PricewaterhouseCoopers

[ Part I | Part II | Part III| Part IV | Part V ]

Three Forces of Change

1. An Empowered Consumerate Creates Impatient Patients.

2. E-Health Adaptability Equals Survival.

3. Genomics Shifts Healthcare from Cure to Prevention.

Force #1

An Empowered Consumerate Creates Impatient Patients

Healthcare systems have traditionally been confused about who their customers are, and rightly so. Is it the doctor? Is it the patient? Is it the health insurer or government purchaser?

While the doctors and purchasers have received most of the attention from healthcare systems in the past, we believe that situation is shifting.

Consumers are starting to spend an increasing percentage of their own personal income on health, and they're making more decisions about their own treatments. Consumers will be the key customer group of the 21st century in healthcare. Beware providers and health insurers. Tomorrow's consumers may be adversarial, fickle and decidedly impatient.

Yet, hospitals and insurers are generally not prepared for the demands of tomorrow's consumers, according to the PricewaterhouseCoopers HealthCast 2010 survey of top healthcare executives, employers and policy makers. Only 25% of the 390 thought leaders surveyed agreed that hospitals were prepared. Interestingly, hospital executives in the survey thought that they were more prepared than others thought they were. In addition, only 14% of the survey group thought health insurers were prepared for empowered consumers.

The post-war baby boomers who have been an egocentric and demanding group at each stage of their lives are now becoming the key healthcare consumers, purchasing care for their own aging bodies, as well as for their frail parents. Other forces that contributed to the Impatient Patient:

Healthcare's Traditional Purchasers Will Begin Shifting More Costs to Individual Citizens

There's one irony. In the United States, at least, consumers have actually been letting others foot an increasingly larger share of the cost. Yet, that's starting to change.

In the United States, the percentage of healthcare costs paid by consumers has dropped drastically over the past 20 years. Consumers' percent of out-of-pocket costs, which include health insurance premiums, co-pays and deductibles, has dropped from 34% in 1970 to 17% in 1999.

Yet, over the next 10 years, we believe that trend will level off and could begin to rise slightly as employers shift more of the cost of care to workers. Some other countries are already seeing this increase in out-of-pocket spending.

As consumers in developed countries dig deeper into their pockets to fund their healthcare needs, they will become even more demanding consumers who are sensitive to value and hungrier for information. This trend also resounds in nations with universal health coverage where government is pushing more of the cost onto its citizens through higher statutory payments or higher direct contributions. In some countries, minor treatments or procedures are being de-listed from reimbursement, which will throw those products or services into the realm of commodity pricing in a free market.

All health providers will acknowledge the new consumerism and include that component in their marketing strategies. "The design of facilities must change to better accommodate patients," notes Douglas Peters, CEO of Jefferson Health System in Philadelphia. "We must move beyond these monolithic structures that are suited to staff but are not user-friendly." To do so, hospitals will need to balance efficiency, access and relationships with physicians.

In addition, some healthcare organizations and insurers will consider the incentive systems of retailing and other market-driven enterprises to meet the demands of the patient-consumer. Patient satisfaction will be more important and quantifiable through consistent survey techniques. "We periodically measure patient satisfaction and compare the results against standards to improve performance," notes Geert H. Blijham, M.D., professor of internal medicine, president and CEO of the University Medical Center in Utrecht, the Netherlands. "We know the major drivers for patient satisfaction are the patient encounter, scheduling, transparency of the care process and the hospital facilities."

Major surveys of patient satisfaction are now under way in the United Kingdom, Sweden, the Netherlands and Switzerland. Many healthcare providers will enlist patients as vested partners, conducting focus groups and organizing community boards that infuse them with new ideas.

In 1998, the International Alliance of Patient Organizations was formed, bringing together 40 patient groups from across the world including Denmark, France, Germany, the Netherlands, the United Kingdom, and United States. This group has formed the first global patient consumer forum promoting the voice of the patient at all levels in health. "This could be the point at which health consumer organizations finally create a structure that can face up to the interests of the health and pharmaceutical industries at national and international levels," notes Marianne Rigge, CEO of the College of Health, London.

