Closing Plenary and Discussion: "Reflections and Visions"- Michael D. McDonald, Dr. PH, Director, Health and Telecommunications Office, C. Everett Koop Foundation, Inc., Moderator

Moderator: Michael D. McDonald, Dr. P.H., Director, Health and
Telecommunications, The Koop Foundation, Inc.

Robert G. Blank, Jr., Director of Health Care, Personal Online
Services, AT&T

Linda F. Golodner, President, National Consumers League

Peter R. Seaver, Vice President, Health Care Policy and Advocacy,
Pharmacia & Upjohn

Admiral William R. Rowley, M.D., Commander, Naval Medical Center,
Portsmouth, Chairman of the Military Health Services System 2020,
U.S. Department of Defense


* Michael McDonald *

Thank you.  Now we're shifting from the mechanics to the methodology
-- looking back and looking ahead.

We've got some imminent people looking forward, so what I'll do is
go over a bit of the context first, and then focus on specific
visions of the future of the field.

Any revision is very hard to predict -- but the outcome will be that
the health infrastructure is broader than it is today.

When we look at the health infrastructure and ask the question of
how informatics fits into it, we need to see that there are seven
parts to the infrastructure -- and that informatics is one of them.
The full list of the parts is: administration, education, tele-
medicine, consumer health informatics, population databases, system
coordination, and communication networks.

Let's look briefly at the shifts which are occurring in science and
technology.  A computer that cost $12 million and sat in the air-
conditioned back rooms of corporations 12-15 years ago today sits in
our children's laps for the price of about $2,000.  This kind of
change is mind-boggling.  In terms of the speed differences you're
looking at a 10 to the 4th power increase. We are talking about
entirely different devices being used today -- a device that is used
to expand cognitive learning.

When you think about the ramifications, it is a global phenomenon.
And it's not about building better machines, but about building a
human network worldwide.  82 countries now have access to the
technology.  That's 36 million people.

One of the key challenges we are facing is that as we are adding
more and more machine power, what is the role of increasing human
capabilities?  We need to look at building machines that actually
focus on making people more innovative, not machines that are just
more powerful.

In the game of informatics, the people in this room are playing off
different goals: enhancing the quality of service and the scope of
it, improving the system and access, and expecting a fair return in
the process.  But we have to think about how we are going to serve
those in need.  They will be the hardest to reach and involve, but
we've already had of some solutions presented to us.  Our goal is
empowering people to live better lives.

I want to provide you with a context for how the health care system
is evolving.  Some of this is nonintuitive.  We were meeting with
David Lawrence earlier and talking about whether it is a good idea
for Kaiser to be integrating its systems.  He said, "I don't think
health care is going here; I think we are already dropping into the
medical game.  We'll see the prices drop and access to care drop,
and equity will be a problem."  So we'll either shift back to a
single payer system or we will shift to facilities with access for
people on Medicare and Medicaid.

We need virtual systems that are network based -- not hospital
based.  This is clearly a shift away from our current facilities,
and a massive investment in a managed care information system.

There also is a virtual vertical and horizontal integration taking
place that will lead to major consolidation.  Demand on managed care
will become one  of the central  factors.
Virtual managed care attempts to manage the demand and reduce entry
into the health industry.  If we can do this we will be ahead of the
game.

Then as you go through the consolidation phase, population health
will be critical.  If an HMO now has 40-70% of the population, then
they have strong incentives to employ population health initiatives
community-wide.  Those that are successful -- they will be the
organizations that will manage complexity better than their
competitors.

Whatever we do has to enable the transformation of the larger health
systems.  We have to keep in mind the massive trends which are
taking place.  We are adding an average of almost a billion people
every decade; 40% of the world's children are living in poverty; the
world's brain trust is gone.  We are in what is being called the 6th
wave of extinction -- more species are disappearing today since the
disappearance of the dinosaurs.

