hospital readmissions doesn’t really solve the fundamental problem we face as a nation because it maintains a bed-filling economic incentive, even if we simply specify exactly how long we want to fill those beds to make the math work out.

Furthermore, why stop there? Let’s measure the true quality of healthcare in America–and the true impact of reform–by tracking the reduction of the total number of hospitals in our country! I’ve written many times in this blog space that there will always be a time and place where hospitals are required, but not for every time and place that care is needed. Hospital-at-home models are flourishing in many parts of the world, and some of the Scandinavian countries have consciously and conscientiously reduced their number of hospitals to force themselves to invent other means to deliver high quality care to their citizens. If we aimed our reforms and innovations at bed-avoiding–and hospital avoidance–we’d end up in a very different place, quality-wise and economically.

I know, I know. This is “crazy talk” to almost any audience I could find. Yes, I realize that Americans are addicted to our hospitals. It is almost a rite of passage for a small community that they have “arrived” when they get their own hospital in town. But hospitals often become an economic albatross around a community’s neck. The psychology of “sunk costs” sets in, and every dollar invested in hospital infrastructure becomes a requirement to invest many more in the future to maintain the facility, to be competitive,  and to “keep up with the Jones’s” hospital. We need more and more dollars to maintain and accelerate our “hospital habit” once we become dependent on them. Or, I should say, this is crazy talk to almost any audience other than the American Academy of Home Care Physicians. Because they perform miracles every single day by delivering hospital quality care and intervention in the homes of patients with very limited resources. They already know it can be done.

So they didn’t blink at my suggestion that the real measure of quality over the next couple of decades is not reducing hospital readmission rates, but decreasing hospital construction rates. Or put another way, let’s drive a paradigm that is all about increasing “hospital reconstruction rates”….as we figure out new things to do with those shiny, expensive medical megaplexes we have built all around the country. These home-based doctors, nurses, and nurse practitioners may end up not only tearing down the walls of a conference room to make room for new ideas…they may literally tear down the walls of our medical institutions to show us a better way. They may just be the key to achieving our cost, quality, and access challenges by taking care home again. Or perhaps those investment bankers just ended up in the wrong conference room by accident.

Hear ye, hear ye, read all about it! For those of you who have been waiting with bated breath (you know who you are!), the U.S. Department of Health & Human Services has just published the proposed rules and guidelines for Accountable Care Organizations (ACOs) and the Medicare Shared Savings Program (SSP). You can download the 428-page document here and see the official press release here. Though, unless you are a policy or healthcare reform geek (which I guess I am becoming, frighteningly enough), you might want to wait for the inevitable summaries to be done by various consulting firms, non-profits, and individuals. I will post some of the good ones here when I see them.

These rule-makings around ACOs are a major component of the Affordable Care Act signed by President Obama last March, though most citizens and press outside of the healthcare industry have no clue what this is all about. ACOs are the primary mechanism for beginning to shift the American healthcare system from a volume-driven to a value-driven paradigm. In other words, today, the majority of healthcare is paid based on the volume of face-to-face visits, labwork, and prescriptions generated more than the value of the care provided. And these payments occur regardless of whether the treatments given (and charged for) are effective or helpful. The strategic intent of the health reform bill is to shift to a mode of payment that focuses much more on rewarding the quality of care over the volume of care.

There are three primary aims of these reform efforts (sometimes referred to as “the triple aims” or as “Berwick’s triple aims” named for Don Berwick, the current Administrator for the Centers for Medicare and Medicaid Services). First, the goal is to provide better care for individuals. Second is to improve care for populations. And third is to lower the growth in healthcare costs and expenditures. ACOs are one of many tools to achieve these three aims, and healthcare providers and companies have been eager to see what the Secretary would propose as the specific requirements for becoming an ACO.

Basically, an ACO is a group of care providers–usually centered around primary care physicians–who commit, according to the proposed rules released today, for a minimum of three years to manage the overall care and costs of at least 5000 Medicare patients. And the ACO has to have a legal structure (though they are very flexible on the different kinds of structures permissible) that allows the organization to receive and distribute payments to all its care providers in the management of the care.

So imagine, for example, several physician practices, a hospital, and a home care agency within a particular town coming together to form an ACO to care for at least 5000 Medicare beneficiaries in that community. They would be paid what is often referred to as a “bundled” or “global payment” annually to care for all of the health needs of those patients, and they could participate in the Shared Savings Program by which they could get bonuses based on helping to reduce healthcare expenditures while boosting quality. Lest you think these providers would just ignore the needs of the sickest patients to keep their costs low and leave more shared savings in their pockets (and I should say that I have never met any clinicians in our 10+ years of fieldwork who would be so inclined–the majority are good people who went into medicine to help people), there are clear rules and data-driven quality measurement mechanisms that prevent that from happening.

