This article originally appeared in the Fall 2022 issue of the Ontario Medical Review magazine.
Zayna Khayat, PhD, is a future strategist and vice-president of Growth and Client Success at digital health-care solutions firm Teladoc Health. She is an adjunct professor of health sector strategy at the Rotman School of Management at the University of Toronto. In this exclusive Q-and-A for the Ontario Medical Review, Khayat was asked to describe the future of health care and what doctors can do to prepare.
Zayna Khayat is a future strategist and vice-president of Growth and Client Success at digital health-care solutions firm Teladoc Health. Khayat describes what health care will look like in the future and what doctors can do to prepare.
Khayat: There are three major forces that have come together at the same time that make the current way we do things inconsistent with the future.
Patients and their families have information at their fingertips and COVID accelerated this shift. People got more comfortable with alternative ways to do things so there’s this pull toward the future. We designed health care 150 years ago without these very important people in mind. It’s a reckoning, to be honest.
The second big force is the business model fundamentally doesn’t work, in particular for primary care. When your business model is broken, it means your ability to do what you need to do to add value in an economically sustainable way is not working. Demand exceeds our capacity to deliver in the current architecture. The way the resources and payment models are organized does not make sense for today’s needs. When your business model is broken, you either go out of business (which means rationing, wait times) or you rebase the business model; that’s what innovation is.
The third parallel force is there’s technology to do something about the first two. A lot of people think of technology as a separate thing over there that’s cold and expensive. Technology replaces labour and physical assets – either it completely replaces them (like an antibiotic pill that replaces the need for hospitalization) or it makes the current labour and assets a lot more productive (like a self-scheduling tool that frees up a receptionist to support more complex and high-stakes, patient-facing engagement). Since most health-care delivery is labour and physical assets that cannot keep pace with demand, the possibilities abound for technology to help ensure health care is sustainable, while also meeting patients where their expectations are for a great experience. That is, technology allows you to break the economic constraint of health care which we’ve been stuck in — more hospital patients, more beds, build more buildings, train and hire more clinicians, etc. And technology allows us to create a patient experience that is unlike anything before.
The combination of these three forces – patient revolution, unsustainable business model, technology – are both propelling us to the future or repelling us from past models that no longer serve.What could the future of health care look like?
Khayat: I organize the future of health care into a few topologies, different cuts at looking at what’s different, what is shifting today, all over the world.
The first shift is the timing of when health-care services are applied along a patient health journey. Timing is shifting from sick care – reactive care – to proactive and even predictive care.
For example, you’re a single parent, you struggle with income security, you’ve got a difficult family situation to navigate. Health systems are shifting resources to proactively intervene a lot more upstream from when symptoms onset, to prevent sickness from happening.
The next level of the timing shift is towards predictive health care; this is where technology comes in. Algorithms will readily predict based on patterns of people’s normal ‘digital exhaust’ as we all now live in a digital world. For example, what did you search on Google this morning? Every day you walk this way, but today you’re walking less or a different way. The algorithm will detect that something’s up; it can pair-match you to a million others like you and suggest this person is likely to soon have a hypoglycemic episode or kidney failure or schizophrenic escalation. Ninety per cent of all health-care resources are spent on reactive sick care, medical care. It should and will be switched to the fair share of resources moving upstream towards stopping the escalations from ever happening.
The second shift is personalization. The current industrial model of health care says everybody gets what works for the average, which means nobody’s needs get met. Patients are largely getting one care model for all, or what I call a ‘segment of one.’ We had to organize health care that way because that was the most efficient approach and the easiest way to be equitable. Now we can efficiently design hyper-personalized care, where we shift from a segment of one to an ‘n of 1.’ That’s not just personalization based on your biological signature, such as genetics. We’re talking personalization based on comorbidities, demographics, language preferences, sexual identity, you name it. You could use dozens of variables to personalize care and treatment plans, in real time.
The third shift is the location or channel or modality where care is delivered and received. We’ve timeshared and centralized care into clinics and hospitals and buildings because we pulled all the expertise and the equipment to these places, and we made the patients come to get care. Those days are over. Just as malls and stores are no longer the dominant channels to purchase goods and bank branches are a minor channel to access financial services, physical places to go to for care will be a minor modality. This is a reckoning for Canadian health care because we are largely organized around buildings and visits. The visit-based paradigm makes little sense with new models of care because you don’t need all the action to go down in a 15- to 20-minute time slot where we timeshare a physical location or an expert’s time. The value creation from care actually happens in between these points that we call visits. The future of place in health care will be decentralized, dephysicalized, and a seamless, frictionless intermingling between physical and digital experiences. Care anywhere could mean the home, the workplace, school, in your car or truck, etc. It’s wherever people are, versus making them come to you and saying that’s the only thing that ‘counts’ as quality care.