There are big challenges that consumer health informatics faces
today.  For the players in consumer health informatics are changing.
Even from a year ago we're seeing a change in the players and the
audience in this room.  Some of you I have known for 20 years.
Others of you are coming onto the scene for the first time this
year.

One of the key factors in our work will be finding the balance
between competition and collaboration.  The rules are dynamic and
the game cannot be played alone, but the most import rules are yet
to be set.  For example, the standardization of a person's health
record.  This can only be done with collaboration between all the
parties involved.  Everyone in this room has a role to play in this.
There is a tremendous market which is emerging, and a tremendous
need that needs to be filled.

Big gorillas will be defining the rules.  It's not going to be one
player that will define what happens.  It will be a composite of a
lot of people in this room.  Most of the successful players will
have their best strategies for collaboration worked out soon.

We are going to see the elephants dancing, and as they roll over in
their sleep, a lot of people will be squashed.

We will begin the panel presentations with Rob Blank.


* Robert G. Blank, Jr. *

I want to start by expressing my gratitude to the organizers of this
conference for the invitation to speak here today.  I would also
like to offer my congratulations to Mary Jo Deering; this is the
best work the government has to offer and she's done a fabulous job
these past two days.

And to Mike -- I'll try not to roll over in my sleep!

I would like to talk about the process that we've taken in
assembling the information -- and I won't give you a sales pitch! --
the research and the thought process that led to where we've arrived
today.  There is an entirely new paradigm of information, and the
only way we will move into the market is by developing applications
that people can use.

The other thing that I want to mention as a key factor is that there
has been concern raised about getting the wrong consumer health
information.  I have  faith that the group of people assembled here
will bring it into the


I'm going to steal some ideas which were presented by Tom Ferguson
-- like everyone else! -- and talk about the important notion of the
health pyramid moving from individual to community.

In the information age we need a model which inverts the pyramid
with people at the bottom.  The consumer becomes the key player, as
Tom points out.  In the information age we return to the natural
order of things, but with new individual power.

I wan to spend a few minutes reviewing a few of the trends --
trends affecting the consumer -- from demographical trends to those
of technology.  The focus is the bottom up view of what the
economist is looking for in the system.

The aging population -- This is clearly a major phenomenon.
Biological and pharmaceutical advances have made it possible for
people to lead longer lives.

A paradigm shift to the perception of rationed care -- There is a
large issue of concern about the bottom line, not with their health.

Who are the stake holders? -- Impacting the cons is the delivery
system that is currently involved in connecting various entities.
At the same time, we are trying to link these together and deliver
information.  We need the ability to put information into and back
out of the system for the consumers.  We are concerned about being
able to hold on to the market share.  All of them are spending two-
thirds of their time on information technology.

Pharmaceutical entities are seeing major changes also.  The reality
is that in all corners, the manufactures are discovering that people
are moving from the product to the service industry.  Government is
also trying to expand access, basically so that they can reduce
costs by preventing and ensuring better health.

What is the consumer looking for?  They want to resolve a problem.
They are looking at serious problems -- often facing issues of death
for themselves or of their loved ones -- so it is up to informatics
to provide them with information to facilitate decision-making.  One
anecdote I have to offer related to this: the director of marketing
came to me recently and told me that he spent time on the Internet
trying to figure out what do about his daughter's hearing problems.

Users are asking questions in their quest for answers to critical
questions and problems.  "What do I do about this?  How do I take
care of myself or the person I care about?"  This shows just how
important this communication is.  It is connecting people to
emotional experiences, and consumers are getting very sophisticated
very quickly.

Finally, a few words about information technology.  If you look at
the paradigm shift in technology, you see that we are going from
computers in the back room to laptops.  What will the advancements
be over the course of next 20 years?  What we see are three basic
areas of approaches:  consumer information, the ability to
communicate and simply educating the population.

There is another major area which I haven't really spoken about --
alternative medicine -- which a lot of people have mixed feeling
about.  But there is more and more interest in getting involved with
the spiritual as well as the medical.

Those are the trends as I see them that will come in the next 20
years.


