The Future of Hospitals

However, we have a very long road ahead. When we look at the 70% of global deaths are coming from non-communicable diseases. If we look at and realise that nearly 100 million people per year are pushed into poverty because they have to pay for their healthcare out of pocket. If we recognise that nearly half of the world’s population still does not get access to a basic package of health care services, it tells us that we still have a very long road ahead. And if we want to be delivering on the needs of populations, on the needs of individuals and families, we need to transform the healthcare system and we need to transform how we think overall about the care delivery. So, likely, we have to move from a hospital and curative system to a communetive and preventive system. We need to move from a silo, vertical system to one that looks at multi stakeholder and multisect or cooperation and we need to move from a fragmented and sometimes paper-based system to one that is fully integrate and has data interoperability and I hope that our panel this morning helps us get to some of the how can we get through these transformation s. V. Without further ado, let me hand over to the Michael Clarke, the former Prime Minister of New Zealand.>>And also a former Health Minister for my sins! But thank you for the leadership you and the WEF are giving on health issues. Now, we have clearly an audience in the room and it’s going to be a little bit hard to see your questions so please if you want to speak do speak up from behind and we also have an audience online and particularly for the benefit of the audience online let’s do the formal introductions of who is sitting at the table. We have Shobana, who heads Apollo Hospitals Enterprise in India. We have sitting immediately here, we have Jeff van Houten. We have Prasanth Manghat, who is also healthcare provider based in UAE. We have Nancy Brown from the American Heart Association and we have Stephen Klasko from Jefferson Health USA who also doubles as a doctor. Just to frame a little bit further from what Vanessa has said, with my background, in politics and looking at resource allocation, of course health is always one of the most challenging areas because there’s an infinite amount of what you could do but the money is never infinite so you are always looking at what’s the best use of the health dollar and how do we minimise hospital admissions and length of stay. How do we support primary prevent and — prevention and secondary prevention and how do we make hospitals effective and what is the role of technology – all the issues we have a tonne of expertise around the table around. So, in our discussion before, we thought we’d start with the people who have a background in health and in the advocacy around prevention and heart of heart disease, then we will come to the providers and then the technology people. So that will be our structure. So I’m going to start with you, Stephen, and you’ve kind of framed a question for us in the green room along the lines of what would our jobs like like in the future? So over to you?>>Yeah, I feel like a panel on the future hospitals is like asking folks what was the future of retail after Amazon started. And I had my wow moment when I was at Standard & Poors and they downgraded the entire non-profit health quaer provider –care provider system because they said if you folks don’t disrupt you’re going to become a commodity. And I think it’s really a math equation. 40 years ago, Bill Keswick wrote a book and he was talking about the iron triangle of access quality of cost. And he said you are not going to break that triangle unless you are willing to break the system. It gets down to healthcare becoming digital and global and bringing personalised and global medicine together and it gets down to healthcare being consumer centric, just a few examples. We can do all our shopping in our pyjamas watching TV but if we have a symptom ach — stomach ache we have to get out of our home. How can we get the care out of the home? I think part of it is getting away from talking about the technology. We talk about telly health. We don’t talk about telebanking. We don’t say I’m going to telebank, it’s just that bank went from 90% at the bank to 90% at home. We have to start to bring the technologies together. We have to think about what is the humans are in a new healthcare system because once we do have better augmented intelligence opportunities, we still accept physicians in most places in the world the same way we did before based on memberisation, size, and we amazed that doctors aren’t more empathetic and creative. Last year, it was said that when we created cars we didn’t design it for humans to run faster. Computers will always be as smart as doctors but not as wise. We also have to retrain our work force. Finally, I think, health care is the only sector in this entire forum that’s not global. I go to the smart cities piece, you go to the finance piece, head of finance in Shanghai, it’s just as brilliant in the United States or Australia. But if you’re the head of cardiothoracic surgery in Shanghai or Bangalore and you come to United States we make you restake your residency. The things that are done around two-thirds of the world like acupuncture, in the United States that’s considered alternative health. That’s kept us. At the end of the day I believe we run an A-team hospital system. I believe we will start to be paid based on how healthy our population is versus how many people come in to fill our beds. And I think that that’s a revolution that has to start now. We have to align some of the payment models. The last thing I will say st there’s a great quote that said it’s hard to get somebody to do something when their salary depends on them not doing it, and we have a lot of that in policies when we talk about population health but we still pay people to have acute care in hospital beds.