If the healthcare system were a patient, and we were its doctors, we would be unable to read its vital signs.

When it comes to banking, we can easily transfer funds and make payments between institutions. The same goes for air travel with reservations connected to ticketing, payments and loyalty programs. Why? These systems have standards and interfaces that permit information and data to flow; not so with healthcare.

Technologies are becoming more sophisticated
From wellness and preventive care benefits to better chronic care management, the value of medical devices is becoming more important to patients and the continuum of care. Device companies are changing their business models to become more customer-centric and play a more tightly integrated role in the healthcare ecosystem. Because of these changes, consumers have better access to care, R&D is spurring greater collaboration across the industry and drug and device safety is improving.

Competition is changing too. Device manufacturers are developing business models in response to hospitals and retails such as CVS are entering the market. More pharmaceutical companies are selling drugs, devices, therapies and services supplied by different partners, and they’re serving smaller patient segments rather than relying on major new drug discoveries to drive revenue over many years.

And the connected care market is growing as the world get “flatter” and more integrated. According to a recent Parks Associates report, the U.S. market for wireless home-based healthcare applications  and services will become a $4 billion industry by 2013, growing at more than 80% a year. While smaller, the Canadian market will also experience substantial growth.

More devices are equipped with sensors and other technologies to share data and address new market opportunities, making them more intelligent than ever. Advanced analytics and supercomputers can turn years of data into intelligence that can find better treatments or track a global pandemic.

 Not being connected is expensive in many different ways
Yet, while our testing capabilities, hospitals, emergency response technologies and systems, pharmaceuticals, etc. are world-class, they lack connectivity, and we’re paying the price.

Physicians in medical practices average three weeks a year on insurance-related administrative tasks. Less than one in 10 American hospitals has implemented any kind of electronic patient record system. And more than 20% if lab tests are repeated unnecessarily because patients’ medical records are not available at the point of care. (While TMTA is not aware of similar research for Canada, the situation is not likely to be any better. Ontario’s recent eHealth-related scandals program have highlighted the fact that no consolidated records program exist for Canada’s largest province).

This situation of healthcare non-connectivity is not only expensive, it also introduces multiple opportunities for error and inconsistencies. Not only is this bad for patients, from a systems-management standpoint, it makes impossible to gauge the status of the systems or its components. If the healthcare system were a patient, and we were its doctors, we would be unable to read its vital signs.

Some success stories
However, some success stories are coming forth. In the US, the 1,000+ hospitals and clinics of the Department of Veterans Affairs, with one of the most advanced electronic record systems in the country, have been ranked best-in-class by independent groups across a range of measures – from chronic care, to the treatment of heart disease, to the percentage of members who receive flu shots. While studies show that 3% to 8% of the country’s prescriptions are filled erroneously, the VA’s accuracy rate is greater than 99.97%. And yet, through it all, the VA spends annual average of $5,000 per patient vs. the national average of $6,300.

Across the US, electronic health records can serve as the basis of a true healthcare system. This is not unlike what happened with UPC codes. The massive changeover to the UPC code not only altered the retail industry, it changed it for the better by ushering in better inventory management, simplifying returns and rebates, and streamlining global supply chains.

Likewise, digital records for patients can serve as lingua franca for health and medical information. But electronic health records are just one step. Aside from them, we also need to be build connectivity and intelligence right into the system.

A smarter system could bring many benefits
A fully connected healthcare system promises be a smarter system, a system optimized around the patient to increase efficiency, reduce errors, achieve better quality outcomes, and ultimately save lives. It can embed best practices and medical knowledge – as well as real-time patient monitoring of devices – into clinical and business workflows, for error-free delivery of care.

A smarter healthcare system can apply analytics to look across the medical histories of many patients and unlock new insight into the treatment of a disease. It could speed discovery of new drugs and therapies as well as tract infections diseases to predict high-risk populations, enabling governments to intervene early and keep people well.