* Linda F. Golodner *

I want to say that it's been a pleasure to see so many consumer
advocates at this conference.

The National Consumers League is celebrating its 100th anniversary
this year and we've seen a lot of changes over the years.  We still
work in child labor issues -- there still is slave labor in the
world -- and we work on a lot of online  and Internet issues.  We
are working with the Online Services Association to develop consumer
information and are working on privacy issues.  We are working with
companies to develop privacy systems.  Intellectual property issues
has been a focus of our work as it has emerged in recent years --
how important it is to respect intellectual property.

Last week the National Consumers League held a centennial countdown
by examining the issue: "Cashing in on the cashless society."

As we try to move into the use of debit cards, smart cards, e-
commerce for your computers, we looked at those who will be left
behind.  We examined the use patterns of those that enjoy it as well
as those that don't want to go along with this change.

Very few people talk about the ones that will be left behind in this
shift.  The banks have moved out of their neighborhoods.  They don't
go to banks -- they go to pawn shops and check-cashing
establishments, etc.  Those who don't want to go along -- they like
the feel of the money.  They don't want electronic funds transfers
of their social security check.  They love to have the hands-on,
personal relationships.

In our work on the community based health care project we formed
coalitions at the community level in order to look at access to
care.  One of the things we found important was the approach of "We
want you to define what the problems are."  We worked with several
free clinics -- places which give free health care to the working
poor.  They get free care from doctors and nurses, and free
pharmaceutics from pharmaceutical companies.  When we went online,
we were able to establish communication among the different actors.
One successful project was done in South Florida.

One things we found important in carrying out this project was that
training and support were the two most important things we could
provide these people who had never been online before.  A lot of the
people are volunteers and we can provide a lot of information.  But
one thing you learn from the consumer movement is that you can't
provide information without first providing the necessary training.

They talk to their peers and to their family.  They read the
promotional materials.  They talk to their doctors, and they share
information online on the Internet.  But the information can be
confusing and conflicting to the consumer.

The Internet can make people become part of the team with their
doctors, nurses, etc.  But information rich and education poor won't
cut it.  The doctors, the home care, the nurses -- they are the
informed members of the team.

The system -- or non-system -- of health care is where he have to
make sure that the revolution in technology that is taking place
works with the system.  We know that we need to cut the fat from
health care.  By all accounts, managed care has cut much of the fat
from health care.  But we have to ask if they are cutting from the
wrong end.

Almost 1/4 of every dollar of medical care is paid for something
other than health care.  We talk about what information consumers
should have, but we need to talk about how we listen to consumers.
We do need to listen within the health care system -- and not only
in conference.  We should require individuals to be more accountable
to consumers.

There are lessons to be learned from the consumer movement.  There
were five consumer rights that Kennedy proposed, and they're still
around: choice, information, education, being heard, and faith.

People are going to have to have a choice of whether to network or
not.  But they need quality information and the ability to sort
through all of the information out there so they can go to the FAQ's
or a glossary in order to personalize their care.  We have to make
sure that consumers are heard.

A lot of people in this room are looking at forming companies or
starting online services.  We need to take an example from AT&T, or
NYNEX.  They are developing services; they talk to consumers and
make sure the consumer understands the information they are putting
out.

Here are some recommendations and things we need to look at.  We
need to have outcomes and statistics in order to better keep tabs on
what's happening out there with the consumers.

We need to make sure that we're more inclusive.  There will be a
shift in money in the industry.  Some of it is new money because
there are new people entering the field for the first time.  But
some of it will only be changing hands from one to another.

The challenge to HHS is to bring consumers in on the early stages of
the development-- as seen during the telecommunications debate.
More emphasis needs to be on the consumer on the individual level.

We all need to have affirmative action to include the have nots.
Community reinvestment programs as it's called in some business
circles.  For every dollar from the haves, give a percentage or a
tithe to the have nots.

We need to realize this is not only the teachable moment, but also
the learning moment.  Those developing information online have to
make sure they capture the learning moment for consumers and that
they are not just putting information out there.


