As a follow-up to my last column (Skiba, 2018), I want to speak to an emerging idea, that of the invisible health care professional. In one of the "Next Big Thing" talks at the Consumer Electronic Show 2018, which focused on the invisible doctor, the primary message was that the "digital health industry will take signals from all parts of our lives and integrate them into personalized care." This talk (available at https://www.ces.tech/Conference/ConferenceProgram/Conference-Tracks/SuperSession) led me to question how we are preparing future nurses for their interactions with future patients; in particular, I have been thinking about the future role of the nurse practitioner (NP) in the connected age of personalized care. As many of you know, the University of Colorado's Drs. Loretta Ford and Henry Silver initiated the first NP program in 1965. Now, I wonder, how will the NP role evolve over the next decade with the intersection of data, devices, and artificial intelligence (AI)?
THE CONTEXT
A recent publication by Bazzoli (2018) identifies six trends that point to a revolution in health care. The talk about revolution in health care is not new - it seems to keep coming up - but I believe that one trend in particular is helping to catalyze this movement. As Bazzoli notes, consumerism is on the increase - more patients want control over their health records and are not just relying on the health care establishment, family, or friends for knowledge about their health. The Internet has unleashed knowledge so anyone can access information about health conditions and treatment options. Consumers are also collecting health data from their devices, tracking their activity, and even obtaining blood pressure readings on their watches. According to Bazzoli, consumers are paying a larger share of their health care costs, which, in turn, leads to higher expectations and greater demand for control. Just take a moment and think about your students. What expectation do your millennial, Gen Z, and iGen students have for their health care in the future?
Bazzoli's other five trends include business migration, price frustration, provider disintermediation, health concentration, and, lastly, data and technology affirmation. Business migration is something we see in the news almost on a daily basis: the opening of the AppleTM Health Care Clinic for its employees, for example (https://www.cnbc.com/2018/02/27/apple-launching-medical-clinics-for-employees.ht), and the new partnership between JP Morgan Chase, Amazon, and Berkshire Hathaway to launch their own health care company (https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan).
Think about all those digital tools that were showcased at CES 2018 entering into the health care market (Skiba, 2018). As part of the CES panel on "The Next Big Thing," Paul Sterling, vice president of emerging products at UnitedHealthcare, talks about incentives for employees who are willing to be monitored when wearing an activity-tracking device. The MOTION project (https://www.uhc.com/employer/programs-tools/for-employees/unitedhealthcare-motio) provides a monetary incentive to the employee's health savings accounts each day the tracker is used.
Price frustration is a no brainer. Despite all the advances in health care, health care costs continue to skyrocket.
Provider disintermediation is an interesting trend. In the past, traditional providers served as gatekeepers, maintaining the knowledge base and providing service. You had to go to the provider's office to get care. But remember what Sarasohn-Kahn (2018) says, "The new front door for health/care will be the patient's home front door." As Bazzoli points out, there is more value in optimizing health than in trying to charge more for sick care. For nurses, the focus on promoting health, as opposed to caring for the sick, is not a new trend.
The last trend, data and affirmation, has the greatest potential to impact health. The more data that can be collected, verified, and distributed, the better one can receive the right care at the right time and the right place. Health data, whether collected by a health care institution or by the individual, will facilitate better decision-making.
THE INTERSECTION OF DATA, DEVICES, AND AI
Although electronic health records allow us to collect and store patient data to facilitate decision-making, we are still trying to maximize their use and minimize provider frustration. There is still a disconnect with the need to pull data from various sources - inpatient records, primary care visits, urgent care visits - to get a complete picture of the patient's health. Many electronic health record systems are still struggling to add the social determinants of health and genomic data to support health care delivery.
Despite these issues, health care organizations have managed to access data and use data for predictive analytics. Big data, data science, and data visualization are terms that consistently appear in the health care literature. They speak to the need for health care organizations to harness the power of data.