A smarter system can also lead to breakthrough discoveries of genomics and to more personalized medicine. For instance, a recently developed nanoscale device could act as a kind of “bar code reader” for an individual stand of DNA. The goal for this type of technology is to make personalized genetic makeup readily available to each individual for less than $1,000. That is especially significant since the first sequencing done by the Human Genome Project cost $3 billion.

Connectivity could be a catalyst for real changeAs medical technology progresses, changes in three key areas must take place to accomplish true connectivity and make it effective across the board. These are:

Standards: Healthcare content must be standardized and these standards must be agreed to across the whole system. Furthermore, the standards must be open so they can interconnect devices, processes and data sets across the whole system. This fist step in itself could be a catalyst for real change.

Collaboration: The healthcare sector is a large ecosystem with multiple stakeholders. The whole industry needs to recognize its intrinsic diversity and work at bringing all parties to work together on a daily basis, at the point of care. That’s where the system needs to be optimized for team-based care.

Policy and ethics: The whole healthcare sector must come together around clear guidelines on how to manage healthcare organizations and industries, from an ethical and societal point of view. For example, as home monitoring becomes more pervasive, device manufacturers and designers will want feedback directly on how their products are working for patients and consumers. Making that information available while still respecting a patient’s privacy will require new policy frameworks around the rights of patients.

Not having a smarter system is no longer an option
Granted, the goal of developing a smarter, truly interconnected system can seem daunting. But achieving it is not some grand futuristic ideal. Not only can we build a healthcare system­ that truly serves patients, we have to. Because not having one is simply too expensive, both in terms of human lives and economics. And building one will enable us to achieve both societal progress and economic growth.  

This article was edited from a column by Dan Pelino, General Manager, Global Health Care and Life Sciences at IBM. The column  appeared in the March 2010 issue of Medical design.

CALGARY – Canada is slow to adopt the latest medical technologies, forcing Canadian patients to rely on old and often outdated medical equipment for treatment, says a new study from the Fraser Institute, an independent research organization.

“Lack of access to cutting-edge medical technology has significant consequences. The most obvious is that a patient’s survival or return to full health is compromised because of a later or less sophisticated diagnosis and more invasive treatment,” said Nadeem Esmail, Director of Health System Performance Studies at The Fraser Institute and co-author of Medical Technology in Canada.

“Equally disconcerting is that Canada’s total healthcare expenditures are among the highest in the developed world and yet the limited inventory of advanced medical equipment found in our healthcare system is often old and outdated.”

New medical technologies can provide faster and more efficient identification and treatment of disease. They can offer the patient safer, less invasive and more comfortable treatments and care, as well as offering new treatment options where none previously existed.

The peer-reviewed study, Medical Technology in Canada, evaluates the availability of medical technology in Canada compared to other nations within the Organization of Economic Cooperation and Development (OECD), measures the age and sophistication of medical technology in Canada, and measures the stock of available cutting-edge medical technology in Canada’s five largest cities: Toronto, Montreal, Vancouver, Ottawa, and Calgary.

This study focuses principally on technologies in the diagnostic imaging, laboratory diagnostic, surgical, and patient services areas.The complete study is available as a free PDF download at www.fraserinstitute.org.

Using data from a number of international reports and research articles, the study finds that access to medical technology in Canada is well below average. For example, according to the OECD, the number of MRI units in Canada (6.2 per million people in 2006) lags the OECD average (10.2 per million), and the number of CT scanners (12 per million people in 2006) also lags the OECD average (19.2 per million). Tellingly, the availability of both is about 60 percent of the level of the OECD average.

Another key indicator of Canada’s performance on the medical technology front is the availability of PET scanners (Positron Emission Tomography) which are used in cancer detection and treatment, as well as for Alzheimer’s disease, epilepsy, and in cardiology. The study finds that Canada ranks below average and ahead of only Finland, Spain, the United Kingdom, and the Netherlands among developed nations in the number of PET scanners per million people. In total, the study finds that Canadians receive less access to advanced medical technologies than their counterparts in other developed nations, with Canada lagging behind a number of other nations in the rate of expansion in the inventory or application of technologies after their introduction.