I am particularly heartened to see some of the following language in the proposed rules:

• The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies (p.17)
• The ACO shall demonstrate to the Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans (p.17)
• An ACO will manage resources carefully and respectfully. It will ensure continual waste reduction, and that every step in care adds value to the beneficiary. An ACO will be able to make investments where investments count, and move resources to meet beneficiaries’ needs. Because of its capabilities with respect to prevention and anticipation, especially for chronically ill people, an ACO will be able to continually reduce its dependence on inpatient care. Instead, its patients will more likely be able to be home, where they often want to be, and, during a hospital admission, they receive assurance that their discharges will be well coordinated, and that they will not return due to avoidable complications (p. 25)
• An ACO will be proactive by reaching out to patients with reminders and advice that can help them stay healthy and let them know when it is time for a checkup or a test (p.25)
• An ACO will collect, evaluate, and use data on health care processes and outcomes sufficiently to measure what it achieves for beneficiaries and communities over time and use such data to improve care delivery and patient outcomes (p. 25)
• An ACO will be innovative in the service of the three-part aim of better care for individuals, better health for populations, and lower growth in expenditures. It will draw upon the best, most advanced models of care, using modern technologies, including telehealth and electronic health records, and other tools to continually reinvent care in the modern age. It will monitor and compare its performance to other ACOs, identify and examine new processes for care improvement, and adopt those approaches that are demonstrated to be effective (p.25)

While I have several hundred more pages to go, my initial read shows some very promising directions. The rules feel very innovation-friendly and leave lots of flexibility and experimentation for communities to try different approaches to setting up ACOs. The focus on “patient engagement” shows a much-needed momentum around providing tools and expectations for patients to be a more proactive and responsible party in our own care. The explicit references to the use of telehealth and remote patient monitoring and the calling out of the need to move care to the home shows that CMS “gets it” in terms of the need to “place-shift” (a topic I bring up frequently in this blog) where care occurs away from more expensive settings like hospitals. And the requirements for incorporating and using data-driven, evidence-based tools to drive best practice care and continuous innovation/improvement will help us finally achieve a 21^st century healthcare infrastructure that is scalable and competitive, internationally.

I will post more of my own and other peoples’ summaries over the next week. Meanwhile, what say ye?

Last week I had the honor of speaking to the City Club of Portland, an organization founded in 1916 to highlight the diverse opinions, issues, and talents of local leaders and organizations. I often hear their Friday Forums on Oregon Public Broadcasting radio while I am driving home from work, so it was a real treat to be there in person in the grand Governor Hotel in downtown Portland. I very much appreciate the City Club members inviting me and giving visibility to the important issues of Global Aging and what I have frequently referred to in this blog as “gray technologies.”

The title of my talk was “Technological Innovation and the Future of Aging”–you can click here to find a free download of the audio cast of the speech–in which I focused on Oregon’s opportunity to lead in the development of new technologies, services, and jobs that promote independent living for our graying population. I shared some of the research prototypes and findings that Intel, Oregon Health & Science University (OHSU), and the Oregon Center for Aging and Technology (ORCATECH) have developed from our more than ten years of exploration into home-based technologies that can help people to age-in-place with good health, social engagement, purposefulness, dignity, and choice.

I promised attendees (and the many radio and TV listeners who have been writing to me ever since!) that I would post some links where you can find more information. To that end, here are a few that I referred to in my talk…

ORACTECH, the Oregon Center for Aging and Technology at www.orcatech.org, is a passion-driven, grass-roots center founded in Oregon Health & Science University to help coordinate statewide collaborations around independent living technologies amongst universities, companies large and small, non-profits, and government agencies. The funding to get this started came from Intel’s $3 million dollar donation to OHSU and a prestigious NIH Roybal Center Grant awarded to ORCATECH director, Dr. Jeff Kaye and his collaborators. You can join the mailing list by emailing orcatech@ohsu.edu or, if you are local to Portland, come join “upcoming events” announced on the web page.

CAST, the Center for Aging Services Technologies at www.agingtech.org, is a non-profit advocacy organization I helped to develop with the American Association of Homes & Services for the Aging who recently changed their name to LeadingAge. CAST is a national (or actually, now international) version of ORCATECH, designed to bring together providers, university researchers, technology companies, and others to help ignite a wide array of innovative technologies and services to help seniors to age-in-place from the “home” of their choice. Be sure to view the free CAST vision video shown to Congress and the last White House Conference on Aging.