The fourth shift is moving from episodic and intermittent care to continuous care. This shift takes a few forms. The first is no longer treating the person as a constellation of body parts and diseases, where each is treated by separate care pathways. The other is using the precious time in between ‘visits’ to gather, monitor and intervene in important dynamics with the patient. That’s where sensors and wearables come in. Instead of getting one sleep apnea test at a high-cost clinic with an expensive staffing model that costs thousands of dollars and can only be done once at usually an inconvenient time or place for the patient. And that one night, depending on how you sleep on your back with a bunch of wires on you, determines a multi-year treatment course afterwards. Now, you can do it at home with inexpensive simple technology, do dozens of apnea tests – and make an evidence-based decision on treatment in real time. That’s going to happen to nearly every diagnostic that is currently largely done in facilities with time-shared equipment, clinicians and technicians.
Then the last shift is the currency – i.e., what metric we use to measure value and reimbursement. At the end of the day, payment is power. For 150 years of medicine, we have largely operated on a fee-for-service model, which is a relic of the industrial era of medicine. This means we pay by the visit, pay by the prescription dispensed, pay by the bed. This was the easiest way to measure and pay. Now we shift to more of health care being on a currency of ‘value’ where we pay for the results. This is because health systems and society will no longer tolerate paying for ‘stuff’ if the result is not more guaranteed. Thankfully as health care becomes digital, we have a technology layer that can measure outcomes in near real time, allowing ROI on almost anything to be measured and tied to payment. This shift underpins and enables the four other shifts I talked about.In other words, if you get a medical service and you don’t like the result, you don’t pay? How would we define a favourable result?
Khayat: It’s a shift from fee-for-service to fee-for-health. Health is largely defined by the quadruple aim – clinical outcomes, patient experience, staff experience and cost. It’s all four. With objective measures for each. For example, it’s not if you ‘don’t like’ a result, but rather, if the result along one or more of the quadruple aims is not worth the investment. Many health systems are well along the path of shifting to this model, like the Netherlands, where 50 per cent of all budget and care is on an outcomes-based payment model, where patients co-designed what the outcomes are that matter.In what ways will technology alter the future of health care?
Khayat: As I mentioned, technology replaces labour and physical assets. Simple things like keyboards and typing will be emancipated. For a busy clinician, you and the patient will just talk, and the data will go in the right place in the electronic medical record. Voice is the future interface for all experiences, not just health-care experiences.
Another technology area is sensors, wearables, the internet of medical things, where ambient devices will be gathering and monitoring biometric data seamlessly. It’s not about doing a diagnostic test like a radiology image or drawing blood at one point in time to try to figure out what is going on. It’s about collecting data continuously – on your body, in your body, your walls and sheets, in your car, in the ceiling tiles, in your clothes. You won’t need to wait for symptoms and then go do a test to rule in or out what may be going on.
Gigantic data is another major technology underpinning the future of health. And not just your genomics, it will be all-omics – your socio-nomics – all your patterns on social media, will be clinical biomarkers now. The filter you use on Instagram when you want to show the world who you are can predict your mental health state. Your physiome is all your movement data. There are millions of data points every day that are becoming clinical biomarkers, relegating traditional forms of clinical data – such as physician notes, bloodwork, etc., – to become a minor part of your story and your health record.
Another game-changing technology coming to health care is autonomous transportation. This will allow us to challenge many constraints on how we move physical things – defibrillators, drugs, vaccines – to whoever needs them, including patients, nurses, phlebotomists, technicians. Imagine an autonomous vehicle comes to your house, you go in, it does your workup, gives you your treatment, you go back to your house and it goes to the next place. This agile model of flexible infrastructure is a way for health care to evolve from its heavily static approach to building needed infrastructure.
"Simple things like keyboards and typing will be emancipated. For a busy clinician you and the patient will just talk, and the data will go in the right place in the electronic medical record. Voice is the future interface for all experiences, not just health-care experiences." — Zanya KhayatWhat do the changes you have identified for the future of health care mean for doctors?
Khayat: There are three segments of reactions I find when engaging with physicians about the shifts in the future of health care. One third are already ahead of me in their thinking and often remark, “I know this already. Tell me something I don’t know.” Another third are just opening up to what the future of health care could mean for them and for their patients: “You have blown my mind. I’ve never seen things this way,” and you can literally see the mind shifting. I love those types of clinicians because they’re able to adapt, and doctors are going to need to be amazing at adapting to the multiple unfolding futures I have described.
And then a third are often unhappy with the description of the future. “I don’t like this. This is never going to happen. Not on my watch.”What can doctors do to prepare for what’s coming?
Khayat: It’s a mind shift. Are you spending your time and your energy protecting the past or protecting the future? Are you going to fight for the past to stay and hang on to what all the trends make clear is not going to stay? Or do you want to create the future on your terms? That’s a generative mindset; I call it a future-proof mindset. How do you future-proof yourself, future-proof your profession, future-proof health care?
Practically speaking, there are several ways physicians can participate in – and even shape – creating the future of health care. Here are a few that I often see, globally: get into entrepreneurship (start a health-care company or be a medical adviser to an upstart); lead innovation or be on the innovation team at your health-care organization; shape the policy agenda on key regulations or policies that are bottlenecking the shift to the future of health care; spend 10 to 15 per cent of your time on an innovation project or cause. To get the needed skills for any of these expanded roles, many physicians are doing health MBAs or other master’s courses or doing bespoke training or bootcamps such as hackathons.
Wendy McCann is a Toronto-based writer.