When examining the age and sophistication of medical technologies used in Canada, the study finds that the Canadian heathcare system relies heavily on an inventory of older and outdated medical technologies. Canada also often relies more on less sophisticated forms of technology than is optimal.



For example, at the beginning of 2006, 14.8 percent of Canada’s hospital-based CT scanners, 29.3 percent of hospital-based MRI units, 26.1 percent of hospital-based SPECT units, 35.7 percent of hospital-based gamma cameras, 56.3 percent of hospital-based lithotriptors, 47.4 percent of hospital-based angiography suites, and 40.2 percent of hospital-based cardiac catheterization labs were older than their respective Canadian Association of Radiologists-developed lifecycle guidelines.

The study also surveyed the availability of 50 cutting-edge medical technologies at hospitals in Canada’s five largest cities and found that only 10 of these technologies were available in more than half the facilities that responded. 



Of the remaining 40 technologies, 21 were present in 25 to 50 percent of the responding facilities, and 19 were present in less than one-quarter of responding facilities.“

The results of our failure to invest in new medical technologies are exemplified by long waiting times, less efficient use of medical resources, and less timely and sophisticated diagnosis and treatment,” Esmail said.

“Canada’s failure to invest in the latest medical technology cannot be explained by a lack of money. On the contrary, Canada’s universal access health insurance program is among the developed world’s most expensive such programs.

”Esmail points out that the federal government transferred $3 billion in targeted funding to the provinces between 2000 and 2004 in an effort to improve the availability of medical technology. Yet modern medical technologies still remain notably rare.

“Canadians desire access to modern and advanced medical technologies and they are already paying for that superior access. So why is spending on new medical technologies so constrained in Canada? Why are Canada’s relatively high levels of expenditures not purchasing the access to medical technology that one might expect?”

Esmail concludes that solving Canada’s medical technology dilemma can best be done by introducing more competition into the delivery of publicly funded services in Canada; using comprehensive, private insurance, both in parallel to and as a part of the universal system; and by strengthening the connection between the delivery of and payment for services.

The Fraser Institute is an independent research and educational organization with offices across Canada and the United States. Its mission is to measure, study, and communicate the impact of competitive markets and government intervention on the welfare of individuals. To protect its independence, the Institute does not accept grants from governments or contracts for research. Visit www.fraserinstitute.org.


“It was the best of times, it was the worst of times.”
Charles Dickens, A Tale of Two Cities

Ok, so maybe we haven’t seen the best or the worst of times, but when it comes to science funding in Canada, and particularly funding for health research, we have certainly been on one heck of a roller coaster ride.

Earlier this decade, an unprecedented number of new health research funding vehicles were created. These included, for example, the Canadian Institutes of Health Research, Genome Canada, the Canada Foundation for Innovation, the Canada Research Chairs program, and Networks of Centres of Excellence. Provincial governments also stepped up with important agencies like the Michael Smith Foundation, the Heritage Fund for Medical Research and the Fonds de la recherché en santé du Quebec.

Working behind the scenes in government, there was a Chief Scientist at Health Canada, as well as a National Science Advisor to the Prime Minister. Also, many committed politicians from all parties worked to advance the cause. The stars, it seemed, were aligned, and health research was established on a firm footing.

It is not entirely clear what accounted for the success – champions, inspired leadership, good economic times, new organizational models for research, public support? Perhaps all were factors. It is also worth noting, however, that public support for health spending was high. Perhaps, at least to an extent, health research was riding on health’s coattails!

That was then and this is now. This year, health funding has come under significant pressure and the financial crisis is leading to massive government deficits. It seems health research is now viewed as “soft;” cuts are the order of the day.

The Spring 2009 budget slashed $150 million from the three federal research granting Councils under the guise of administrative efficiencies. $28 million was cut from the National Research Council, and there were additional cuts to other federal science programs. Gone are the Chief Scientist and the Science Advisor. In fact, there was no explicit mention of the important role of science, technology or innovation in the economy of the future in either the throne speech or the budget. Moreover, the government served notice that, over the next three years, funding levels would likely not increase and may decrease even further.

