Decision time: Prioritizing state health care agendas

by Jessica Blume, Vice Chairman, U.S. Public Sector Leader, Deloitte LLP

In November U.S. voters across the country will face decision time as they head to the polls. Between the 36 gubernatorial races, 36 Senate races and all 435 seats of the House that are up for election, it’s hard to miss the campaign commercials and fliers that have come our way and will continue to do so right up to election day. But voters aren’t the only ones who face decision time. Many governors and state legislatures are weighing their options for where to spend precious resources with respect to their health care priorities.

Since the Affordable Care Act (ACA) passed in 2010, there have been many revisions, delays and even permanent removals of certain provisions of the law. These changes in legislation and regulation have brought significant decisions to states’ front doorsteps. Many of these have been covered extensively in the news, and in some states, are as hotly debated as (or sometimes even inserted into) the elections themselves. To date, 28 states and the District of Columbia have made the decision to expand their Medicaid programs.1 Similarly, states have faced decisions around their health insurance marketplace operations—more than half have defaulted to the federally-facilitated model, while the remaining states are either implementing state-based marketplaces or working in conjunction with the federal government in a partnership model.2

Other health care issues states have faced are not as well known or widely publicized—these are the issues that have yet to make the headlines. But as we quickly head toward the end of 2014, many states are grappling with some big decisions in health care:

  • State-based health insurance marketplaces: In the future, where will funds to sustain operations come from? Given the dual aim of re-enrolling last year’s enrollees and signing up new enrollees, how should spending on outreach and in-person assistance for the second round of open enrollment be focused?
  • Small Business Health Options Program (SHOP) marketplace: What is the status of the SHOP marketplace in the state and how does that map against the federal government’s efforts? Where should resources be spent to increase employer awareness and understanding?
  • ICD-10 delay: How are individual states and their Medicaid programs mapping to the updated plans? Are mid-course adjustments needed?
  • Provider network standards: Should provider network standards be stricter or more lax? How should the state work with health plans and providers to refine network standards?

These decisions and others are difficult for states to make, especially as budget constraints continue to increase, legislative mandates loom and consumer demand grows. Meanwhile, populations are aging, fewer are entering into the physician workforce and outdated technology infrastructures are lagging in interoperability, security standards and analytics capabilities.

There is not a “one size fits all” solution for states as they contemplate these tough health care decisions. As decision makers determine how they want to position their states for the future, the following three paradigms, in my opinion, will be critical considerations:

Adapt the role of the state to promote innovation: As providers, payers, regulators and collaborators, states should seek to use their influence and authority to innovate and drive population health management. States can encourage public and private players across the health care system to work together to achieve better outcomes and value. This involvement will be critical, and state decision makers should consider their state-wide population as a whole as well as the individual needs of specific communities based on socioeconomic factors and social determinants.

State-based health insurance marketplaces can be structured so that, as a regulator, the state can help providers and plans react and adjust to increased consumer demand for quality and affordable health insurance and health care. Outreach can also be tailored at the state level to specific groups and hard-to-reach populations. In Washington, D.C., for example, workers from the state-based marketplace, DC Health Link, canvassed local laundromats to help residents enroll in health insurance while their clothes were drying.3

Build a 21st century connected infrastructure to enable transformation: Reliance on technology will continue to grow, further necessitating interoperability between electronic health records (EHR) systems, Medicaid Management Information Systems, all-payer claims databases, health information exchanges (HIE), integrated eligibility systems and state health insurance marketplaces. With the explosion of mHealth, building an infrastructure that connects all the dots between technology and people becomes even more important. States occupy an important position at the epicenter of the infrastructure to help drive transparency and transformation through integration.

For example, established in 2003 as an independent state agency, Maine’s all-payer claims database allows stakeholders across the health care system to access critical information on medical, pharmacy, and dental claims and information from commercial health plans, third party administrators, Medicaid and Medicare.4 The state’s Maine HealthCost website also provides health care consumers transparency around health care prices such as the average cost of certain medical procedures.5 States can enhance their role in making information available to individuals as stakeholders in the system aim to help individuals move from passive patients to informed health care consumers.

Unleash the power of data to drive outcomes: Population health can be within reach if states help influence data sharing behavior and support integration efforts among all stakeholders. Once this is achieved, states will be in a unique position to educate and empower health care consumers.