Consumers Will Want "My Healthcare, My Way"

One size will fit no one in the 2010 healthcare marketplace. Customization of care will grow in importance as consumers choose their own care paths. Since behavioral health has a big impact on disease, putting consumers into the equation could be a big benefit and lower costs. Yet, the 21st century consumers will no longer trust their physician to make all the decisions for them.

"Canadian data shows that 10% to 15% of all patient encounters with primary care physicians involve patients who have already consulted sources on the Internet," says Dr. Michael Guerriere, chief operating officer of the Toronto Hospital. "Patients will finally realize that it is impossible for their physician to know everything."

The Chinese call it "losing the mandate of heaven." Caregivers, particularly physicians, once wore the halo of angels. They were God's presence on earth and each patient recognized that his or her future rested in their hands. In recent years, the halo has slipped. No self-respecting obstetrician gets by with patting the knee of a pregnant mother and saying, "Don't worry, honey. I'll take care of everything." The pregnant mother most likely has downloaded report cards on hospitals in her area, interviewed pediatricians, and researched the pros and cons of various anesthetics used during Caesarian sections.

Still, how much of healthcare can consumers understand and could they really make intelligent purchases? "Healthcare literacy is going up and at the same time we're working to bring the sophistication of quality information down to a level at which most people can take advantage of it. But it's still early to expect a wide range of consumers who are highly informed and sophisticated about healthcare," says Margaret E. O'Kane, president of the National Committee for Quality Assurance (NCQA) in the United States. Will a little knowledge be a dangerous thing for consumers? Healthcare organizations will be challenged to bridge the gap to help consumers make complex health decisions.

Organizations like the NCQA are working at making provider report cards that are relevant to consumers. Not only are report cards becoming more detailed and relevant, but provider organizations that previously turned their back on the grading process are trying to incorporate their ideas rather than stand in the way of this runaway train.

In addition, a common vision of some healthcare futurists is that consumers won't have to decipher the healthcare world alone. They'll hire intermediaries to handle their healthcare needs. Whether these intermediaries will be brokers, agents or nurses remains to be seen.

Consumers may pay for them, or in some cases, employers may do so. This will especially have a major impact on general practitioners, who currently see themselves in this role. Also, such intermediaries may merely be virtual health agents or software programs, similar to intelligent search agents that sort through health information according to a particular profile.

Some consumers may rely on both human and virtual health agents. In the United Kingdom, the National Health Service has created a call center of nurse advisors. NHS Direct is a national telephone triage and advice service system that covers 20 million citizens; it will reach the entire population by September 2000. NHS also has proposed the appointment of a patient advocate at every United Kingdom hospital.

Consumerism Creates Contradictions

As we said before, consumerism could save money. Many diseases can be reversed or treated far less expensively than they are today. Heart disease, osteoporosis, diabetes - all are diseases in which the costs drop drastically when the patient takes an active role in managing the illness. Consider that depression and alcohol use are two of the top causes of disease now and beyond 2010. "As countries get richer, alcohol becomes more of a determinant of disease," notes Richard Wittenberg, president and CEO of the American Association for World Health.

Yet, in practice, consumers have not been responsible stewards of their own health. Obesity, smoking and alcohol are three primary causes of disability and death in many industrialized countries. Ten years ago, one-fourth of Americans were overweight. Now, it's half, and one-half of those are considered obese.

Clearly, Americans are better-educated, but they're also fatter. Combine these rising health costs with the boom in anti-aging pharmaceuticals, nutraceuticals and cosmetics that have biometric formulations. The verdict is in. Healthcare costs will continue to trend upward.

With anti-aging treatments on the leading edge, consumers are more likely to see a blurring of the lines of wellness, prevention, acute care and chronic care. Already they're spending more on alternative treatments such as herbal medicine, relaxation techniques, massage, acupuncture, spiritual healing, vitamins and chiropractic services. In 1997, United States spending on alternative care was estimated at $21.2 billion.