The response from the research community was predictable. 2,000 researchers signed petitions in protest, and the likes of John Polyani, Alan Bernstein and even Preston Manning penned op-ed pieces beseeching the government to reconsider its priorities. It was a sad realization for many that, within a few short years, Canada had gone from rapid growth in public research support, to a funding plateau, to outright cuts.

Canada’s reversal comes at a time when political leaders in other countries, including Barack Obama and Gordon Brown, have charted quite a different course. In the US and UK support for science is a key strategy in combating the recession and promoting economic recovery. In Canada, in contrast, economic recovery seems to hinge on stimulus for “shovel ready” roads and bridges, in other words, the old economy rather than the new economy.

The US has committed $25 billion from its stimulus program to health research, whereas Canada has not allocated any funding from its stimulus program. (Not that any one would recommend temporary stimulus as an alternative to stable, long-term funding for science.) The policy environment in other countries is also shifting. For example, the Obama administration has lifted the ban on government funding for stem cell research. All this raises the prospect that we will, once again, have Canada’s best and brightest heading off for opportunities in other countries.

The data is not encouraging. Canada spends 1.9% of GDP on science funding, whereas the OECD average is 2.2%. The US, our closest neighbor, is already higher than the average and the Obama administration has publicly committed to a 3% target. Obama has appointed a highly respected Nobel laureate to lead the development of American science policy. Here, it seems, no one is in charge and science advocates are apparently thrown out of ministers’ offices!

What do we do now? Creating stable, increasing public support for health research requires systematic and on-going efforts to overcome the vagaries of government financial and political cycles. Unless support is at a high level, there can be no hope of ever getting off the roller coaster.

Of course, the research community cannot control government policy. However, there is much the research community can and should do to contribute to establishing research policy and funding on a solid foundation. Here are four suggestions.

Firstly, the research community needs to completely leave behind any sense of entitlement. It is true that research in Canada is good, often world class, but that doesn’t mean research is entitled to funding in the eyes of government or the public.

Second, the research community should commit itself to continually measuring and conveying the value of research to the public and policy makers. Often, the public does not understand the value of health research and governments are fixated on tangible, short-term results when the benefits of research are usually realized only in the longer-term. A good place to start is by paying much more attention than in the past to effective public communications and government relations.

Third, the research community should answer policy makers’ questions about the return on investment (ROI) in health research. As the recent report from the Canadian Academy of Health Sciences (www.cahs-acss.ca) points out, the science community must demonstrate, based on evidence, that research advances knowledge, builds capacity, informs decision making, improves health outcomes, and contributes to broad economic and social benefits.

Finally, the research community needs to demonstrate that its collective efforts are optimally organized. A good place to start would be the development of a comprehensive health research plan for Canada that clearly sets out priorities and strategies. As the international review panel examining CIHR’s first five years pointed out, the development of new agencies and programs occurred so quickly in Canada that: “a major outstanding challenge . . . is the apparent lack of coordination at the federal and provincial levels of the many different types and sources of funding for different aspects of health research.” Such observations cannot be allowed to go unanswered.

At present, health research spending in Canada is, at most, a modest $3 billion. When considered as a percentage of the $180 billion healthcare budget, research funding represents less than 2%. Knowledge intensive industries often spend 25% or more of their budgets on R & D! Rather than going forward, when adjusted for inflation, Canada is returning to funding levels of a decade ago. This picture is dire, indeed.

Now is the time to start building more support for a robust and effective R & D system in Canada. Such as system should bring together and orchestrate infrastructure, talent, capital, partnerships, markets and a supportive policy environment. The stakes are high, with the potential of tremendous social and economic benefits for Canada. Only by increasing awareness and support for research will we be able to ride out the next financial crisis or “flavor of the day” – and hopefully not on a roller coaster!

Dr. John H. Hylton spent 25 years as a healthcare CEO, including responsibility for the Council for Health Research in Canada (now Research Canada) and the International Regulome Consortium. He now consults and speaks regularly on strategy, leadership, governance and organizational performance.