>>Just kind of maybe an evolution of the captation payment model for primary practitioners, which a number of countries have but has never really been taken to the whole health system as it were. Nancy bringing you in.>>It’s really interesting. Steve mentioned the word it’s all about the person and I think that the thing we have to remember as we think about the future is that individual people still need to make decisions about living healthier lives. When you think about what has happened I can use as an example in cardiokas Kewell ar diseases and this downturn of death rates in the United States because of the onset of fantastic scientific discovery – statins, other medication, procedures that have really reduced the rate of people dying earlier from cardio vascular diseases but you look in the US the social determine nanlts of — determinants of health are standing in the way of individuals living their longest life. 80% of the world’s cigarette smokers live in low and middle income countries or in the United States in communities that don’t have the same privileges of other areas, we have a lot of work to do. Not just in inspiring people to care about their health and well-being but also to address things that are not traditionally connected to the healthcare system. Earlier this week we were talking earlier today about the smart cities initiative, urban planning, the projections of how many people will be moving into urban centres. And as that work is happened, how are we designing cities so people can get physical activity and access to nutrition? We see this alarming rate of individuals taking up e-cigarettes, vaping, that we are very concerned about will addict the next generation of smokers. So many of the things that bring people to Steve’s hospital are things that can be prevented and so we have to think about the holistic environment in which an individual live, what is their education level, how do we use advocacy to make our cities smarter, how do we make sure that all people have access to high quality healthcare? These issues will continue, unfortunately, to be front and centre so that as Frans is creating state-of-the-art technology for our healthcare systems and for us as individuals to manage our own lives, we at the American Heart Association worry a lot that in the US and globally not all people will have access to this state-of-the-art technology and so we really need to think about that when we think about the future.>>>>Where you’ve done great is going at that 80% of health that doesn’t happen at the hospital. Because that as technology got better and we did better of looking after someone with a heart attack, you said I’m going to have Go after that 80% that the doctors had not concentrated on.>>And going after the 80% makes a big difference and it happens by inspiring people and making sure all people have access and it happens through advocacy and public policy. If you can’t help an individual change their behaviour. If you change the system around them, look at what has happened in the US, this avoidance of second hand smoke has reduced drastically and has been proven scientifically to reduce recur ence of heart attacks>>You’ve pointed to the whole environment around people because if you’re in an obesogenic environment, where they the advertising suggests that tobacco smoking is a terrible thing — horrible thing to, do you are up against a hot of externalities.>>Absolutely. And if you don’t have access to fresh food, and the only thing you can have is pro-Peednd — processed and packaged food, why are we surprised that there’s an epidemic of obesity and type 2 diabetes.>>Let’s come to the providers. In our discussion before, Shobana, you were talking about the investments that your enterprise is making beyond the hospital, as it were.>>So I hear everything you say and I think people are not different. It’s just that in the scale of how you have to provide it becomes very different when you come to a country like India. And some of the others when you say that they’re 1.3 billion people and all of a sudden the highest that a person wants to pay for a heart surgery is probably 5,000 dollars but the government wants you to do it at, you know, a tenth of the cost. And then you start talking to see where do hospitals fit in so your solutioning becomes so different. So then you think about how can we keep them out of a hospital? What is it that we need to do to create facilities around it? So we’re all comes from the same place. You want to keep them out for other reasons. We want to keep them out because nobody is build the infrastructure of hospitals in India when we started 38 years ago we had to change regulations that hospitals were not even considered as something that, you know, banks would fund. So we had to change things around, build it, and then you start and understand and all of us – it’s still is there that when you talk about the future of hospitals, when you start designing a hospital, by the time it’s built, it’s probably obsolete. So you have that big challenge in terms of a facility and then we say with Committee do differently? I’d like to actually talk about a cup of things that India does differently and some things that will probably be tomorrow’s scaled models. So if you talk – and that’s necessity is the mother of invention. So we had a project with Philips to do in EICU. Who does EICUs? This is something we’re putting in rural hospitals because you can – you know, you can train doctors but how many of them want to move out of a city and live in a village? But there are people there. You want to keep them well. So it’s not just in countries like India but it’s China, it’s rural America, rural Canada, all these people have the challenges, so I think that the