If that category of health spending increases at an annual rate of 15%, it could reach $130 billion by 2010.

Even the staid curriculums of medical schools are opening the door wider. Thirty-four of the country's 125 medical schools - including Harvard, Yale and Johns Hopkins - offer courses in alternative medicine. Some hospitals already have integrated their traditional caregivers with alternative ones.

Consumerism Breeds Branding

Healthcare providers and vendors will spend more on strategic marketing and in particular on branding. As healthcare consumers become more brand savvy, they will become more brand dependent, according to David A. Shore, Harvard's branding expert and the associate dean of the Harvard School of Public Health. "It used to be that the physician was the brand and thus consumer's dependency was to the physician. If a physician moved across town, the patient still went to him or her," he says. "However, in an era of managed care, the likelihood that a patient will see the same physician when they return next year for their annual physical is low. Thus, it behooves healthcare organizations to brand at the parent or institutional level, rather than at the sub-brand or clinician level. Consider the parallel in the airline industry. The brand equity is with the airline carrier, not the individual pilot."

In the United States, studies have shown that the influx of direct-to-consumer advertising (up 23% to $1.32 billion in 1998 compared to 1997, according to IMS HEALTH) spurs consumers to ask for certain brand-name drugs from their doctors. In Europe, such advertising is prohibited, but consumers are finding their way to pharmaceutical promotions through drug makers' Internet sites. Some are questioning how long the advertising prohibition can hold when consumers have access to drug advertising through other means, and others argue that healthcare advertising is beneficial in providing information.

Direct-to-consumer advertising in pharmaceuticals may be just the first wave of an onslaught of branding and multimedia advertising of healthcare products and services. Between 1980 and 1999, pharmaceutical spending saw the biggest increase in United States health spending, a surge that may be encouraged by direct-to-consumer ads.

When Ethicon Endo-Surgery, a United States company, found that most women were not being told about its new product, Mammotome Breast Biopsy System, a minimally invasive diagnostic technology, the company went to a direct-to-consumer advertising campaign. The spring 1999 campaign produced 35,000 inquiries and each inquirer was mailed an information kit about the Mammotome system.

With success like that, other cutting-edge medical device makers may see direct-to-consumer advertising as an area with a high return on investment.

Yet, advertising and the money to brand could shift the balance of power even more to well-capitalized pharmaceutical companies. If so, will they sidestep into other areas of care through disease management, becoming the virtual door through which patients walk to receive disease treatment?

"Providers may have a more adversarial relationship with pharmaceutical firms in the future," says Jefferson's Peters. "They need hospitals and related physicians to do clinical trials, but the relationship may become more competitive."

Forks in the Road

Consumerism will change the curvature the healthcare system in ways that we can't yet comprehend. In addition, drastic changes in policy or economics could have equally drastic effects on a consumer-driven healthcare marketplace. Possible forks in the road include:

• A recession hits and disposable income plummets.

• The United States adopts a single-payer system.

• Health spending accelerates at a much higher rate of inflation than other goods, prompting government to introduce price controls.

• Consumerism forces commodity pricing on healthcare services and procedures.

Force #2

E-Business Adaptability Equates Survival in the New Healthcare World

Mr. J. Consumer in 2010

Meet Mr. J. Consumer. His experiences and demands are characteristic of the new consumers in the United States, Canada, Europe and the Pacific Rim in 2010. His generation is the most prosperous and best educated to walk on the earth. He is the consummate consumer, buying products in an open global marketplace.

Mr. J. lives in a wireless, interconnected e-world. He has the Web in his pocket. Traveling in his car, equipped with a Web-enabled directional system, Mr. J. shops, transacts business, sends messages and receives news updates through his palm-sized personal communicator, a fifth-generation mobile phone that combines voice, data and images. Push technology on his communicator reminds him when to monitor his vital signs and make tele-appointments with his healthcare providers.