The TRIL Center, or Technology Research for Independent Living, at www.trilcentre.org based near Dublin, Ireland, is Intel’s largest investment in independent living technology research with a $30M joint investment with the Irish government. TRIL includes our multidisciplinary Intel team and three universities in collaboration with St. James Hospital in Dublin to invent and test out these home health and independent living technologies. You can learn more about the falls work there at the TRIL Center site, as well as go here to read more about the Shimmer “matchbox-sized wireless computer” I described in the talk.

ETAC, the Everyday Technologies for Alzheimer’s Care initiative, a collaborative program between Intel and the national office of the Alzheimer’s Association, has published information here about the grants that we have funded since 2004. This was one of our first programs to start funding university research on independent living technologies and has produced a great international community of dedicated researchers and entrepreneurs focused on Alzheimer’s care specifically.

Care Innovations, at www.careinnovations.com, is the name of the newly formed joint venture between Intel and GE to produce disease management, independent living, and assistive technologies for the home. Full disclosure: I run healthcare policy for Care Innovations (in addition to my Intel role). I didn’t feature our products at the City Club talk because my focus was on the R&D infrastructure that Oregon has built, not a commercial for our products. But I don’t want to leave the impression that everything is stuck in research…Care Innovations (and many other companies) is diligently working to get these kinds of aging-in-place solutions to market worldwide!

And realizing now that I had to fly through my recommendations to the state of Oregon at the end of that lecture (I warned everyone that, without PowerPoint, there was no predicting what I might say!), I want to highlight some of the main points I tried to make last week. My overall thesis was that Oregon has some enormous advantages in trying to become an international leader of independent living technologies and jobs. Just as we have with Wave Energy and Biotech, our state needs to bluntly ask ourselves as Oregonians what future industries we could really lead in?  I argue that Oregon is already a big fish in the small pond of independent living R&D and that we should put forth a state plan to go after this opportunity.

So, why Oregon?  What are our particular strengths?

1) We have a head start: We can build upon the foundational technologies, data, and know-how of ORCATECH, OHSU, Intel and many others in our state who are recognized leaders internationally in this emerging field. Today, we already host numerous Minister of Health and other visitors in our labs, as other countries and states come to see what Oregon is doing. Now we need to make sure our own state knows the assets we have!

2) We have our own fiscal challenges: Oregon itself is already in the top ten of states with the highest percentage of an aging population, and we likely face cuts to our Home and Community Based services as we, like so many other states, try to balance a budget in the midst of a recession. We need independent living and home health technologies just to drive up quality and drive down costs of the care for seniors–and people of all ages–in our own backyard.

3) We have flexibility. Though many of my friends and colleagues in the long term care industry in our state would like to see even more flexibility, we need to realize that we have more regulatory/licensure freedom to pilot and develop new care models for seniors than do many other states. Less red tape for us means faster innovation cycles and learnings than many other states can produce!

4) We know high tech. There is a large information technology presence here in Oregon to draw upon–not just Intel but many other technology companies who have intellectual property, innovation methodologies, and entrepreneurs to bring to the challenge of addressing Global Aging.

5) We are the right size. I believe we are the right size and geography of a state to develop independent living technologies and the care models to use them. It is hard to imagine a state as large as California or as small as Delaware doing this. With our four million citizens living in a mix of rural and urban environments across the state, it is conceivable and achievable to build a state-wide strategy and infrastructure to enable aging-in-place.

6) We can collaborate with Asia. Oregon is already seen as a “gateway to the Pacific Rim” with a wide range of trade and research collaborations going on with Asian countries. Having just keynoted to the APEC (Asia Pacific Economic Cooperation) meeting just weeks ago in D.C., I can tell you that the need and market for independent living solutions in Asia is significant given the longevity in many of the countries there. If done right, our state plan for Global Aging should foster collaboration and export of our Oregon technologies and services to some of these countries.

7) We have national political leaders for aging issues. It is rare as I make visits to Congress that members know much about gerontology, but when I visit the Oregon delegation, they often end up teaching me more than I do them! Senator Wyden has a background in gerontology, as does Congressman Peter DeFazio, and both have shown a commitment to aging and health reform issues in their political careers. I believe we should be leveraging their understanding and leadership on aging issues to make Oregon the center of the independent living technology universe!