telemedicine part of it, so you can come into a very high solution that is an EICU, we do teleradiology for around the world, and you do this at scale and telemedicine is something that, you know, we have a track record of actually doing 2 million consults and that is a large number but we do think that that’s obsolete today. As you said, you know, that nobody thinks about banking. So what we’ve done is actually put it there on a phone, on an app that you can ask people and two months ago I was in Israel. They have the coolest of technologies and everything knows that. So what they did is you can start monitoring your blood sugars, your blood pressure and so many more parameters. All this can come and they said the reason – so they have an autoscope and everything and they said your mobile phone has the highest computing and the best imaging, so why do we have to reinvent that? I think that is the disrupted technology. Our mobile phone is the disruptor and could be very well where the future of hospitals will move us in that direction and a recent study that, you know, said what would be your biggest disruptor and like you said, Amazon. Amazon has even got into the act. Apple at least has the phone that is doing so many things and in that they said technology will disrupt hospitals by 30%, insurance by another 32%, and all the others. So you know this is what we’re looking at. We’re looking at finding solutions a) for population, for scarcity and also for the wonderful technology we have in disruption. So we truly live in exciting times>>This could be a good topic for next year’s forum, instead of going self-driving cars we have self-healing humans!>>That could happen!>>Yes!>>As long as you can make it affordable!>>Prasanth, how does this resonate with your provision based in the UAE?>>Thank you. Definitely I have the same view. We have an organisation who are active the last 45 years in various economies. We have decently last player in developed markets in the UK, Spain and Italy and we also have been concentrated on GCC where we control one-third of the market of the GCC which is having highest purchasing power. We have recently been very active in markets like Africa. To me when I look at the entire healthcare problem I divide that healthcare problem into three sets of problems. Sometimes we discuss with Philips on this particular subject. It’s not an order of importance but if you look there is a percentage of population in the world who pay from their pocket who are affluent, who have the money to pay, who want the best of the best. So this, if you look at it, providers like (inaudible) in that market to a certain extent they’re subsy dieders for a largest platform for us. Then for them the problem is different. From their perspective, am I getting value for money? From a healthcare provider like us who are working in that environment, most of our healthcare resource s are sucked by these high value paying customers. So how will you balance your healthcare resources to the other set of people? Then we have a second set of problem that comes from maybe not 25, 30% globally, but some economies like maybe US or UEAE where we have 90% which is solving directly and directly supporting the insurance programs where sustenance of healthcare is primarily focussed on how government can continue to fund this people arem of insurance companies. They’re the sub-Stanance comes into the fact that we need to make sure that government should be able to pay for that for a longer period of time. If government system fails, none of us, the private healthcare provider, won’t be able to work. The investments go completely futile. So we need to identify that problem and how can you do that? That is where we believe this entire tele medicine, the TeleTech nothing, we also work on ICU – tele-ICU. We also started the telepathology where the resources – so if you look at it from a healthcare prospectsive. One is the consumer and one is the human resources. How can you optimise or maximise your entire – these two expenditure, definitely is a key in this access of this — success of the second set of problem. Then we have the majority of the problem which is 60% of the world who are paying from their pocket the healthcare. Which as Nancy said people who are earntering the poverty because they spend money or people who are not able to enter into healthcare because they don’t have money to go for healthcare. And the entire system is spent on to that. So they’re the – that problem I think I completely go with your view that telemedicine – that disruptive technologies should be used to find a solution for those set of people. Today, we work globally around 8.5 million patients walked into a MC facility in different Xstrata. So we started recently with a telemedicine program to reach into 3 million students in Kenya as a country who are on the puberty age of 11 and 16 where they enter into communicable diseases. So we started that as a pilot project. We started working on the refugees under d UNHCR in Jordan using the telemedicine program. So tele medicine definitely has got big value in that type of population which definitely all the three problems has to be seen to be going in hand in hand otherwise providers will find difficult to – there’s no one solution that will suit every country and every demography>>You remind us too of the global agenda for universal health coverage and how to make it possible.>>Right >>And it’s a top priority for health and sustainable development goals. But we keep coming back to technology as having a lot of answers. So I will throw the ball to you!