Mr. J. dwells in what might be referred to as an e-go bubble. Everything is customized to his wants and needs, e-healthcare included. He knows and understands the medical treatments he is receiving. Many of his e-posodic care is delivered through Web-based tools and telemedicine consults. He maintains his own e-patient record on an Internet portal service and updates it with his own personal comments that are synthesized through speech recognition technology. He gives e-practitioners access to update the file through a security code.

Mr. J.'s mother often gets blood clots. Through an online older women's organization, she shares experiences with about 1,000 other patients all over the world. Together, they're chipping in to fund and participate in clinical trials for a new gene-based therapy. Through the Internet, they're taking bids from various research organizations, biotech companies and drug makers throughout the world.

Cheap computers and telecommunications have e-qualized access to the Internet so that all classes of citizens, rich or poor, can log on for e-healthcare in libraries, community centers, schools and malls.

It's an e-, e-, e-world...

The cost of telecommunications and computing power has dropped so dramatically that the potential finally exists to unite healthcare providers with patients and purchasers in a virtual seamless system. Tele-everything through television sets and other terminals will change the way patients are treated, operated on, monitored and counseled.

If patients could communicate with physicians or be monitored through the Internet, more than 20% of in-office visits could be eliminated, according to respondents in the HealthCast 2010 survey. In addition, respondents said they generally felt that more than 30% of physicians' time will be spent using web-based tools by 2010.

Instead of traveling to a physician's office and waiting, a patient in the future may be able to communicate with a physician or nurse at home through telemedicine links. On-line eligibility and verification will be checked instantaneously when a patient calls in to request a session with the physician or at a less expensive rate, a physician assistant.

Some healthcare plans may give patients with chronic conditions cheap computers, encouraging them to engage in two-way monitoring and education. Providers will have new opportunities to deliver personalized care by integrating customer data across interactive channels.

Healthcare has been slow to achieve the cost savings potential of information technology. Will it be penalized while other non-healthcare businesses try to usurp its turf? Or, will the complexities and ethical considerations inherent in the industry necessitate partnerships between seasoned providers and E-business interlopers?

E-Business is Business

Think about the traditional business world as a comet streaking through the sky. Week by week, pieces of the comet are breaking off. They're no longer part of the traditional business world.

They're dot-com companies. In the future, dot-com will be an integral part of all healthcare business strategies. Business-to-business I-commerce is expected to explode from $43 billion in 1998 to $1.3 trillion by 2003, according to Forrester Research, Cambridge, Massachusetts. Nearly 10% of all business will be transacted over the Web, according to that prediction. Forrester believes pharmaceutical and medical product transactions will flourish to $44 billion in 2003, up from less than $1 billion in 1998.

The Internet will erase one of the biggest handicaps of the healthcare industry - relay speed. It will slash the time it takes to make referrals, get test results, get paid, find patients for clinical trials, disseminate best practices, share cost information, on and on.

It will quicken the pace for the adoption of new ideas, new therapies and new measurements.

Already, the custom of waiting for monthly medical journals to disseminate new discoveries is being challenged by Internet publishing companies. Rather than waiting for medical staff meetings, health professionals are educated through the Web and communicate in realtime with peers about diagnosis, treatment and best practices. Searchable databases in evidence-based medicine enable healthcare providers and buyers to read about the outcomes of studies on protocols, formulas, standards and health economics.

The rate at which healthcare organizations are developing Web-based solutions is neck-snapping in the United States. In Europe, the adoption of Internet solutions has been somewhat slower, but is accelerating. In fact, government is just beginning to grapple with the regulation of Internet transactions.

How deep their role will be is the subject of much debate. According to the HealthCast 2010 survey, either government or a quasi-government agency is favored to regulate healthcare goods and services sold online. However, it's worth noting that Europeans and United States policy makers felt most strongly about this.

Healthcare has spent hundreds of millions of dollars on disparate systems that can't communicate with each other. The Internet changes everything. Proprietary solutions become impractical, rigid, and outdated as everyone flocks to Web-enabled applications that use Internet protocols to allow information to be exchanged among physicians' offices, HMOs, hospitals, labs, pharmacies and health plans. Browser technology eliminates the problems of interconnectivity and advanced security systems safeguard confidentiality.