The Centers for Medicare & Medicaid Services (CMS) and others are focused on finding ways to reduce costs and improve quality. For example, earlier this month CMS released its latest figures on hospital readmissions, announcing that more than 2,000 hospitals across the country would be penalized with reduced Medicare reimbursement for high readmissions in their patient populations. States are working to help reduce high readmission rates by implementing certain population health strategies. Data from Kentucky’s state Medicaid program were integrated with data in the state’s HIE to identify “super-utilizers” of the emergency departments statewide. Now, when a super-utilizer patient returns to the emergency department, their medical record is flagged and the provider is sent an alert.6

As voters educate themselves on candidates’ platforms for the election, they are likely to take a keen eye to how the state is performing on important issues. Some issues come up in every election—economic and social factors can make or break a candidate. As state decision makers and legislators begin to take on greater responsibility for the health and care of their populations, voters are likely to increase their focus on health care, especially state health policy decisions that affect them, their families and their wallets.

Read the entire Health Care Current here and subscribe at: www.deloitte.com/centerforhealthsolutions/subscribe.


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1 See Deloitte’s State Medicaid programs: Map of expansion by state
2 See Deloitte’s Health insurance exchanges: Map of enrollment by state
3 DC Health Link, “DC Health Link Says: As You Spring Clean, Start With a Clean Bill of Health and Get Affordable Health Insurance,” March 20, 2014
4 Main All-Payer Claims Database, http://apcdcouncil.org/state/maine
5 Maine Health Data Organization, “Maine HealthCost,” https://mhdo.maine.gov/healthcost2014/
6 North Carolina Health Information Exchange, “Leveraging HIE for Medicaid Reform: Quality Improvements and Reduced Spending,” http://nchie.org/leveraging-hie-for-medicaid-reform-quality-improvements-and-reduced-spending/

Jessica Blume, U.S. Public Sector Leader, Deloitte LLP Jessica Blume is the U.S. Public Sector Leader for Deloitte LLP, which includes audit, consulting, financial advisory and tax services to state and federal government clients. She has held several leadership roles in the organization, including leading the Deloitte Consulting LLP Public Sector Consulting practice. She has nearly 28 years of experience in transforming business operations across multiple industries and has served dozens of clients in the state and federal government, health care, manufacturing, consumer business and financial services arenas since joining Deloitte Consulting's government sector practice in 1989.


Lessons in health system consolidation from the State Bank of Lodi

by Ion Skillrud, Senior Manager, Deloitte Consulting LLP

I grew up in a small town in Wisconsin with one bank, the State Bank of Lodi. The State Bank of Lodi had two branches; its flagship operation in the 2,000 person town of Lodi, and one branch five miles down the road in the neighboring town of Dane, where I lived.

I can remember the day I opened my checking account at the State Bank of Lodi. I deposited a $20 bill, the majority of which was used to pay for checks and my monthly checking fee. In response to rising “consumerism,” my branch eventually installed a drive-thru window with extended hours of 7:00 a.m.–4:00 p.m. The only financial product it offered at that time was a CD. I remember seeing ATMs, but they were not an option through my bank.

Like many community banks, the State Bank of Lodi was eventually acquired by a large regional bank in the early 1990s, a trend that has resulted in roughly half the number of banks today compared to 1990.1

A new piece from the Deloitte Center for Health Solutions explores a similar phenomenon occurring with health systems. “The great consolidation: The potential for rapid consolidation of health systems” parallels the current environment in the health system space to that of banking, retail, and airlines. In each of these industries, the combination of regulatory and market pressures led to rapid consolidation as smaller and larger players attempted to defend and grow market share in the face of evolving industry demands.


The ATMs of the 1990s are likely tomorrow’s telehealth applications; a lower cost way to provide and receive care. Free checking services are akin to “free” preventative care visits. Of course, these “free” services require significant costs, and therefore, a larger base of revenue and assets is needed to recoup these investments. Similar to the way the State Bank of Lodi couldn’t afford to offer free checking, an ATM network, or investment options beyond a CD, the majority of stand-alone hospitals, and even many health systems, cannot afford the required investments to manage population health based upon EBITDA. The natural result is consolidation in the industry. Deloitte’s analysis in this new report – using three independent approaches where results converged – estimates that only 50 percent of today’s health systems are likely to remain in the next decade.


Consolidation has already begun, as demonstrated by the growing number of hospital acquisitions the past few years. Given the current market landscape, it is likely only going to grow. In the face of this potential rapid consolidation, staying the course is no longer an option. Health systems should consider differentiating their service offerings and outcomes or acquiring/aligning with another organization in order to compete in an increasingly complex and costly environment. 

It is hard not to be nostalgic for the State Bank of Lodi, an institution that was founded in 1897. But, like in many industries, market, regulatory, and competitive change happens. While the small towns of Lodi and Dane may have “lost” their banking namesake, they gained access to more expansive financial services at a lower cost on more convenient terms. Similar changes among health systems may also improve the convenience and offerings of the U.S. health care system.

Read the full report to learn more about the potential for rapid consolidations of health systems.

To learn more about M&A activity in life sciences and health care, register for the November 11 Dbriefs webcast: “Life Sciences and Health Care Deal Activity: Is M&A Here to Stay?”