>>There’s something to do for us. To Philip, we focus on health and healthcare, and then our strategy some years ago we said consciously we are not only going to focus on hospitals, we are going to focus on the entire continuum of care from healthy living, consumers, how do you keep them healthy to early diagnosis, screening and then the acute and episodic care and then the chronic care. So I lay that out as a continuum and your introduction you mentioned what can you do in preventive care and how can you make healthcare more efficient and how can you work on secondary prevention? And here in value-based care we often talk about access, cost, and outcomes. So we need to tackle all three. Access is about the social distance of people – will they get care at all? Productivity – I mean, as I serve customers all over the world I see huge differences in efficiency. I would say I can – we can probably make hospitals 30% more efficient without huge interventions. And then you could redirect some of those resources to your primary and secondary prevention. And then of course outcomes I think science and technology will still advance further to make prevision health — precision health work even better so we can tailor it to who needs it. To envisage such a continuum, you need actually a care orchestrator. And who is the care orchestrator? You could say that is the consumer but the consumer has not always the knowledge when they’re healthy they don’t care, when they’re unhealthy they need specialised knowledge. So if you talk about the future of the provider, I see that the role of the provider is the care orchestrator. Second notion that I would put on the table here is that we need to work towards network care. So now we have a concept where we bring care into the community linked to specialised centres, and somewhere we have an air traffic control which should focus on coaching people to stay healthy, which should help to direct the right special itself care to — specialist care to fix people and if they have a chronic care, how do we support them to live at home in the community with a chronic issue without all the time having to go back to the hospital. So the care coordination can be greatly coordinated by technology. We have heard how access to specialist care in remote areas can be done via telehealth, teleradiology, telepathology, EICU, which brings doctors into contact with patients in remote areas. But we need to take this all a lot further where where we longitudinal information about patients which means we need to slide all the silos of information which is a horrendous issue today where we don’t get a holistic view of parents when they come. So there is an in-formatics opportunity and challenge because once you have data, both on population view but also on the individual view, you can become proactive. Now I can say, you know, you’re trending in the wrong way or the right way, if there’s a digital twin kind of a picture of how people are doing with their health, especially there is very realistic for chronic parents, then we — patients, then we can exercise that role of the care orchestrator much better. We can be proactive rather than reactive. I think that will enhance the quality of life but it will also avoid unnecessary cost. So we envisage that through the cloud we are connecting patients and providers. Technology can make hospitals a lot more efficient and then I would hope that we would redirect that money both to primary and secondary prevention. Because, altogether, we burn enough kots in the world — cost in the world, and I think we could do more with that effectiveness. I think examples in India also demonstrate that you can do interventions at a fraction of the cost. That is not always popular and we all of course like to charge big bills but when they want to reinvent healthcare, we need to look at it much more holistically and some disruption will have to happen.>>A common theme among all of us is getting away from Philips just looking at itself as a technology piece or us – when someone comes into our hospital, or in the heart you’re looking at how that inter acts with the brain. We have come to healthcare with no address. The definition of Jefferson will be the care we give no matter where it is. I personally believe that most of the non-surgical healthcare that we provide in hospitals now will be done at home with a new level of provider that will go out to the hospital and do most of those things probably be better food and nicer TVs at home than they have here. The other thing is that the whole equity piece, a lot of those things are solvable. We talk about global equity, but even within Philadelphia, there’s a 21-year life expect tansy different. And we have six academic medical centres there. And that gets to 80% of the education and housing and food. We looked at readmissions for congestive heart failure. These patients allowed us to do digital foot print of what they were doing. It turns out we could predict who was going to come back by how many pizzas they ordered the first week. We put them on a low salt diet.>>People don’t recognise that bread is the biggest source of sodium that their diet.>>We have run with a health system in North America a program for congestive heart failure patients who very often have also other morbidities and very elderly and through a telehealth program that include ed behavioural coaching and daily measurements and all the data was collected into our command centre for care coordination, and thousands of patients this was a large scale trial, we demonstrated that we could reduce rehospitalisation by 50%. Their enjoyment of life went up.>>Absolutely.>>They felt better cared for.>>Weir doing this in India for condition management of diabetes which is the big killer in India that we are trying to get patients on boarded for compliance. We have seen that we are able to reduce hospital bills and actually ensure them – insure them better and that is important>>A critical piece.