E-business can improve business performance through connectivity. However, some healthcare systems may buckle under the financial demands of building an Internet capacity that includes tying in clinical results, prescription and supply ordering, and payer transactions. They may have to focus their investment on one or two targeted efforts first. For example, few healthcare organizations will have the capital to launch a healthcare portal. Portals such as Yahoo! and America Online serve as the front door to Internet surfers. They are extremely expensive to build and maintain, and most healthcare Internet enterprises are choosing to partner rather than build.

However, this could change drastically by 2010. Just as cable television has multiplied the number of channels on television, so could dozens of healthcare organizations serve as portals to distinct patient populations in the next decade.

The primary E-business channels for healthcare are transactions, information and interaction:

Transactions

Within the next five years, most healthcare organizations will communicate with suppliers, other providers, payers, regulators and patients through the Internet. New Web-based languages will allow integration and transmission of information and data less expensively than ever.

The Web has the potential to make the industry much more accountable. Clinical accountability has always been a bit vague in healthcare, but through Web-based tools, an electronic trail is built that measures, dissects and ascribes accountability all along the way.

"Ninety percent of healthcare today has no real outcome measures. There is tremendous duplication, waste and absence of quality," notes Wilbert J. Keon, M.D., founding director general of the University of Ottawa Heart Institute. The Web is a conduit for accountability that can track duplication, measure costs and compare outcomes.

In the consumerism section, the likelihood of health agents was discussed. In terms of transactions, the Internet is already cluttered with transaction intermediaries. Examples are E-Trade in the brokerage field, Lending Tree in the consumer loan marketplace, CD Now for music. All of these put consumers closer to the transaction. The basics of the transaction -cost, speed, value - are laid bare. How will healthcare organizations compete on those basics? The Internet has drastically recalibrated consumers' expectations about speed, and healthcare organizations must live up to those new expectations.

E-business could lead to the development of new payment mechanisms. Providers may be able to engage in outcome auditing that focuses on healthy, satisfied patients in the determination of pricing. Reimbursement structures have paid the same for a heart bypass, regardless of whether the surgeon was a neophyte or an established world-class expert. New reimbursement systems may be structured to reward performance.

Healthcare providers must retool their organizations based on the faster, less expensive framework of the Internet. They need to consider the overhead that can be eliminated because of the Web. What real estate, labor, processing and marketing costs can be downsized or even eliminated?

Information from Providers and Manufacturers

The number of Internet surfers consulting the Web for healthcare information has been growing faster than overall Web readership, according to Cyber Dialogue.

However, healthcare organizations must understand the marketing power of the Web. The goal is to design a dynamic, searchable, easy-to-use Web site that can engage the consumer. A hospital's marble lobby, a clinic's personable staff, even a strong local reputation aren't worth much - if anything - to a point-and-click Web surfer.

Healthcare organizations need to ask themselves: What new audiences, referring physicians, patients, investors or purchasers could I attract with a site that is multilingual, dynamic and speedy?

Many United States health plans and providers are already using Web sites to distribute information, schedule visits and ask questions of nurses.

Some healthcare Web sites aim to provide a host of information from different health sources and generate revenue through ads or subscriptions. Trustworthiness is important, and some sites publish their ethics policies to distinguish themselves. Informational Web sites must become part of patient, family and physician learning and utilization of the Web. For example, women often direct healthcare purchases and their use of the Internet is growing dramatically. In Japan, where Internet use is forecast to double between 1998 and 2002, women make up nearly 20% of all subscribers, up from 10% in 1994.

Interaction with Providers and Intermediaries

E-business volume is growing exponentially. Healthcare providers need to start taking cues from other industries and engage in processes such as "customer relationship management." Because the nature of the Web is two-way communication, physicians' clinics can gather information about patients at the same time as patients gather information about the providers.