1 “Changes in the Number of FDIC-Insured Institutions,” Federal Deposit Insurance Corporation, http://www2.fdic.gov/qbp/grtable.asp?rptdate=2013dec&selgr=QSCAL1, accessed October 26, 2014.

Ion Skillrud, Senior Manager, Deloitte Consulting LLP


Ion Skillrud is a member of the Deloitte Consulting LLP Life Sciences and Health Care Practice where he focuses on serving health care provider clients. Ion’s engagement experience includes merger planning, post-merger integration, functional carve out, and a variety of sustainable margin initiatives. Ion resides in Saint Paul, MN with his wife and three children.


What are the implications of the CIO as a venture capitalist?

In the face of disruptive technologies, more and more CIOs are shifting from a world of known problems into one filled with unknowns. CIOs are realizing that their current tools for managing risk and leveraging assets may not work in this new world. To help drive business growth and innovation, they will likely need to develop a new mindset and new capabilities. To do this, many CIOs are borrowing from the playbook of today’s leading venture capitalists. Watch the video below as our leading specialists share their perspectives on the implications of the CIO as a venture capitalist.

"The CIO as a venture capitalist: Working to establish an IT portfolio" is part of a new three-part video series Innovative challenges for the modern CIO which explores the advantages of disruptive technologies, the comparative and predictive nature of analytics, and the evolving role of the CIO as they hedge their bets, manage the IT portfolio across the enterprise, and address the care of growing patient populations with complex needs.

Video transcript

Brett Davis, Principal and General Manager, ConvergeHEALTH by Deloitte, Deloitte Consulting LLP:

To really move from being a CIO to a CIO as a venture capitalist, I think it really starts with a 5-to-10-year plan. You need to know where you are going, and begin to make the platform investments, as well as the incremental investments to create value on that journey. So if you don’t have a plan, if you don’t know where you are going, you can’t get there.

Harry Greenspun, MD, Director, Deloitte Services LP, Deloitte Center for Health Solutions:

CIOs have to act as a venture capitalist these days because they face a lot of disruptive technologies and one of the challenges they face is that there are lot of needs that they have, and a lot of solutions in the market. But how do you connect your needs to the solutions in the market?

Tim Smith, Principal and National Leader of Health Care Information Technology, Deloitte Consulting LLP:

An IT portfolio is really looking at what you have, your IT assets, and looking at them differently than what was traditional in an IT organization. It forces you to look at a clinical portfolio, a business portfolio, potentially a research portfolio if you are at an academic medical center. So, it really forces you to think about all of your IT assets in the services that they provide to different aspects of the organization.

Harry Greenspun, MD:

So when you think about IT portfolios, this concept has expanded year over year. IT used to be a supporting function. And now, it’s actually integrally involved in everything from their operations, their finances, their clinical work, their research work, and are drivers for all their analytics. The portfolio, has expanded and expanded, and contains a much broader array of technologies.

Tim Smith:

I think what’s important in looking at IT capabilities is to come up with some buckets of where as an IT organization do I need to provide value to my health system. Clinical portfolio would have my core clinical bucket. It would have my core ancillary, my lab, Radiology, Pharmacy buckets. It would have my revenue cycle buckets. And, what I need to do then is to look at what is the application services I have within the bucket, what are the potentially the medical devices that are required to really satisfy the requirements of the bucket? And also, then what data is being produced, so that I can then do other things within that portfolio of the bucket.

Harry Greenspun, MD:

CIOs have a difficulty hedging their bets. Some venture capitalists can often hedge their bets and diversify their portfolios. Very often, CIOs kind of have to at one point, lay their money down, and choose what they are going to choose. What’s been interesting they have been able to create a number of incubators to allow them to find different technologies that may address the same sort of thing. We are now seeing a rise of the Chief Innovation Officer as a way of looking in that. So I think that’s one way they are able to hedge their bets.

Tim Smith:

So hedging for modern day CIO is really taking a look at the overall application landscape, and making sure that there’s thoughtful investment that where I’m looking at, potentially innovations or bleeding edge technologies, that I really have a backup plan, that I have the ability to still satisfy my clinical requirements, still make sure that the claims are being paid, but also allow physicians, clinicians to be on the forefront of technology.

So, if I think of a couple of things that really should be top of mind for a CIO. One is a key change. What can I do with my IT portfolio to create better interaction with my patients? Whether it’s mobile technology, whether it’s portal technology, whether it’s some other way of getting the providers to interact more directly with the patients, that’s a great investment. I think investing to make sure that you have standardized yourself enough in that, and you’re flexible enough to be able to adopt an affiliation, or take on a merger to be effective.