* Peter R. Seaver *

I want to congratulate all of you for coming to the finishing line
of this meeting!  This is the kind of meeting that I expect will
grow every year and will then explode and people will be waiting in
line to get in.

On Sunday night when Tom Ferguson was speaking a human quality came though in
the way he was talking about the application of the technology.  It
was the self-correcting aspect --  the fundamental goodness in the
American people -- that impressed me the most.  They need more
education and more information, but let's raise the standards.  The
pioneers in this country have shown use we can do great things.

There is no opposition to taking out the social ills which are
causing the rising costs of health care.  Let's get off this
business of talking about how much we are spending -- it's the
violence that's causing the high cost of health care -- substance
abuse, guns, unwanted pregnancies.

The politicians can't do anything about this.  There's not a man or
woman in office today that can do anything bout it.  That's not how
were going to get our future taken care of -- through politicians.

I have always said that the health care profession has good people
in it.

Remember that research is our sole reason for being -- it is our
only enterprise.  But we have a long way to go toward the technology
that needs to be developed.  We've got to be thinking about
patient's needs for the early trials of what will come out of our
labs.

You are giving us the tools to do that.  We need to be careful about
what we say to people, when we say it, and whether we have the
authority to say it.

Someone wrote an article recently -- it was in the Harvard Business
Review -- that more and more people bowling, but fewer people are
bowling in leagues.  People are becoming isolated from one another.
There a paradox here.  When I see someone with a laptop, it's a
whole new take on things.  Through this technology, maybe people can
connect with one another and build our communities up again.

If we look at the ethics of care and how health care should be, we
need it to have a community sense.  It needs to be the management of
the total patient.  Patient based, individual medical care.

There needs to be an honoring of stewardship.  There are many bright
people here.  It is your obligation to have the stewardship to makes
sure this all comes out right.

We need a concept of justice to be in operation.  If we are unable
to work out the system so that it works for everyone -- if it isn't
available to everyone who needs it -- eventually, then, it won't
work.


* Admiral William R. Rowley *

I would like to offer a vision of the health system for the
military.  The military realized that the world was changing really
fast and we had to get out there and develop a plan.  We're doing
almost all of this on the Internet.

In the first phase we analyzed the key trends in 20 segments of
American medicine.  Combining those we looked at four visions of the
future.  And this  is all on the Web.

I want to talk about where I think American medicine is going.  I'm
trying to get you to let go -- to expand your vision -- because the
world is going to be a lot different in the future than it is right
now.

I think we have gone through several phases in health care.  The
first phase was problem.  It wasn't too successful and we did not
get what we needed from it.  Secondly the stage of managed care came
in to being.  As a result, by the year 2000 we will have 165,000 too
many doctors.  And finally there is health status improvement -- and
that's where I want to start now.

Between 1900 and 1990 life expectancy went from 45 years to 95
years.  But it's not American medical practices that has made this
difference.

What can we do to prevent premature death?  Well, about 50 percent of the
things we can do to make a difference involve lifestyle choices.
Those are behaviors.  About another 20% are environmental factors.
Genetics make another 20% difference, and in the future we will have
more and more control over genetics.

Only about 10% is medicine.  Now that's a totally different way of
looking at the world!

No modern nation has enough money to pay for the cure of all of the
diseases that it has generated.  We wait until you are sick, and
then we spend a lot of money to get you better.  Rather than treat
all the problems we create by society, we need to design them out of
the society.  Think about the system that puts money into fixing
sick people.  In the future, we will maybe put money into the
society to keep people well.

Where does American medicine focus?  Illness.  We wait until someone
gets really sick.  As soon as someone is well, we turn them away.
Our medicine only focuses on eliminating the negative -- we never
focus on the positive.  There is a positive side to the equation
too:  health, wellness.  Beyond that, maybe self-actualization --
living up to your expectations-- physiological health, mental
health, spiritual health.