This article first appeared on the bioscienceworld website. For more similar articles,go to

Open letter to

Marguerite Pridgen, Office of Federal Financial Management, Office of Management and Budget,
Room 6025, New Executive Office Building, Washington, D.C. 20503

Re: Buy American requirements of the ARRA 

As is the case with other industrial sectors, the medical technology industries of the United States and Canada benefit greatly from being part of the world’s largest trading relationship. The integrated nature of the economies of both of our countries is vital to all of us. This is even more so in the case of our industry. Not only do the jobs of millions of Americans and Canadians depend on this reality, so do the health and wellbeing of hundreds of thousands of our respective citizens.   

For these reasons, TMTA member companies and their US suppliers and customers have grown alarmed at the confusion and uncertainty surrounding implementation of the ARRA. Again, as is the case with other industries, the situation in the medical technology industry is resulting in unwarranted delays in project start-ups, cancellation of contracts and new orders, delayed shipments, and consequently the serious erosion of long-standing cross-border supply relationships. Business transactions are also being severed for projects outside ARRA coverage because of the uncertainties arising out of the upcoming legislation.

Our industry is specifically concerned about the following points:

Use of the insufficiently defined term “manufactured” is already resulting in differing and/or conflicting interpretations from various procurement agencies and/or US contractors. 

Also of great concern to our industry is the legislation’s use of the term “substantial transformation”. Such a term can indeed only lead to confusion since many medical technology products are the result of cooperation between companies which ship components to each other several times across our respective borders before a “finished” product is completed.

As your letter points out, ours is truly a continental economy. Not only have our two countries enjoyed open and transparent access to each other’s procurement markets for many years, our respective industries they have literally grown around this reality. To rip that out now would not only endanger the survival of our respective industrial sectors, it may even set medical technology back several years as doctors, hospitals and medical suppliers are forced to scramble to find new alternatives for long-established therapies and healing processes.   

We, at TMTA, think that the Buy American provisions contained in the ARRA may have many unintended consequences, consequences that most companies can ill afford in these trying economic times.  We are especially concerned that a retaliatory backlash in Canada and other countries could inflict serious harm to American and Canadian manufacturers alike. As you point out in your letter, if Canada and the United States, the world’s two largest trading partners, cannot avoid imposing restrictions on our bilateral trade, then it is difficult to see how the global economy can avoid falling into a vicious circle of protectionism.

For these reasons, we ask the American Administration to not impose Buy American requirements on sub-national procurement contracts, or on grants and other financial assistance awards and cooperative arrangements with private entities funded by the ARRA. 

Just as you do, we take heart in the fact that the ARRA does offer provisions for waiving regulatory restrictions in case where it is determined that applying Buy American constraints would be inconsistent with the public interest. Clearly, the loss of US jobs and the disruption of a highly competitive manufacturing base in North America are not in the public interest, either of Canada or of the United States. Neither does threatening the health and wellbeing of hundreds of thousands of people. For these reasons, we join you in urging Congress to use this waiver in exempting state and other sub-national entities from Buy American provisions attached to ARRA funding.

TMTA is committed to open and reciprocal access to procurement markets in both Canada and the United States and will partner with the CME and any federal agency towards that end. There is no doubt that the present economic downturn does indeed present enormous problems for our industry. But we believe that, if handled well, the situation can offer Americans and Canadian a significant opportunity to improve upon existing trade agreements. We too are encouraged by the willingness of the Canadian and Provincial Governments to propose the negotiation of a more open procurement agreement between our two countries covering federal, state/provincial, and local authorities. 

American jobs are being lost by Buy American as Canadian companies see business in the United States disappear. More jobs will be lost if our two countries do not act quickly to keep our procurement markets open and enhance new business opportunities in these troubling times.  

