A growing number of cities and communities across the globe are on the front line of creating smart cities. According to the National Conference of State Legislators, the aim of a smart city is “to improve quality of life, economic opportunity and security for those who live in cities and surrounding areas.”
Driven by the demands of an evolving digital ecosystem and governmental systems, municipal and state leaders across the globe are reaching for IT to modernize systems while simultaneously improving the quality of life for citizens.
Recognizing the opportunity to connect the growing abundance of health-related data, along with health and human services integration as part of this movement, we set out to explore how a smart city can also support health system transformation.
In terms of healthcare, a smart city is a community “where the residents can engage with smart services that are specifically designed to improve their health,” shared Chris Gibbons, MD, MPH, chief executive officer of Greystone Group. Additionally, he underscored the value of smart environments to patients’ and the public’s health, “We have to develop a system that can interact and engage with all of the things that patients rely on to optimize and improve their health in order to help them manage their health in between doctor visits.”
A smart city may be most impactful when it is interoperable across core health, human services and non-health sector systems, including public safety, environmental health, social services, emergency services and transportation.
Interoperability and integration of these systems and services in smart city policies and practices could enable real-time response to health crises, social determinants of health, meet Quadruple Aim goals and support the interconnected health and wellness goals of communities across the globe.
According to Dr. Gibbons, “Optimizing clinical practices alone is a good thing, but it is not enough to guarantee good health of everybody. Technology is the only way we are going to be able to do that. We have got to rely more on technology to retool for a digital delivery system and market based value that brings better and lower costs.”
Valerie Rogers, director for state government affairs with HIMSS sat down with Dr. Gibbons, to learn more. They discussed the value of the health innovations and systems transformation generated by smart cities and how clinicians along with local, state and federal governments can leverage this movement to impact health and wellness outcomes.
I am a physician by training. I went to medical school at the University of Alabama and did all of my training at Johns Hopkins in Baltimore. I trained in surgery and preventative medicine, with several years of molecular neuro-oncology and epigenetics research.
I also did a fellowship with the Centers for Medicare and Medicaid Services (CMS) and helped lead an early disparities project. Congress passed a law that CMS should do a study to understand cancer disparities in the Medicare population. Based on what we found, one of our recommendations was that the government should put more computer and IT infrastructure into the problem.
Shortly after that, in 2001, I was recruited to Johns Hopkins faculty. As I began to think about my academic focus, I thought on the work I had done for CMS. About that same time, I heard of a meeting that was happening on the National Institutes of Health campus about a term I had never heard of: eHealth. So I went out there and I was absolutely fascinated. They were talking about the future of society, future of healthcare and how technology was going to help us solve things. There were no EHRs at this time and technology was a new phenomenon.
I walked away from that meeting realizing no one was talking about technology in underserved populations and health disparities or health equities and I said, ‘You know what, that is going to be my field.’ Technology, health and health disparities. This initial focus led to an interest in smart cities and ultimately enabled a vision of smart communities and smart care, with a special focus on underserved populations. That is kind of how it all got started.
As you rightly point out, most smart cities focus on infrastructure, transportation, city lighting and other city government services. Most do not have an explicit focus on health or healthcare beyond enhancing quality of life. In addition, smart cities are by definition located in urban areas. However, there are some notable rural areas that have a similar focus on smart solutions for their residents. This is why I often use the term smart communities for health and strongly believe these ideas are valuable for both urban and rural areas. My organization’s vision is to build smart communities with an explicit focus on health and healthcare as a core feature of the smart city, rather than building it in secondarily after other sectors have been addressed.
So let’s dig into the word ‘smart’ and give you a little background on that, since people are using the term in a number of different ways. Remember when we used to talk about mainframe computers—large computers that filled up buildings in the 50s and 60s that housed the central processing unit (CPU), which were the brains of the computer system and the main memory of those older computers.
As our CPUs became more powerful and smaller, they could be placed in smaller and smaller devices and eventually enabled things like smartphones and mobile computers to become more powerful than those early mainframes. Today you can embed that intelligence in a whole variety of very small things. This enabled the computational power of the CPU to move to the edge of the network inside remote sensors and devices, instead of being at the center of the network where the mainframes were. This simple change allows faster and more complex computations to occur in devices while also decreasing the impact of network issues that slow down computation and network response. This helped to form a foundation for building smart devices and systems.
Another important milestone was the development of advanced sensor technologies. Sensors play an important role in enabling things to respond to changes in the physical environment. Sensors collect data used to raise awareness about the environment. When powerful CPUs are also located in the devices, this essentially puts brains or intelligence in the device and has the effect of enabling the device to make independent decisions instantaneously, without direct human involvement. These types of devices are what are known as “smart devices.” Simply put, they are devices with embedded sensors and intelligence that enables them to act autonomously. Advances in miniaturization now mean that these smart devices can sometimes be as small as red blood cells in the body.