We are trapped in our paradigms -- the old paradigms.  We looked at
the body so we treated things on the physical level -- not realizing
that the physical disease usually was caused by something below the
physical level.  Now we need to have a multidimensional approach to
care.  They want more alternatives, more understanding.

The most important factor that we've only recently admitted is that
there is the spiritual health issue.  There's all this new age stuff
-- rows and rows of books in stores devoted to it.  And books on the
best-seller lists for weeks on end.  The world is really changing.
So we put in all these computers and information systems.  We think
we don't need people in the systems, but we're wrong.  We need
people there.  I think we ought to have more people, not fewer
people.

We've always focused on the physical side, but American medicine
pretty much ignores the other three -- we don't know much about
fitness, or wellness, or the spiritual and emotional.  We ignore
those things in American medicine.

We have to realize how important the community is as well as the
inside of the patient -- where you have to ask how they think, how
they feel.

So the basic question is, "What kind of vision of the future do we
want to create?"

This is what I think health is going to be in the future:

I think people will start taking responsibility for health.  If you
can't have education, a rewarding job, a place to live, food, etc.,
then you're not healthy.  You can't have healthy individuals without
a healthy community -- a community that has a value system -- where
they feel they are connected to each other.  If we don't take care
of nature, none of us will be around.  The health care system has to
deal with all of these levels.  This looks like the tribes of old --
the tribal community.

So how does all this apply to you who are involved in the
information age?  There are lots of ways to deliver information
about medical care.

We need to provide communication among multidimensional caregivers.
We all have to start working together and talking together

We need to motivate people to manage their own health.

That's where I think we're going and that's how information will
help us get there.


* Q & A *

Q:  If the Internet is a global system worldwide, and if the 80% of
the world practices alternative medicines and we are one of the only
exceptions, then why are we trying to design the Internet around
western medicine?  I strongly believe that natural medicine needs to
be a larger part of what we create.  The people are demanding it.

A:  We're evolving -- the money right now is in mainstream American
medicine.   The evolution will happen at the grassroots.  When the
patients want something different -- and we're seeing that. now --
then things will change.

Q:  I've heard the term consumer informatics.  I'm curious how many
people are involved in informatics?  Are there overlapping fields?

A:  I think it's all meshed together, it's exactly the way we want
it right now

There is duplication, the technology, the promise of the technology
is part of the solution.

Q:  What other sectors of society we should be aligning with to make
this vision work?

A:  Right now most of what's going on the market -- I think we have
no idea about the backlash we will see from the consumer, in terms
of what they will have from us.  We need to be much more inclusive
and collaborative in our efforts.  Among all the folks that we need
in order to make this successful -- someone was saying the church
needs to be involved -- maybe.

Whenever we involve community organizations -- we look not only at
consumers unions, but when you look at women's' groups, there are
about 300,000 people in local communities.  You look at what's in
each community and you involve those people.

Q:  As I see it, we're heading for a real problem -- as the patient
becomes more sophisticated, and I read this information on the
Internet, and I know where I ought to go, I want the very best and I
don't want my HMO telling me that I can't go there -- how will we
put together the growth of managed care and the growth in
sophistication?

A:  I know this will be misinterpreted but you're talking about
marketplace and action -- and hopefully as people become more
informed, that will raise the battle cry -- the technology comes
out, but that's what you have in a free society.  Those plans that
can adapt, those will be the most successful.  marketing --
marketplace.

And now, to recap the lessons from what we've learned:

Tom led us off with a brilliant presentation -- the most important
thought was that we're building these self-correcting systems --
it's about the people, not just the machines.

And the idea of a personal community -- a spiritual community.  We
have a big chore ahead of us in standardizing the personal health
information form -- we have to standardize.

We also have to think about what is coming up in the economy.  How will
we go about conceiving of intellectual property rights?  It's going
to be a big challenge.

And the globalizing intelligence network.  It's not about building
content but designing environments at the community level as well as
the individual level.

Play fair.

Share the wealth.

Collaborate.

Have fun.