Large physician clinics can provide links to medical content and know whether patients took the time to download the information. A mother whose son is diagnosed with asthma can receive via the Web a prescription, a link to medical content about the disease and a reminder schedule for communicating with the physician's office. The physician's office can check for compliance and send reminders via the Web on check-ups.

Some e-businesses are measuring themselves using a new metric called "information float," which is the amount of time between when data is captured in one place and becomes available in another. Healthcare organizations may begin to measure "information float" in terms of prescriptions, admissions, treatments and other communications with various providers and purchasers.

Already in the United States, some asthmatic children are involved in pilot programs in which their inhalers are embedded with electronic monitors that track dosage and timing. The data is downloaded to a personal computer and transferred to a central database. Algorithms are applied to the central database that identify indications of potential asthma attacks and medical interventions needed to prevent attacks.

In the Netherlands and the United Kingdom, electronic prescription systems for general practitioners are under development. These systems would connect all general practitioners and offer them guidance in the prescription of drugs. Once practitioners and patients begin using the Internet for prescriptions, they'll want to use it for other healthcare transactions.

Global E-conomy: A Race to the Web

Companies and countries don't have to be monolithically large to compete in the global e-conomy.

Systems must be shared, ownership doesn't. That means that small companies and small countries could win the race to the Web because they'll adapt faster than large bureaucracies.

The Euro will accelerate the spread of E-business in Europe, which adapted to the Internet much later than the United States but is catching up rapidly. In terms of healthcare products, pharmaceuticals were the first medical product to be actively marketed internationally over the Internet, but E-business will soon permeate the strategies of most healthcare vendors.

Singapore is in the process of wiring every home, office and factory up to a broadband cable network. The Singapore ONE nationwide high-speed broadband cable network is

accessible to 98% of Singaporean homes and offices. "The citizens can transact most of their business with government online, including paying taxes and obtaining passports."

Those without computers utilize ones in community centers and libraries, a system that other nations may well consider. "Our vision," says Yeo Cheow Tong, Singapore's communications and information technology minister, "is to transform Singapore into a dynamic and vibrant global information and communications technology capital with a thriving and prosperous net economy by the year 2010 ."

Do You Know Who Your Competitors Will Be Tomorrow?

E-business is already changing the way healthcare organizations market and interact with clients and suppliers. Since 1997, the University of Texas M.D. Anderson Cancer Center in Houston, Texas, has allowed consumers to self-refer through the Internet.

A consumer can log onto the Web site, request an appointment and see a specialist in some instances as quickly as three days.

Think about a local community hospital. It probably considers a hospital across town, or even across the street, as its main competitor. But, how much business is it losing to M.D. Anderson or some other Web-enabled hospital? How much of its market share is seeping away unnoticed? All things being equal - such as perception of clinical quality - to what extent will patients exchange the convenience of a local healthcare provider for the quick, customer-friendly attention of another provider? Think about the information that M.D. Anderson is collecting through the Internet on its patients who are electronically registering.

How can it use that information about its customers? How can it build a lifelong relationship? How long will it be until M.D. Anderson offers medical consultations over the Internet.

 

Force #3

Genomics and Biotech Advances Will Shift the Healthcare System from Cure to Prevention

"At a cost of $25 billion (1960 uninflated dollars), Neil Armstrong became the first human to

set foot on the lunar landscape. Three years later, the United States took its last manned trip to

the moon's surface - and has never sought to return."

In the 1970s, the baby-boomers witnessed one of the most remarkable events of their young lives: a man landing on the moon. That government-funded effort will be followed 30 years later by another blockbuster event: the completion of the Human Genome Project, a $3 billion international endeavor. Just as the space program helped launch a satellite industry that revolutionized communication, so will the mapping- of the human genome drastically alter health delivery and wellness. While the mapping itself is a huge effort, the science and discoveries that will fall out of it promise to be breathtaking in the decades ahead.

