The Shape of Preventive Care in the Future

This blog post is a lightly edited version of an inaugural session talk I was invited to give by PC Quest on October 22 as part of the PCQuest Healthtech virtual conference on "Transformation in Healthcare".

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Imagine this for a moment. We are in late 2022 and the Covid pandemic has been beaten back comprehensively. What do each of us seek from the healthcare of the future that is attentive to our needs – even before we need it?

I expect this would be some version of “being healthy”, “not being diseased”, or “not be hospitalized”. That is, in fact, a tall order and calls for the kind of preventive care we need in the future. Luckily for all of us, there is now a virtuous alignment of many stars: need, awareness, disease context, political momentum, and technology. All we require is intent and design for execution.

Every transformation has a genesis in some singular event, and Preventive Care as we know it today, is no different.

So What is the Future State in the Light of History?

Much of the stream of industrial innovations we have hitherto observed, been affected by, taken a part in, consumed, and taken for granted through much of the 20th century and continuing to the present day had its origins in the onset and during World War II when the US government embarked on rapid, emergency, wartime requisitioning of extraordinary funding for research and, together with it, the assembly of extraordinary minds in diverse areas from mathematics and statistics to natural sciences to engineering to managing complex systems. They were put to task to solve complex – and barely understood – problems confronting war: weapons systems, communications systems, security and encryption systems, navigation systems, vehicle systems, chemicals, biology, material science – you name it.

These activities happened in all parts of the world but were brought to great focus and the results available and exploited as industrial innovations for decades after the close of the war in the United States and as spillovers eventually in the rest of the world. We live, daily, the benefits that accrued from these disparate and diverse activities that were accumulated in those initial years and arising out of an emergency.

Healthcare from 2021 onward will be no different, thanks to the ongoing pandemic - our singular contemporary event – that focuses minds, energies, funding, and long-lasting innovations.

It has brought particular and acute focus, again thanks to an emergency, to issues like Availability, Accessability, Affordability, Assurability, and Auditability in the conduct, efficiency, and delivery of healthcare to large masses of people. The talk today is of vaccines specifically to slow and end the rampaging virus but it could well be of healthcare in general and prevention in particular tomorrow. The pandemic is that singular event that presages an impending transformation.

The Classic Pyramid of Care

In Medicine, a classic description is of a pyramid: Preventive or Primary Care at the base, Secondary Care in the middle, and Tertiary Care at the apex. It shows, graphically, how human beings transition through the stages of early, low-complexity, medical issues to very complex ones requiring hospitalization and the intervention of specialists. A majority of health issues lie at the base affecting the largest segment in a population – in everyday problems and niggling issues like cold, fever, aches and pains. They are the easiest to solve for at least cost. Unfortunately, this base gets the least attention with the result that preventive care gets the short end of the stick and ends up as the poor cousin - literally and metaphorically - in healthcare systems. The pyramid, in fact, is inverted in its relative importance as the graphic above shows.

The reality of how we approach healthcare all across the world is muddled in this very description of transition. Most healthcare systems at the base are basically stationary while activity gets loaded on to the top. In both cases, healthcare as a system is passive and the consumer is an equally passive participant in his or her care. We were witness to this in a dramatic way last year when the Covid-19 virus that called for vaccinations at large, quickly overwhelmed the system at the tertiary end when complexities arising from age, co-morbidities, and rapidity of organ failures collided with an inability by hospitals to cope with surging admissions, inadequate oxygen concentrators, ventilators, and drug shortages to treat respiratory disease.

Where does Preventive Care Miss the Bus?

Let’s take an example.

An adult in his 50s visits a doctor, a general practitioner, complaining of some problem. The doctor treats for the symptom. An episodic visit that may go well or may not. Individual returns home; days or weeks or months later the person is hospitalized for a heart attack. Further tests show blocked arteries and procedure initiated. What we have is one of possibly many episodic preventive care visits that did not discover underlying major issues and resulted in a later acute care hospitalization entailing much aggravation, trauma, and expense. As we all know, this is not unique.

Could this have been avoided? Yes, but only if the healthcare systems are designed and adapted for a much more sophisticated and proactive preventive care delivery. It entails recognition of the critical difference between acute and chronic diseases and how the latter could be made reversible through early detection and acute hospitalization minimized to a great extent.