>>And so now we’ve actually using data we’re able to say if you have this test in this compliance we can actually cut down your hospital – your insurance cost and these are models that are being used across the world saying if you’re connected to the smart devices, so we should think that that is another part of it.>>Absolutely. I was going to say that. You look at some of the great frontiers in heart disease management, look at the new Apple watch and the ability to detect heart rate, variability and how that might ultimately interact with the kinds of systems Frans is building.>>We can do that today >>I know, but we need the science to be able to help without a trained doctors on the other ends.>>We make it personal. That’s another point, that the data can bring it down to the person.>>Our biggest investment this year has been on wearables. So let’s just picture this technology exists, it’s all got to come together. You will go to sleep in your pyjama s, monitor your heart rate and respiratory rates. If you have asthma, when you wake up your Alexa which will soon become $2 each, your Alexa or home pod, instead of playing the daily podcast will say your respirations were a little laboured, the AQ out there is X. Maybe you should take an extra inhaler today. Literally that will ->>Or do yoga >>That is where healthcare starts at home.>>That is on the secondary prevention level. What I am interested in is from the point of view of the person who sees themselves as healthy, they’re not used to the doctor ringing up and saying by the way I had an alert from your fit bit. So it’s kind of also got to change the way people are thinking about their own good health and I want to bring you back in, Nancey.>>I think it all comes back to does it take to inspire people to realise the most important thing they have in life is their health. You said this at a meeting we were at a dinner, we were at the other night. Health is wealth. And you see people that are more affluent that can afford the wearable device s, focused on getting their steps. We were talking about how much we were standing up. But I think this idea of helping people protect the health that they have, you know, most people are born, as we often say, most people are born in ideal cardio vascular health and it’s their lifestyle or the environment around them that makes that deteriorate over time and so it is – there is no magic bullet. It is helping to inspire people to want to eat right, to make sure they’re not smoking cigarettes and to get exercise and to manage their health with their healthcare provider. But it’s also this changing communities and environments. Let’s give people the best chance possible to not be exposed to cigarette smoke, to make sure there are healthful foods available . They’re all important in prevention>>We have a very articulate panel but we also have a lot of expertise in the audience. Please?>>I’m coming from Mexico. I would like to raise a question – we’re talking about hospitals here. The future of hospitals. What do you think about the PPs – private public partnerships working in hospitals? This is very important because we built with design and we also operate but what is the future because the governments don’t have money. So there a big need of hospitals over the world. What are your thoughts of doing this if you have any experience on private public partnerships in hospitals?>>Well, we do. We did the first one in India and it actually turned into a hospital in New Delhi with the government. Then we went through 20 years of expertise about how the first fundamental thing in a PPP is we have to assume that something will go wrong and what have you done to be able to address it as the government changes? So you have to put that together. And, having said that, there’s no moving away from it because if the government is planning like in India, for instance, and I don’t know about Mexico, but in India the government today spends only 1.5% of its GDP on health. And that’s nowhere near enough. They need to spend like other countries, maybe 5, 6% more. They’ve committed another 3%, still not enough when they want to look after 1.3 billion. So now they’re calling into the private sector saying why can’t you come in and find solution, take over our existing hospitals which we recently did a week ago that we’re managing the services and this is going to be the model that you can go, state by state, and in India it’s a state – it’s a Federal – health is federally run. So I do think the future, glad you brought it up, hospitals cannot ->>There’s a lot of context in this, isn’t it? Because in my country, if you even mention putting a public hospital over a private provider there would be a revolt but other countryies are saying ->>In Australia you did. : I am from New Zealand>>But as a neighbour – >>In my country it would be seen as very difficult. In a different context where there is not a role to play.>>I have a few examples.>>I thought you were only cricket fren Mis! .>>No, no.>>>>What is the role of government. Personally I believe it should be policy setting and the guard rails and the direction. I’ve seen many countries where government-run hospitals are not the best run hospitals. So countries ->>And also where they are.>>OK. There are exceptions. So whether it’s Brazil, Turkey, Saudi Arabia, many other countries, they start PPPs to actually move public – old public, poorly run hospitals into PPPs which are in the case of where you’re involved special purpose vehicles where we all invest, technology companies and we go at risk and we basically work on access, productivity and outcomes what I talked about earlier.>>Exactly.>>And then the governments can supervise that and hold us honest, right. And it is a model that works rather well. I think this is a way to modernise health care in all those countries that – and also free up then resources to actually do more on the population.>>Prasanth??