By 2010, only 20 to 30 treatments and drugs are likely to emerge from genomics, and this type of medicine may only be the province of a few hospital specialists. However, practitioners will be able to see the direction of the pendulum - a time when individuals know their health risks based on inexpensive and readily available testing.

Certainly, there is the possibility that hospitals' bread and butter business of surgery and treating the chronically ill will decrease as genetic screening keeps people from getting ill. The implications for doctors and nurses are beyond what most healthcare economists and policy makers can comprehend.

"Ten years from now, I can imagine a patient comes in with hypertension and I would get a genetic test, maybe even tests on the whole family," says Edward Miller, M.D., dean of the School of Medicine and chief executive of Johns Hopkins Medicine in Baltimore.

Providers will need to anticipate drastic changes in privacy protection and care delivery that will result in markedly different staffing, operations and facilities.

A Primer on the Book of Life

The human genome is the blueprint for each human being. It consists of up to 140,000 genes and 4 billion units of DNA. DNA are the letters that spell out the "words" represented by genes. Of all the genes found in the human body, 99.9% are the same in everybody. The remaining 0.1% is what makes all the difference.

While DNA words are important, they're not as bankable as DNA words with typos in the lettering. Single letter differences in DNA are the ore of the coming genomics' gold rush. (These typos even have their own acromyn - SNPs for single nucleotide polymorphisms.) Think of SNPs as the rare coins with flaws that prompt collectors to bid up their price. It is these single-character flaws in DNA that cause inherited disorders affecting millions of people, diseases such as cystic fibrosis and sickle cell anemia. Find a way to repair or turn off a gene causing those maladies - the profit potential will be millions, maybe billions.

For a decade, the researchers of the Human Genome Project have been reading each and every gene, writing down all 4 billion of the characters in proper order. As one can imagine, computerization has greatly speeded up this process. The project was scheduled to map the entire human genome by 2005, but is now scheduled to finish in 2002. Spurred by competition from a private firm, Celera Genomics, that was also mapping the genome, scientists from the project were spurred to finish faster. A working draft of 90 percent of the human genetic map is set to be completed by spring 2000.

Implications for Physicians are Complex

Physicians will have an integral part in the genomics revolution. Health leaders surveyed in the HealthCast 2010 survey said they believed that physician specialists would be most impacted by genetic mapping and that physicians would be the most likely source for consumers to get their genetic maps

However, physicians will have plenty of competition. United States health leaders believed slightly more strongly that third-party businesses would be the primary source for such maps, according to the survey.

Genomics will open markets for diagnostic testing, preventive medicines, follow-up treatments and even support services such as lifestyle counseling. The businesses of life sciences and information technology will fuse into a glorious era of biotechnical discoveries in the decades ahead, restrained only by the financial purse strings of government agencies, private foundations, pharmaceutical companies and equity investors.

The discovery of the human genome map may be equivalent to discovering the "missing link" for healthcare informatics. The human genome map is an operating system map for the human body, enabling healthcare providers and product companies to customize healthcare for each individual.

With computer-generated molecular libraries and chemical screens, in silico tests for toxicity, metabolism and bioavailability, and virtual clinical trials, the role of "traditional" chemistry will change beyond all recognition. And, the industry will demand far different skills for caregivers and researchers.

Knowledge management departments will be vital for all healthcare organizations, as the sheer volume of data explodes.

Advances in combinations of chemistry and high throughput screening mean that by 2010, it will be possible to screen one million times as many compounds as are processed at the end of the 20th century. Figure 3.3 shows the growth in the number of genes disease through positional cloning, a process in which scientists map disease-linked genes to a specific chromosome.

Genetics + Consumerism = Prevention

Welcome to the world of pharmacogenetics. By 2010, individuals will know much about their genetic profile, which enables their doctors to prescribe the best drugs for each patient. In the distant future, a patient's genetic profile may be used to design a custom drug for each individual, a prospect that is likely to ignite investments in personal drug design software for physician clinics, labs and hospitals. Experts anticipate major diagnostics advances by 2010 as more tests are developed for genomics variations with infectious disease, cardiovascular disease and cancer being the primary applications.