For example, automatic doors, which open and close by themselves when an individual approaches, are an early form of a smart device. More recently self-driving cars have been developed—another type of smart device. Continuous glucose monitors are a smart device used in healthcare. These devices check a person’s blood sugar level and also automatically give them the correct dose of insulin without the input of the patient, a doctor or caregiver.
Smart services then, are services that can be delivered, at least in part, by smart technologies. Smart cities utilize the same basic elements as smart devices. These include data, technology, broadband internet and artificial intelligence to deliver services to the residents of the city. Smart communities for health then, are those communities that build on the foundation of a smart city, but take the next step to deliver automated services explicitly designed to address health concerns or otherwise improve the health of the residents in the community.
There are many opportunities to increase the value of care. We have to shape the question around who it is we’re providing value.
In the past, we largely placed the value proposition of healthcare on clinical processes, but this is not enough to get us to our national health goals. We are pivoting to not only clinical processes, but population outcomes with accountable care organizations and managed care. We’re getting closer but still not where we want to be because health and healthcare inequalities and disparities have not systemically improved.
Future value in healthcare will increasingly be defined by the consumer and the patient. It will require a greater focus on social determinants of health. Because patients rely on many people and services to manage their health, the patient’s true healthcare team in reality is always much larger than simply the medical providers. Patients and caregivers will find significant value in a system that can interact and engage with all of the people, information and resources they rely on to manage and improve their health. Technology is the only way we are going to be able to connect all these important elements in a system that works for patients in real time.
We have to rely more on technology to retool for a digital delivery system and market-based value that brings better and lower costs to every single patient, every single day.
I fundamentally believe that the companies that excel are those that understand their target consumers the best and give them products they want and need, and value. What’s happening in healthcare is that healthcare hasn’t really been a market-based system. This is where we are going—and that shift is very difficult for the sector to make—we are making progress but we haven’t really gotten to what consumers are demanding.
In every other sector where technology has come in, the technology has actually changed consumer behavior. We (providers) still largely have the perspective in healthcare and public health that we know what’s best for you and we will decide this. What we risk is outside competitors listening more closely to our patients and learning how to give them what they want and need than we do. This will inevitably result in the traditional healthcare system losing our market share—our patients. Today major retailers are focused on become primary healthcare providers of choice for most consumers. They can offer patients clinical services, very little wait times and medications for low costs and greater cost transparency. How can traditional hospitals compete with that? They must do something radically different.
Use of social media as an example: Social media has changed people’s behavior. Social media developers have figured out how to change shopping, voting, dating, research and many other behaviors. For healthcare, we need to learn the principles that make social media effective and then use them to enable people to change their behavior in a way that improves their health.
The other side of the coin is the example of online coupon services, a type of social media offering coupons for goods and services, including healthcare services. One ophthalmology group offered a new patient eye exam for a reduced price through an online coupon. They shared the experience ‘exceeded their expectations,’ bringing in more than 300 patients—many without insurance. This is one example of how social media and market-based principles can benefit everyone, including those without health insurance.
We need to align market-based forces in healthcare with healthcare services that help lower income classes in a way that is also financially viable for the healthcare system. This is exactly how healthcare needs to think about structuring services and how to deliver them in the technological age.
In terms of funding and making it happen, many smart programs use a variety of public and private funding mechanisms to cover costs. Public funds such as bonds or grants from agencies are often the initial funds, with private sector funding such as loans, private equity and philanthropy also viable funding sources.
Another area that traditional healthcare systems have not spent a lot of time thinking about are monetization opportunities outside of reimbursement or other more traditional healthcare revenue models. Smart cities can actually become new revenue generators in communities. There are many ways this is possible. For example, employing user fees, subscriptions and license fees or collecting advertising revenue are some business models not historically used within the context of healthcare that may be valuable.
I am intrigued with what New Zealand is doing. At their federal level, they have instituted a well-being budget, specifically focusing on well-being in their national budget. They believe that defining national success primarily on the financial health of the nation has limited value and that it doesn’t equate to where they want to be as a nation. They are using this well-being budget to not just define financial health terms, but also the health of the natural resources, the people and the communities.
The other is North Dakota. The health officer and governor for the state have started a mission to make North Dakota the first smart state. This is even more transformative when you think about North Dakota being a predominately a rural state. Having the vision and working with those that want to go farther is the start.
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Originally published November 19, 2019; updated August 4, 2020