The pandemic, of course, is an extraordinary once-in-a-lifetime occurrence. But healthcare systems have always operated within the same exigencies – in simultaneous small segments, not whole populations as with the pandemic. We call them “acute” illnesses and “chronic” diseases. And they work in much the same way as what we observed with the virus: something not tackled in preventive care that explodes in an acute care setting. The numbers are more gradual, but the end results are the same.

Global Burden of Disease

The WHO estimates that 50% of the global burden of disease today owes to chronic diseases. Chronic diseases differ significantly from acute illnesses – they are often lifelong, slow in gestation, and reversible when detected early. Their complexity increases with co-morbidities – when more than one chronic disease exist simultaneously. The good news is that they can be treated, and reversed, when the individual participates in a system that calls for the active participation of consumer, clinicians and non-clinicians alike, health indicators are monitored often, risk identified and stratified, use of predictive measures, and in providing proactive care.

All this calls for a complete revamp of how healthcare systems are structured and care services delivered.

The required overhaul, therefore, would start with increasing funding for preventive health by an order of magnitude while recognizing that there is possibly a fine balance in funding between acute and preventive health. It also calls for placing the consumer of health at the center of a symphony of players that includes stakeholders in the healthcare fraternity – professionals, providers, insurers, drug and device manufacturers, pharmacies – and those outside such as employers, policy makers, government, etc. Finally, it equips the system with a panoply of tools to make delivery of preventive care seamless across time and space in the form of adequate staff, process and methods, standards, and technologies that could be brought to bear to address the issues.

Transforming Preventive Care

Such a transformational preventive care has to be designed from the ground up. But it can be hastened through learnings from other industries and absorbing where and how innovations happened. Industries such as automotive, defense, financial, telecom, retail, logistics, technology, etc contain a lot of embedded knowledge in the form of standards, processes and systems, vendor accreditations, recruitment, training, customer engagement, etc.

The military standard in the US – “milspec” – for example, are defense standards that go back to the Civil War and has been responsible for everything from the height of tables to sampling and testing of circuits that have shaped and influenced product development in civilian life. In more recent times the technology sector has demonstrated the value of open architectures, interoperability, plug-and-play schemas for third party services, identity verfication, and security. At the same time, it's not all about technology. At the end of the day, technology is an enabler and cannot be the entire solution. Innovations need to crack the complexities we bring as human beings: personalities, psychology, and behaviors.

Transformation requires recognition of and addressing issues relating to the several cogs in the wheel. So future preventive healthcare, at a minimum, must include:

• making complex administration viable through decentralization of ownership and accountability to, perhaps, the PIN code level (in technology parlance, this would be called “distributed architecture”);
• ensuring mandatory citizen screening and monitoring of basic vitals parameters and institute continuous basic health status monitoring and surveillance, through automation, of both individuals and populations alike;
• giving consumers choice in the matter of care, and to offer their current provider as default where appropriate;
• transparency in pricing by means of rate cards, and preferably have any government subsidies credited directly to the bank account as under direct benefit transfer, or DBT;
• a level playing field for player-neutral provision of services relating to care by the public and private sector alike;
• vendor accreditation and empanelment that enables interoperable plug-and-play services to be offered that fosters competition and low cost such as, for example, through implementation of Fast Healthcare Interoperability Resources, FHIR, or “fire”;
• security, transparency, and traceability through the implementation of Blockchain;
• incentivization and dis-incentivization of all players, including consumers of health, through appropriate behavioral psychology constructs and models that preclude gaming and directs behavior in desired ways;
• efficient data structures and data science that enable collection of appropriate data that could be captured as useful real time insights with the use of algorithms, machine learning, predictive analytics, and heat maps showing real time trends in specific clinical variables of interest within demographics and geographical areas for appropriate action;
• care that adapts to the “4Ps” – preventive, personalized, participatory, and predictive – and intervenes proactively before an issue of health gets to become acute

Many of the pieces are already here today in dribs and drabs – advanced sensors making continuous and home care possible, high bandwidth connectivity for our connected devices, remote access to doctors and other healthcare professionals, easy monitoring of data, and real time risk computation. The larger complexity lies in intent, cultural change in terms of administration and focus on outcomes, economics, and behavioral change.

In a manner harking back to WWII, this “preventive care of the future” would be the outcome of innovations coming from all quarters – in incentivizing consumers and providers alike to collaborate and participate in active discovery of potential risk, progress towards distributed care models, novel methods to attract investors to share in the upside from positive outcome measures, and a very disciplined and razor-sharp focus on clinical outcomes with the primary purpose of prevention.