8) We are committed to healthcare reform. I had the pleasure of hearing last week’s “Think Out Loud” radio segment on OPB that was exploring healthcare reform in the state of Oregon. Dr. Bruce Goldberg, head of the Oregon Health Authority, was clear (and I couldn’t agree more!) that we need to transform our culture and infrastructure to do health reform right. At the end of the day, aging-in-place is not about technology but about transforming our culture of care for seniors, and the technology is simply a tool to help do that. But if we are a state prepared to be at the forefront of acute care/hospital/insurance reform, let’s make sure we do the same for long term care!

9) We have a legacy to uphold. Last but not least, innovating aging is in our blood…is in our history…as a state. Oregon is widely credited as the state who invented end-of-life or hospice care, which became a national standard and movement. Similarly, we are known for pioneering the concept of “assisted living” which is, of course, now common-place and taken-for-granted. In many ways, the rest of the country is just waiting for Oregon to invent “what’s next?” for the care of seniors, so let’s not disappoint them!

We should make no mistake as a state to think that we can rest on our laurels or that we will just end up becoming the leader of independent living technologies without investment or a plan. Other states are competing to create these technologies and jobs; I have worked with officials in New York, Minnesota, California, and Florida who are trying to get their act together on this front. I am biased as an Oregonian to want to make sure it happens here, but at the end of the day, may the most organized and proactive state win!

So what would my calls to action be for Oregon? What should we be doing to capitalize upon this opportunity?

1. I call upon Governor Kitzhaber to put together a commission to develop a state Global Aging response plan. Let’s bring together industry, community, and academic experts to identify how we can use independent living technologies to care for our own elders and families and also evaluate new business and job opportunities in this segment. I will certainly volunteer my time to participate!

2. Let’s commission an inventory of Oregon’s assets on aging-in-place…let’s show what we’ve got and what we are missing in terms of building out an R&D and new business incubation infrastructure for independent living technologies and services.

3. We need to identify, with our nursing and medical schools, what new kinds of careworkers and curriculums are needed to enable aging-in-place care for seniors (and people of all ages). If Oregon can develop the models for training and credentialing community workers and volunteers who can use these new technologies to do care delivery in the home, community, and electronically, then we will be the likely creator of the first national call center for electronic care & support for elders. With that asset, we would be a fierce competitor nationwide!

4. Let’s make sure that our current and future technology infrastructure investments–for broadband, for Electronic Health Records, for insurance exchanges–are being designed and built to support aging-in-place and to carry data/transactions from hospital to home. If all we do is connect and coordinate care in hospitals and clinics, then we will fail to achieve the kind of health reform required to make us fiscally, morally, and medically strong.

5. We need to build upon ORCATECH to develop the nation’s first 10,000 household cohort of seniors who can help test and prove the value of these aging-in-place technologies and care models. Today, we have about 300 households in the Portland metro area who are outfitted with these kinds of systems, but we need 10,000 homes across the state to deliver the statistical and economic data that proves which systems are most valuable, usable, and useful. If we build this kind of large-scale R&D infrastructure, it will be very difficult for any other state to supplant our position as a leader in this sector.

6. Like many other states are exploring, let’s develop a policy framework for seniors in our state that makes aging-in-place a right. If we set that as an overarching policy goal, then it will help to guide our activities and priorities for the full range of services–meals, medication assistance, transportation, social support, mental health, healthcare, etc.–that are needed to give people a high quality of life at an affordable cost from a place of their choice.

7. Let’s set an audacious goal–a 2020 vision–to move 50% of care in Oregon out of institutions and into homes and the community in 10 years. We may not achieve 50% or it may happen faster than 10 years, but if we set a goal that everyone knows and can aim for, then we will achieve great progress towards an aging-in-place agenda!

In closing, I want to reiterate a message I have played over and over again in the pages of these blog entries: we need to prepare for Global Aging much as we do Global Warming. Just as our state (and our nation), are competing to try to become a leader in Green Tech industries to address Global Warming, so too, we should be competing to become a leader in Gray Tech industries for Global Aging. The issues and needs are no less urgent or pervasive; the opportunities for economic growth for the state are no less promising. And if we are truly a state committed to healthcare reform, then let’s make sure that commitment includes long term care as we figure out how to improve cost, quality, and access for people of all ages.

Our planet is aging. 1 out of 7 people will be 65+ by 2025 and there will be a shortage of doctors, nurses, and midwives worldwide (WHO reported that this shortage was already  4 million in 2006) to care for them. With more and more care moving home, 1 out of 3 American adults, 53 million people today deliver informal care. The value of the services family caregivers in the US provide for “free” is estimated to be $306 billion a year. Several factors like this are already pushing for the need to better manage our aging population and move traditional care to home-based models.