Sincerely,

Christian Dubé, Chairman, Trillium Medical Technology Association

 

Bench to bedside

Academia slows the search for cures
 
Now that president Obama has almost all of his top science picks in place – from the Department of Energy to the FDA – the lack of an appointee for the director of the National Institutes of Health is standing out like a creationist at an evolution conference. I hope the delay means Obama has grasped the need for, and the difficulty of finding, a powerful director who can get beyond the rhetoric about moving discoveries out of the lab and make it a reality. That hasn’t happened yet, six years after a much-ballyhooed NIH “road map” declared such bench-ot-bedside research a priority and vowed to reward risk-taking, innovative studies, not the same old incremental research that has produced too few cures.

NIH has its work cut out for it, for the forces within academic medicine that (inadvertently) conspire to impede research aimed at a clinical payoff show little sign of abating. One reason is the profit motive, which is supposed to induce pharma and biotech to invest in the decades-long process of discovering, developing and testing new compounds. It often does. But when a promising discovery offers a low profit potential, patients can lose out. A stark example is the work of Donald Stein, how at Emory University, who in the 1960s noticed that female rats recovered from head and brain injuries more quickly and completely than male rats. He hypothesized that the pregnancy hormone progesterone might be the reason. But progesterone is not easily patentable. Nature already owns the patent, as it were, so industry too a pass. “Pharma didn’t see a profit potential, so our only hope was to get NIH to fund the large-scale clinical trials” says Stein. Unfortunately, he has little luck getting NIH support for his work (more on that later) until 2001, when he received $2.2 million for early human research, and in October a large trial testing progesterone on thousands of patients with brain injuries will be launched at 17 medical centers. For those of you keeping score at home, that would be 40 years after Stein made his serendipitous discovery.

The desire for academic advancement, perversely, can also impede bench-to-bedside research. “In order to get promoted , a scientist must publish in prestigious journals”, note Bruce Bloom, president of Partnerships for Cures, a philanthropy that supports research. “The incentive is to publish and secure grants instead of to create better treatments and cures”. And what do top journals want? “Fascinating new scientific knowledge, [not] mundane treatment discoveries,” he says. Case in point: in research supported by Partnerships for Cures, scientists led by David Teachey of Children’s Hospital of Philadelphia discovered that rapamycin, an immune-suppressing drug, can vanquish the symptoms of a rate and sometimes fatal children’s disease calls ALPS, which causes the body to attack its own blood cells. When Teachey developed a mouse model to test the treatment, he published it in the top hematology journal, Blood, in 2006. But the 2009 discovery that rapamycin cure kids with APLS? In the 13^th ranked journal. The hardcore science was already known, so top journals weren’t interested in something as trivial as curing kids. “It would be nice if this sort of work were more valued in academia and top journals,” Teachey says. Berish Rubin of Fordham University couldn’t agree more. He discovered a treatment for a rare, often fatal genetic disease, familial dysautonomia. Given the choice of publishing in a top journal, which would have taken months, or in a lesser one immediately, he went with the latter. “Do I regret it?” Rubin asks. “Part of me does, because I’m used to publishing in more highly ranked journals, and it’s hurt me in getting NIH grants. But we had to weigh that against getting the information out and saving children’s lives.”

Not all scientists put career second. One researcher recently discovered a genetic mutation common in European Jews. He has enough to publish in a lower-tier journal but is holding out for a top one, which means identifying the pathway by which the mutation leads to the disease. Result: at least two more years before genetic counselors know about the mutation and can test would-be parents and fetuses for it.

With these forces in play, NIH has to push back even harder to make translational research a priority. When Stein applied for NIH funding in the 1980s and 1990s, “people didn’t believe a pregnancy hormone could help patients recover from brain injury’” he says. “People said it was too simple.” And when he, too, tried to publish in top journals, the papers were rejected in large part because all he was reporting was success in treating people, not the mechanism or physiological pathway that constitutes the sexy science that wins plaudits. Teachey could not get NIH funding either. Reviewers said the work was too translational – and this was after the NIH road map professed love for translational research. It will take an NIH director of almost mythical proportions to turn around this ship.


Written by Sharon Begley, regular science columnist for Newsweek Magazine.