>>In this case, exactly I go with what Frans is saying. We have a business model where we have the PPP models in multiple countries for government of UAE and other governments. With re in countries which are like Yemen, we run in Morocco, where exactly what Frans said where there is a risk with multiple players and we as a provider comes and works to improve the patient experience and clinical outcomes. Patient experience and clinical outcomes definitely have an impact on the total cost of money that has been spent by the government. It’s not only the infrastructure, so there the technology comes in from the provider, the technology provider and healthcare provider works to improve the KPIs which are – the ambition is in countries like UAE to take to it the US gold standards but other economies to go into the better results of the world. We have seen results. In UAE we are working, this is the 7th year we are working and over the period of time we have been able to take to it the global standards, which effectively is reducing the spend of healthcare of the government.>>I’m so glad you asked that. Because I think we’re about to enter a golden age of private public partnerships. More and more there’s an understanding that it’s not a vendor-Vendee relationship but it’s let’s go into this together and we will share the outcomes. I will you a couple of examples. With reworking with a company where we took out 30,000 employees and offered them free genomic testing and they were willing to go at risk with us because we are self-insured to say, we think that the care, the outcomes of the cost and the access will be better because of that. And we will share in that. I think the thing that has to happen, though, is we have to start to mix both worlds together of technology and provider. I think the EMR is a good cautionary tale. The EMRs were developed, given us, it’s the only technology in the history of the world that, because you’ve paid for that technology you have to hire more humans so it doesn’t get (inaudible). So what we are starting to do with our friends at Silicon Valley is embedding faculty and medical students out in these companies.>>Right >>And they’re taking their engineers and they’re on my cabinet, they’re sitting with me at Jefferson so they actually understand what our problems. So it’s changed some of the business model they’re going to say we’re solving a problem that doesn’t exist. That is the problem they have. So as you start to do that and get patients and providers and social agencies and all that money that’s being spent to disrupt health care in Silicon Valley and around the world together and actually talking to each other it makes a difference.>>Let’s come in again from the audience, right behind me. Robert?>>Yes, thank you. I agree with all of our panelists that more and more healthcare is going to be delivered outside of the four walls of the hospital and I do agree that our smartphones will deliver a lot of healthcare into the future. Being that this panel is about the future of hospitals, what do you actually see the four walls of the hospital still doing in the future? There’s no doubt more medical care is being delivered outside the hospital. Steve, you suggested also more surgery being done outside the hospital. So the hospitals essentially going to be intensive care units or do you see with the ageing population and the onset of more chronic diseases a more broad role for hospitals of the future?>>I think that’s been one of the big controversy, Rob, as I’ve talked to the provider pieces of the forum. You know this – eight years ago people were saying with the baby boomers ageing, et cetera, we will need so many more hospitals. Then of course you know with the value-based stuff and keeping out of the hospital, I think – this is what I think. I think that hospitals that provide acute care or surgical care and intensive care will actually boom. I think what you will see is in communities where there are 43 community hospital, some owned by four different profits, I think those hospitals will be at risk. I think we will probably have less hospitals and the hospitals that we have that are providing good cost access and quality, I’d like to see literally if things are failing we have hospitals with leap frog deeds in our place of doing secondary care. Those hospitals need to frankly fail and other hospitals are running 60% Sensis rates. I think we will see some retraining of some of those nurses and other healthcare providers. The number one college is the college of emerging healthcare professional s home nurses, community health ambassadors, et cetera. In a great system like yours, I think what will happen is you will sort of create a continuum of care across your hospitals so they’re doing the right procedure for the right parent at the right time>>In that context, also technology will start playing a role. I call it the air traffic control of healthcare where you will have your clinical operations planning. If we can predict the patients who will come in rather than they show up at the emergency room, you can also start planning where they need go. Should this patient go to the tertiary centre or have them in in the community in a cheaper bed while you can still, through telehealth, give specialised care to that secondary location? But it means the the whole network becomes a network care organisation.>>Unscheduled care can happen. Almost 70% of our non-trauma, non-ambulance parents are out of EMD. We belt our care centre a block away from my hospital because we might say, yeah, we don’t need to see all the trauma patients coming in. If you need to come in, you can.>>That is a conscious management of traffic.>>That is of Medicaid parent patients and everybody.>>The rate at which it will happen is very different based on countries with this. So it might happen faster for you, it will definitely happen in India. But the rate of what we need first you have to serve that and then we can move on.