Individuals will begin to understand their own genetic maps and their own risk for diseases that have genetic triggers. Mr. J. Consumer, whom we met in a previous section, must face the fact that his genetic profile pre-determines him for certain diseases, but his own behavioral decisions can influence the occurrence or severity of those diseases.

"Knowing your genetic profile will be a great motivator," says Sam Broder, M.D., executive

vice president of medical affairs for Celera Genomics, a United States company engaged in gene sequencing. Celera plans to compete with other firms, including hospitals and physician clinics, to provide genetic mapping services to individuals.

Consumerism, enhanced by the Internet, will create global patient communities that can aid gene research. The creation of such communities will speed clinical trials and could attract international funding from sources that formerly weren't investing in this sector.

The effects of genetic mapping won't be clear for decades. However, health leaders responding to the HealthCast 2010 survey see costs increasing and care moving to more outpatient settings.

Genomics + Standardization

Mapping the human genome will mean "more rational medicine and research opportunities. Medicine will be a much more efficient process. We can avoid incremental progress, particularly in cancer where we have had to keep chipping away at the problem," notes Broder, who formerly headed the National Cancer Institute.

"Much effort to date has gone into research that has yielded only marginal improvements," adds David Naylor, M.D., dean of medicine at the University of Toronto and former CEO of the Institute for Clinical Evaluative Sciences. "The post-genomic revolution will mean it is time for medicine to move out of its current poking, prodding and plumbing mode."

Medicine will benefit from the standardization of a human genome map that will enable care-givers to provide the personalization that consumers want. Drugs can be tested on a specific population of people who have a certain genetic make-up, shortening the clinical trials process.

"The role of the doctor will grow in effectiveness because he or she can more intelligently respond to a patient's needs," Broder says. "The doctor will no longer say, 'Mrs. Jones, this is what I do for everybody with your condition. Twenty percent of patients respond this way, 30 percent respond this way...'." Future doctors will say, Mrs. Jones, this is what should work 100% of the time for someone with your condition and genetic make-up.

Broder notes that physicians will have to be more "fact sensitive," deriving and updating most of their knowledge from Web sites and palm-based computers. Celera aims to be one of those websites, delivering information to physicians, as well as patients, on a subscription basis.

While research costs might be cut by a more efficient system of clinical trials, barriers still await. The process of going through the Food and Drug Administration in the United States and other approvals in Europe is still lengthy. Private industry is counting on the ability to patent certain genes and gene sequences, although that's a controversial subject. Under current law, the United States Patent Office and international patenting agencies allow the discoverers of genes to patent them and thus retain intellectual rights to using the information.

Genomics + Difficult Choices: More Questions Are Raised than Solved...

Emotional moral questions about genetic screening for employment, insurance policies, marriage licenses and government services will nag at each nation's conscience. Solutions are not yet apparent, even though we may soon be overwhelmed with new ways to use or misuse genetic information.

Certainly, many will be watching the experiences of Iceland, where the government has contracted with private industry to create a database that combines medical, genealogical and genetic data. Iceland's experience is unique because most of its nearly 300,000 citizens are related to each other if you go back eight generations or so. Icelandic citizens may opt out of the new database, but its government is promoting the benefits as better overall health at less cost. Still, questions abound as to who will have access to the data and how such a database should be run. The Iceland government has given deCODE, a genomics research company that is aligned with Hoffmann La-Roche, a 12-year monopoly on building the database.

Given Iceland's experience, governments must wrestle with the question of to what extent do privacy issues override a more efficient basis for population health management?

Genetic Mapping Pairs with Other Technologies

While the genomics revolution will be startling in itself, its discoveries will couple with other medical technology and biotech breakthroughs that will dazzle the industry and accelerate change. The power of two or more discoveries creates a chemical reaction. After all, how successful were organ transplants before cyclosporine, the anti-rejection drug?

Other revolutions that will tag team with genetic mapping's breakthroughs:

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