To learn more about this important topic, you are invited to the City Club of Portland’s Friday Forum on March 25th.  To reserve your ticket click here.

Eric Dishman, Intel Fellow and Director of Health Innovation and Policy, Intel Architecture Group, will discuss new “gray technologies” that may enhance social engagement, disease management, cognitive support and healthcare at home.  For the past 12 years, Intel researchers in Oregon–in collaboration with the Oregon Center for Aging and Technology (ORCATECH)–have studied the needs of more than 1000 elderly households in 20 countries to invent and test out new technologies.  Dishman will provide examples of research conducted and he will also address how Oregon is at the forefront of developing new technologies, services, care models and jobs that address the challenge of global aging.

If you are interested in attending this event, please  click here.

United nations department of economic and social affairs. 2007b

I am on a plane returning from the annual HIMSS conference on health information technologies. As I watch the borderless states go by far below, I can see the lines and circles of our interstates and highways, which previous generations had the vision and audacity to create for us. Even with the depressing news headlines in the seat pocket in front of me about violence in Libya, continued economic uncertainty, and the threat of $5 gas prices, I find myself, well, inspired.

Last Friday I had the honor of attending President Obama’s visit to Intel in Oregon. Our CEO, Paul Otellini, gave us some much-needed good news about an additional 4000 jobs Intel will create in the U.S. this year as well as investment in a new Arizona fab. Then the President, humbly and humorously, took the stage in celebration of the accomplishments of some student winners who had invented amazing things in Intel’s education and science fair competitions. In his State of the Union address weeks ago, the President said we should celebrate the science fair winners as much as we do the winners of the Super Bowl, and we did exactly that. Then the President celebrated the magic of Intel’s microprocessor manufacturing. It was nothing less than inspiring.

As part of the President’s “Winning the Future” message, he and Paul reminded us of the importance of investing in education, science, and technology to help a nation solve its own problems and to compete globally. Afterwards, I had the thrill of shaking the hand of the President and speaking with him ever so briefly in what, for me, was the best receiving line of my life. I thanked him for having the courage to push for healthcare reform, introduced myself, and he shocked me when he thanked me for Intel’s work on healthcare innovation to move care into the home. Yes, I was star struck. I was, for once, speechless. I was inspired.

In today’s world, it is easy to be cynical. It is easy to be partisan. It is easy to simply dismiss “Winning the Future” and the President’s visit to Intel as mere electioneering or advertising. And I well recognize that the word “innovation” is fast becoming hackneyed and cheapened in our discourse from overuse and manipulation. It is actually harder to choose to be inspired–and to invest the effort to make these words and slogans real. But here’s the thing: I believe in winning the future. I believe in investing in new technologies, industries, education, and jobs that help us compete globally. And I believe we have to do all of these things for healthcare in particular, with urgency.

Which brings me back to the HIMSS conference, where I had the good fortune to share the stage with the President’s Chief Technology Officer, Aneesh Chopra, in a panel about healthcare innovation and the hot topic of the conference: Accountable Care Organizations or ACOs. Aneesh gave a rousing call-to-action for those on the front lines of healthcare to reimagine and reinvent our healthcare system. He explained how elements of the reform bill such as the CMS Innovation Center and the transition to value-based payment (through care models like ACOs) are meant as mechanisms to open up healthcare innovation, not to prescribe one-size-fits-all solutions from Dr. Government to the medical masses. And, echoing Paul and the President’s Friday messages, Aneesh reminded us that healthcare–like every other part of our society–faces a global competition and that the United States must become an exporter–not just an importer–of  new technologies and services for next generation healthcare.

There was a great deal of discussion about ACOs at HIMSS–some decrying them with gloom-and-doom scenarios, some celebrating them as utopia. But I think those positions miss the real spirit and intent of the healthcare reform legislation. Neither Aneesh, nor the President, nor the Secretary of Health, nor the federal agencies rushing around to implement these reforms are claiming that ACOs will solve all of our problems or that they have it all figured out. They are, quite simply, instigating innovation and creating the conditions (investment,incentives for quality, regulatory support, collaboration, innovation training, data mining, etc.) in which American ingenuity can come to the rescue of our outdated, unsustainable healthcare system. Healthcare innovation in America is going to happen–indeed, it has to happen–whether in the form of ACOs or something else we haven’t imagined yet. We just have to get started without delay.