>>That’s because you didn’t have the hospital room>>So the future, I think, has to be tiered.>>The context.>>Exactly. If you look at it, one is availability of hospital in America may be an exception or the UK but in economies where we work, we have seen that one – availability of money, what we said about India a few year s back, India has availability of funds for healthcare but there are a lot of markets across the world where we’re looking at Mexico as one Economy economy where we find either availability of capital is scarce, or the cash is expensive . So once you enter into 15%-plus financing cost models, the healthcare definitely will not flourish in those economies. Second, the number of people who are coming out of the medical schools, you know, if you look at it, we went to Nigeria, we have operation now in Nigeria, when you look at Nigeria as an economy, Nigeria has been producing medical professionle as working in the US or the UK a lot. They are not ready to come back because of the social system that exists in those economies. So a nation who spends money in medical schools and if there is a dream happening, this will be a second (inaudible). Third, ex extremely simple but lack of clear water, good drinking water in those economies. Water we try we talk about genetics screening globally and preventing effluent, the 3 billion suffers because of lack of drinking water which can have (inaudible). Exactly. I resonate what is said, the future will be different to three different set of people in the world. Somebody like in the US it may be in a different manner but those developing economies like in Saudi Arabia or like India will have a different issue. But those coming from certain other parts of Middle East, come in North Africa, from West Africa, or some part of Latin America will have a completely different problem. The future of healthcare has to be seen in three different manner.>>Those three sets of people exist in all countries.>>We have one solution which on this particular subject – we started working with Cincinnati children hospital Orboston children’s hospital which is also going, we start orking with the UK NHS system. There is definitely a cash strap in the system, either government has to pay, academic institution doesn’t have the money, the NGO funding is coming down, nobody is ready to put the money down oun those activities. How will those institutions going forward continue to be flour iring if we don’t have such institutions globally who are academically incline ed institution to flourish? The global healthcare is going to go into a doom Isday>>Steve, come back in on the medical professional education because you have a lot – very interesting things to stay on that. — say on that.>>I think we have not changed either our curriculum or the way we select our physicians for 50 years. So the simple fact is we’re talking about all this predictive analytic s, genomics and that’s not in the medical school curriculum. There’s almost no population health in most medical school curriculum, at least in the United States and the UK. In fact, I gave this talk to one of the top 10 medical schools in the country and I was talking about quality and population and health and food and the dean was upset that I said they don’t do enough. And I said we have a whole day the third year on population health! And when you think about how ridiculous this is, that most of these folks, their schools major in chemist ry or biology, take four years of just learning chemistry or biology and then the first year of medical school is sitting in a class doing multiple choice tests. We merged our 192–year-old health science university with a design university. We were taking kids after the first year of Princeton and you have to major in something cool – not memorandum trior, take the minimum amount of science courses you have to take and you will get into Jefferson after your four years and they can MD Masters in design because we merged with a design school. The second thing real quickly is we have to retrain our work force because we think in departments, in order for any of this stuff to happen and we have bring care to patients, patients don’t think in departments fxs you have a headache, you don’t know what type of headache you have but you have to go to four different doctor. We actually brought when ALS parents came in, we brought everybody down to where they were and the place that had the centre of excellence in fill Dell #23ia — Philadelphia because the neuro surgeons didn’t want to mix. I think we need a fundamental retraining of the humans because we will have robots next to us and we’ve trained doctors to be really good robots, it doesn’t make any sense>>>>The population health perspective is so vital to the work that you do. Come back in.>>I think the whole issue of what is the role of hospitals, I will just bring it from the patient point of view to what Steve was just saying. The thing that’s most important when people are receiving care is they’re in the state of mind where they can accept the care and their family knows what is going on. And I think we believe really strongly that all the new technologies for people to be at home instead of in a hospital all of that will make a huge difference in terms of out comes for patients and for their families. Having people in a hospital where they’re being shuffled around and nobody understands and things aren’t clear, that really is not good for outcomes. D other thing I want to mention is the organisation that writes guidelines in the United States for cardio vascular disease, stroke and all the risk factors, blood pressure, cholesterol. You think about how positive this new healthcare system we’re envisioning today