Perhaps the most interesting and plentiful data are those being collected between health care visits. Leaf (2018), writing in Fortune, cites Aetna's CEO Mark Bertolini, who notes that, of the more than 6,000 waking hours people have per year, most spend, on average, just 20 hours in health care: "So 99.7% of the time that we're living our lives and being impacted by the world, we're not in a doctor's office, clinic, or hospital." But in that 99.7 percent of our time, we collect a lot of data that will directly impact our health, for example, our sleeping patterns, our activity levels and sedentary activities, and our nutrition data. Each time you add a digital tool to your life, you are amassing more and more data points.
Also writing in Fortune,Fry and Mukherjee (2018) provide a good synopsis: "More specifically, it's your data: your individual biology, your health history and ever-fluctuating state of well-being, where you go, what you spend, how you sleep, what you put in your body and what comes out. The amount of data you slough off everyday - in lab tests, medical images, genetic profiles, liquid biopsies, electrocardiograms, to name just a few - is overwhelming by itself. Throw in the stuff from medical claims, clinical trials, prescriptions, academic research, and more, and the yield is something on the order of 750 quadrillion bytes every day - or some 30% of the world's data production."
All these data have existed for many years, but we did not know how to harness the data deluge and turn it into meaningful information for decision-making. "But now, thanks to a slew of novel technologies, sophisticated measuring devices, ubiquitous connectivity and the cloud, and yes, artificial intelligence, companies can harness and make sense of this data as never before" (Fry & Mukherjee, 2018).
AI pops up everywhere. Reporting on the HIMSS 2018 national conference, Winey (2018) cites Pamela Peele, who thinks the new buzz around AI is "because we have dense, robust algorithms, tons of data and the ability to handle it computationally. It's the perfect storm." For example, IBM's Watson is being used to help diagnose and care for oncology patients. View the video at https://youtu.be/8_bi-S0XNPI and read about Watson and oncology at https://www.ibm.com/watson/health/oncology-and-genomics/oncology/). There are a number of other examples:
* The Babylon app uses AI to provide online consultations (https://www.technologyreview.com/s/600868/the-artificially-intelligent-doctor-wi). Patients report their symptoms, which are compared to a knowledge base of illnesses.
* Molly is a digital nurse that can help monitor chronic conditions and provide episodic care (http://www.sensely.com/#about).
* Boston Children's Hospital has developed KidsMD(TM), which provides basic health information and education using Amazon's Alexa technology (https://www.eurekalert.org/pub_releases/2016-04/bch-bch041116.php).
* An example funded by the National Institutes of Health is the AICure app (https://aicure.com/), designed to optimize patient behavior and medication adherence.
With the intersection of data, devices, and AI, who will be your health care professional in the future? Will your health care provider partner with you as an invisible AI assistant? Will it be Molly, your virtual digital nurse? Or will it just be the invisible AI wizard on your smartphone? Fry and Mukherjee (2018) talk of Daugherty's prediction of "information asymmetry." Patients that own their health data have been able to harness that power and be more in control of their health.
Nurses will not disappear in the future, but their roles and responsibilities will change. Here are some suggestions to get you up to speed as an educator.
* Educate yourself in the use and application of digital health tools. Schedule a visit with your local health care facility or a virtual visit at a distance facility.
* Think about the data deluge that will be facing nurses and how to prepare your nurses to be better data managers. Learn more about data science, data visualization, and AI so you can be prepared to address questions as they arise and begin to introduce these topics in your courses. You might want to take massively open online courses on EdX (https://www.edx.org/course?subject=Data%20Analysis%20%26%20Statistics) or Coursera (https://www.coursera.org/browse) to learn more.
* Do some searches on the web and find the innovation centers being operated out of health care systems. See what is on their horizon. Following are a number of examples: Boston Children's Hospital (https://accelerator.childrenshospital.org/), Colorado Children's Hospital (https://www.childrenscolorado.org/research-innovation/the-center-for-innovation/), Johns Hopkins Hospital Sibley Innovation Hub (https://www.sibleyhub.com/), Kaiser Permanente (https://garfieldcenter.kaiserpermanente.org/), and Mayo Clinic (http://centerforinnovation.mayo.edu/). You can also read about Putting Humans at the Center of Health Care Innovation at https://hbr.org/2018/03/putting-humans-at-the-center-of-health-care-innovation.
As always, you can send any thoughts or ideas about how we prepare our next generation of nurses to mailto:[email protected].
REFERENCES