It is important to realize that healthcare reform is a global competition to invent the 21^st century care infrastructure, technologies, services, and jobs that each country needs to solve its own demographic/economic challenges and to export to the rest of the world. Healthcare reform and economic stimulus are intertwined. At HIMSS and here in this blog, I have described this as the race to invent “gray technologies for Global Aging,” just as the U.S. and other nations are in a global competition to create green technologies, industries, and jobs to address Global Warming. Same message: solve our problems; grow our economy by exporting our solutions.

The United States can’t bury our heads in the sand on the issue of Global Aging, but it feels like we are doing just that. Meanwhile, other countries heed and lead. The European Union recently announced Aging as one of its top priorities, launching a new EU Active & Healthy Ageing Innovation Partnership. Intel just joined a Global Coalition on Aging effort with APEC (Asia Pacific Economic Cooperation) as well as the China Public Private Partnership for Health to help other countries put together strategies and action plans to deal with the age wave and the resulting healthcare challenges it has created. But somehow the U.S. has failed to face this other inconvenient truth with equal intensity and urgency.

Thus, I call upon the President to inspire innovation–to bring his “Winning the Future” message–to healthcare and to work with Congress to do four simple, powerful things to get us started:

1) Create a national commission on Global Aging preparation, innovation, and competitiveness to catalyze U.S. imagination, investment, and action in this sector;

2) Convene a White House Conference on Aging on the topic of Global Aging, with Presidential sponsorship to bring together the nation’s brightest minds and ideas for building out our aging-in-place infrastructure and healthcare system;

3) Make aging-in-place and innovative models of long term care a fundamental pillar in the reauthorization of the Older Americans Act;

4) Build innovation capacity within every federal agency that touches healthcare, so that we keep iterating and improving healthcare quality, cost, and access over time. After all, no one healthcare reform bill, no single care model like an ACO, no one wave of health information technology will solve all our problems; we need to create a culture of continuous innovation in healthcare. All that innovation that the President celebrated at Intel–from the 7^th grade students to the fab workers–is not really “magic.” It is innovation, education, process, and rigor that can be brought to government, too.

Let’s inspire the U.S. innovation engine for healthcare–that could be our most important Sputnik moment in the midst of Global Aging. And that could help insure that we, like the generations before who gave us the highway system, the airport transportation system, and so many other national capabilities that empower modern life, leave behind a healthcare system that is available, affordable, and amazing for ourselves and all who come after us.

I rushed home in crazy, foggy traffic Tuesday evening to see the President’s State of the Union address. I had left work hours earlier to head to a doctor’s appointment that had taken me four months of delay to get. I showed up fifteen minutes early, knowing that I would have to do the “New Year” fill-out-the-paperwork-all-over-again-routine upon arrival. Sure enough, the woman at the front desk handed me a clipboard and a germy ballpoint pen, saying, “James, please fill this out and let me photocopy your insurance card.”

Once again, she called me “James” even though I have explained to them for nine years running that I go by my middle name “Eric.” Once again, I corrected their medication list that was at least five years out of date–which is baffling to me since I have corrected it each time I have come to the clinic. Once again, I sat in a cough-and-hack filled waiting room for over an hour after my supposed appointment time came and went, with the attendant’s voice repeating “the doctor will be with you as soon as possible” like the droning security announcements one hears at the airport.

Finally, I had my seven minutes with the doctor, who asked “James” a few questions, fumbled through a yellowed folder of paper lab work looking for my latest bloodwork numbers (which he never found), and typed a bunch of stuff in what appeared to be a software program from the 1970s. He never physically touched me during the entire visit. It could and should have been a five minute phone call. But this was the price to pay to get my prescriptions renewed, which he dutifully handed to me as I rushed out the door to the awaiting traffic jam.

I got home in time to miss all the pre-punditry and pageantry, just as President Obama was starting to speak, and just as my wife was finishing up a frustrating call with her own doctor’s office trying to find the results of some routine tests she had gone through the week before.  My wife sat beside me in a rage because the nurse had finally told her that one of her test results was abnormal–but that this test is “often abnormal” so the doctor wants to do a series of other tests–but that my wife would have to schedule an appointment with the doctor for any further information because the doctor doesn’t have time to do phone calls.