can be for the implementation of guidelines which ultimately are being put in place so parents can dr dr patienties can live long and healthy lives. Last year we published new guidelines for blood pressure that drastically in the US changed the rye Teera for what is considered for a person with high blood pressure. A day after the provisions were written 110,000 people woke up with high bloods Ure who didn’t have it the day before. How do you get the healthcare system and doctor relevance to understand – doctors to understand what these new guidelines are and how to help patients understand the lifestyle things, not just give them more drugs so these new healthcare systems we’re hearing about and the technologies that Frans is talking about can fix that problem. In the US it takes on average, this is a horrifying number, 16 years from the date a guideline is written until it’s fully implemented in practice and patients are receiving the practice. So all of these Chings in the healthcare system and technology will make lives better for patient.>>We now take our applicants to an art people and say tell us a story so they can start to put stories together and bring that together. I’ve delivered 2,000 babies. And it’s easy to deliver 7 pound baby to a normal – it’s easy for me to say! It’s incredibly difficult delivering an unscheduled Down Syndrome baby. Every time that happened, doctor what does this mean. And there will be a robot next to me that will be taking a picture of that baby saying what’s genetically wrong but it will never get what does it mean for my baby. I want doctors to talk about the impact and this is a beautiful baby we can help you take care of>>The most important thing in the future of hospitals is not forgetting the human touch. And nothing is more important to a patient than having a nurse or a healthcare provider sit them to them and hold their hand and describe what is going on and helping people through that experience. We should never forget that the walls and the technologies matter.>>And I think the future of hospitals if we have to say it would be using all the technology to allow the humans to spend more time with the patients, because right now it’s so ->>And that’s possible.>>It’s not enough >>But some of the faults with the current EMRs is they are claim systems and they take time away from the patient.>>Yes >>Whereas if we have much more context – context specific technology, with AI, we can automate a lot of jobs and make time available for the patient.>>And you don’t want to miss things.>>You can build in – >>Technology is about – to be able to diagnose fast. That is the most frustrating for a patient. You know.>>The uncertainty.>>In India when they’re paying for it out of their own pocket and you send these people for a stoes they say all the doctors will get something out of it so they’re sending us for an MRI and we said we’re not solving for – we’re not solving for the 100%, we’re solving for even the 1% if we miss it and they go into an event, that for them is 100%. So I think that hospitals of the future should be way more caring and clever and accurate about diagnoses and ->>The variance of care between hospitals but also between practitioners within the hospital is huge.>>And get more complex >>If I compare that to an industrial system, coming out of the industry, you would weed that out through process of elimination, through checklists, through best practice adoption across the board. And technology can help do that. I would advocate that I would also free up money to do other things.>>In the one hope I would hope as we start to look at the healthcare world World Economic Forum and we talk about the future of hospitals that we don’t get too caught up in what will happen 10 years from now. What can we do today? At the end of the day things haven’t changed enough globally. There’s a quote I like to use where one said I am going to turn this team around 360 degree. We have the technology and the human touch and great leaders but we haven’t made enough global outcome change because we haven’t concentrated on those social determinants of health.>>That same exact point, when you look at it, more than 35 hospitals across the world, the last few years we have been really working on lean to startise your procedures. — standardise your procedures. Today some of the procedures are highly standardised. And there may be time if I claim myself to be successful as a healthcare CEO I can say all the procedures are standardised. That only patiently solves the problem. The those in healthcare are different in the same head of network itself I see 20 pathologist s working in 20 different firms and some say they should be together. So the future of healthcare and I’m not talking hospital, should be to standardise at least five or six or the top six or seven healthcare problems to be standardised, for example, like in NHS is doing it on resuscitation. Specific areas where we can have a standardised form and that be given to the doctor. Today we run a peer review of doctors and every time it comes to a situation where it comes to my office where the doctors start having problems. So if you – and that is a big challenge in the healthcare system. The practicals and procedures — **Audio lost **>>The training for the people who are going to be doing that, but we also have the other context where countries don’t have enough hospitals yetth yet at all or services and that has to be built and formed by the trajectory that the hospital system has got in other societies.>>Still how are there limits of this. A>>And technology, regardless of the context, is going to have such a huge influence in diagnosis, prescription, support of the patient and so on. Thank you, fantastic panel. Please give them all a big hand.>>Thank you.

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