Then we sat together listening to President Obama lay out his vision for American competitiveness and the need for innovation and investment for us to compete in the global economy. And I about literally fell out of my chair at the point in which he talked about the importance of building out a next generation internet infrastructure: “This isn’t about faster Internet or fewer dropped calls. It’s about connecting every part of America to the digital age. It’s about a rural community in Iowa or Alabama where farmers and small business owners will be able to sell their products all over the world. It’s about a firefighter who can download the design of a burning building onto a handheld device; a student who can take classes with a digital textbook; or a patient who can have face-to-face video chats with her doctor.”

On any day of the week, I would have celebrated this important soundbyte, given my ongoing advocacy for using 21^st century technologies to redesign our healthcare relationships and responsibilities.  Electronic care–or “e-care” as many of us have come to refer to it–must be a part of reforming our healthcare system, and there is enormous potential in leveraging information and communication technologies to drive better healthcare quality, cost, and access. But to hear that sentence from the President on a day in which both my wife and I struggled to be educated, empowered, proactive patients up against a healthcare infrastructure still stuck in the days of fax machines and a healthcare business model premised upon face-to-face visits for every care encounter…well, it was lucky serendipity at least, and I’ll take it as a more fate-full sign of positive things to come!

The speech may not have been the President’s “most inspired”, but looking back on it, I think it may be one of the most important and serious. We have to wake up as a nation to the fact that we are not on a path to compete in a global economy for inventing the next generation of transportation, education, or healthcare systems. We have to recognize that, at this moment, we no longer have the educational base, the scientific edge, or the economic power to be the leader of  “what’s next” as we have so often been in the past. We can get there again, but not without changing our plans and attitudes.

In the case of healthcare, we’ve got to stop the polarizing and misleading rhetorics around “government takeovers of healthcare” versus “evil insurance companies” and realize that America has to  get its competitive act together to invent and invest in a 21^st century healthcare system. Much as we face Global Warming, we must deal with Global Aging, which presents us with both threats and opportunities. We have the opportunity and, indeed, the strategic imperative ahead of us to invest in new technologies and industries that will enable a global, 21^st century healthcare system. We can and must reform our own healthcare system amidst serious economic crises we will face due to Global Aging; we can and must create a lot of new jobs and industries for ourselves along the way.

What concerns me the most in the media cycle following the President’s speech is the cynical characterization of his call for “investment” as merely a smokescreen for “spend, spend, spend.” There is no doubt that we have hard decisions to make about how to deal with the deficit, how and where we allocate our resources, where we cut spending, and where we increase spending to invest in strategic capabilities that help our country grow new industries, markets, and jobs. We can certainly neither “tax and spend” endlessly, nor “slash and burn” recklessly.

But investment means more than spending. It means choosing key areas to try to grow–informed by data, a strategy, a plan, and a means of determining returns on that investment over time. As we revise and improve the health reform bill, we need to move from a “reform” mentality to an “innovation” mentality about healthcare. We need government, education, industry, and the not-for-profit sectors to  develop an investment plan and strategy that achieves our urgent cost, quality, and access goals for healthcare while also opening up new markets for American goods and services. Innovating 21^st century healthcare–the largest sector of every economy and an issue important to every one of us–can generate our next Sputnik moment, if we decide as a nation that we want to lead again–and hold our elected leaders accountable for showing great returns on our national investments.

Meanwhile, I’m going to go search for a new doctor–one who is ready to do secure email and video visits with an empowered patient. I’m tired of waiting.

If , while reading this blog, you have a medical emergency, please stop reading and dial 911 or go to a nearby emergency room. Because sometimes you just need help from a doctor or other medical professional. But what about all of those other times–that aren’t emergencies–where you aren’t sure you really need to see someone, just need a little information, or have a small worry where a nurse or doctor might ease your mind? Can an advice nurse help triage and assuage your healthcare concern over the phone? Does a quick search of the internet help or harm your confidence in knowing what to do? Is it worth making the appointment, trip, and co-pay (assuming you have insurance) to visit your care provider?

I recently wrote about the hype cycle around the topic of “mHealth.” But it’s certainly not the only hot topic making the rounds in the U.S. marketplace of healthcare ideas right now. Perhaps running a close second for the most-hyped award is “accountable care organizations,” or “ACOs” for short. I’ve just landed in Washington, D.C., where I know of no less than five workshops this week on ACOs, yet few consumers (or clinicians for that matter) understand–or have even heard of–this concept, which is a pretty significant aspect of the healthcare reform bill here in America.

ACOs refer to models of care, payment, and governance whereby different healthcare entities in a community (physician groups, hospitals, home care providers, specialists, long term care providers, etc.) come together to form a new kind of organization that is accountable–and paid collectively–for the annual, holistic care of a large group of patients. There are many different kinds of ACOs being proposed and explored, especially via the newly-forming CMS Innovation Center (CMMI) set up to pilot these kinds of approaches. I found the Deloitte whitepaper on the topic to be a helpful summary of the ACO concept.

The bottom line is that, importantly, ACOs are one way of trying to shift our payment model for healthcare in America from a “fee for service” paradigm (doctors and nurses get paid for each office visit, lab, or prescription they generate) to a what I think of as a “fee for results” (medical professionals get paid for delivering great quality care and improved outcomes for their patient panels). Think value, not volume of visits. It’s ultimately about setting up incentives that move us beyond this factory-line, fix-it, fee-for-service, face-to-face care mentality that has dominated our conceptualization of healthcare for a long, long time and that no one–providers, patients, payers, or politicians–is happy about.

I am certainly guilty of adding my voice to the echo chamber on this one as I fly around giving lectures and helping healthcare providers develop their technology strategies for becoming an ACO. But I fear we may be missing the real opportunity for meaningful healthcare reform if we focus too much on the “accounting”–the numbers, salaries, bonuses, and quality measures that will certainly be controversial and suspicious to a lot of healthcare professionals–and too little on the “accountability” that these new care models must instill in all of us. Yes, we must figure out fair, sustainable ways to do clinical payment, governance, and liability as we try out ACOs, but we must also foment a shift towards a culture of accountability for care on the part of patients, clinicians, payers, and everyone involved in healthcare.

At the end of the day (and as much as we don’t like to think about it, especially when we face a medical catastrophe and want every test, procedure, and drug in the book thrown at the problem), healthcare resources–doctors, nurses, bed space, drugs, equipment, education/training resources, and dollars–are limited. Our workforce of trained healthcare professionals–especially primary care doctors and nurses–is dwindling in the midst of global retirement and demographic trends. And somehow–perhaps the bureaucratization of care, perhaps the actual and perceived declines in salary and status for healthcare providers–we’ve not filled the pipeline of healthcare workers fast enough to keep pace with the age wave that is producing a large number of older, often sicker patients.

As with “natural resources” that are scarce or declining, we as a society have to figure out more effective and efficient ways to use and sustain these precious healthcare resources. We need an accountable care culture, in which we all play our part to nurture, sustain, and improve the care resources we have around us. We will have to all change our attitudes and behaviors about how we utilize healthcare resources. In the midst of Global Warming and worldwide conflicts around natural resources like oil and natural gas, we have seen new behaviors, industries, and consciousness emerge. We have become more accountable for our energy use–as individuals and institutions–to reduce our “carbon footprint” whenever possible. So, too (and with surely as much debate, disagreement, education, and struggle as we have faced with energy consumption), we must come to be more conscious and conservationist in our clinical consumption. We must learn how to reduce our clinical footprint.

So what would it mean for us to mind our clinical footprint? I honestly don’t know, entirely. But I am pretty sure that if we only use things like ACOs to change the behavior and payment paradigms of clinicians without also changing how consumers, companies, and cultures manage their own health and resources, then we are doomed to fail. Certainly, doctors, nurses, and other healthcare professionals need to at least be open to these new models of care coordination and accountability for managing the whole patient population with more attention to the costs and benefits–to the value–of different procedures and therapies. And we as patients need to be conscious of at least the days, dollars, and drugs we consume in our quest for health and wellness.

But there is more to accountability than making all of us healthcare accountants, tracking every dime and minute we use the healthcare system. “Accountable” also means taking personal responsibility for something. It means patients will need the means–and the mandate–to take personal responsibility for our health and wellness with more consciousness of–and commitment to–healthier behaviors. And it means medical professionals will have to shift into a mode of coaching and teaching us more about those preventive behaviors, not just putting us back together again when we’re broken or sick.

Some skeptics will say that we’re simply making everyone a healthcare “bean counter” or fomenting a “nanny state” whereby the government controls our behaviors, but I believe we can become more accountable as a culture without going to those extremes. Today’s volume-driven paradigm has made us, as patients, too passive about owning our own health and care, too ignorant of the costs and benefits of the things being done to us in the name of healthcare, too divorced from the financial aspects of care, and too ignorant about whether or not those procedures are likely to prove beneficial. No one should hesitate to dial 911 when help is needed, but nor should we be absolved from trying to minimize our clinical footprint of the healthcare resources we use. If the current hype around ACOs can help stir up that kind of consciousness and personal responsibility, then it will have created healthcare reform, indeed.