Fostering innovation through Medicaid managed care

by Sarah Thomas, Research Director, Deloitte Center for Health Solutions, Deloitte Services LPTwitter

I have had a long and varied career in health care, with a large focus on health care policy. One of my first interests in the policy landscape was in the potential for better health care delivered through health plans—in Medicaid this is known as managed care plans. My first “real” policy job was with the Commonwealth of Virginia, where I worked on a host of issues from a budget perspective. At the time, Virginia had not implemented managed care statewide; in fact, most states were run under a mix of managed care and fee-for-service. But today managed care is a fundamental part of most state Medicaid programs and a major vehicle for expanding coverage.1

It was with interest that I recently read the Centers for Medicare & Medicaid Services (CMS) Innovation Center’s Request for Information (RFI) on Health Plan Innovation Initiatives (see the October 14, 2014 Health Care Current). My first thought was, “At last, the Innovation Center is getting around to health plans!”

When it was created through the Affordable Care Act (ACA), the Innovation Center set coming up with and testing ideas in the traditional, “un-managed,” fee-for-service program (not the care delivery done through managed care contracts with health plans) as its first priority. Many of the initiatives that were funded actually started with health plans, but the Innovation Center has been focused on testing them in fee-for-service instead. Health plans have long sponsored shared-savings programs with providers, have been part of the multiple payers participating in Patient-Centered Medical Home programs and have participated in collaborations to improve patient safety.

The RFI outlined several focus areas where the Innovation Center is seeking innovative ideas, including pharmacy and medication therapy management, value-based insurance design, remote access technologies, hospice care, long-term services and supports, behavioral health and provider incentive arrangements such as accountable care organizations. The second thought I had was, “How would I pick which topics to focus my recommendations if I were to respond?”

Many of these topics are – to me anyway – interrelated. Medication therapy management, for example, is critical for people using long-term services and supports. Accountable care organizations might be exactly the right types to leverage remote-access technologies. And behavioral health is probably linked to many of these issues in one way or another because behavioral and physical health are connected for many people, and this connection is especially visible in Medicaid.

There are many interesting programs that state Medicaid agencies and Medicaid managed care plans have tried over the years to improve quality. One Medicaid-based mHealth program sent out reminders to young, high-risk, pregnant moms using free cell phones and rewarded them with extra minutes if they met all recommendations for prenatal care. Another program run by a managed care plan in inner New York City took lessons learned from “hotspotting” work in Camden, New Jersey to identify high-risk patients and provide supportive services to wean them off their regular use of emergency rooms.

Some Medicaid managed care plans – particularly those in Massachusetts, Rhode Island, Wisconsin, New York and Minnesota – have among the highest quality scores in the country.2 Some credit is due to the Medicaid program directors and clinical leadership who provided the resources and incentives, a supportive community and a culture of raising the bar on performance expectations in those states. Some credit also goes to the plans’ medical and nurse leaders and CEOs, who in many cases rose to the challenge of providing excellent care to populations that may not always be easy to care for.

But in other states, payment rates are low—possibly too low to support the kinds of investments that managed care plans would like to make in analytics to identify high-risk populations and find opportunities to improve quality, new approaches to care management and new and innovative programs. It is conceivable that some of these plans might in the face of scarce resources come up with innovative ways to care for Medicaid enrollees. But, in my opinion, this could be hard. Medicaid programs keep managed care plans very busy with quality improvements, compliance and oversight activity (as they should).

CMS could consider ways to create opportunities for some of the plans in resource-constrained states that allow them to try new things. Of course funds from the Innovation Center shouldn’t be used to offset low payment rates in these states, but perhaps extra support in the form of technical assistance might be warranted. Pairing participants in Innovation Center projects across states so those who are not as far along could learn from those who have invested more into clinical care and analytics might also be an idea. CMS is also focused on developing consistent quality measures in order to measure performance across states and managed care plans. Given the variety of approaches that states have taken to performance measurement, this could be challenging to implement.

If forced to choose one from all of the potential areas to explore, I might choose long-term services and supports. This is an area that even the most exemplary special needs plans are beginning to step into and represents one of the highest in Medicaid spending. Best practices in care management should be figured out. Programs like Evercare and PACE have shown some great results, but may not be scalable with their current structures; more programs that meet consumer demands for care that is better organized around their circumstances and those of their caregivers could be helpful.

I’ll be interested to see what others choose and to see CMS’s agenda around testing innovations in health plans unfold.

Read the entire Health Care Current here and subscribe at: www.deloitte.com/centerforhealthsolutions/subscribe.

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1Kaiser Family Foundation, “Medicaid Managed Care: Key Data, Trends, and Issues,” February 2012

2The Menges Group, “Analyses of NCQA Quality Ratings Among Medicaid Health Plans,” March 2014

Sarah Thomas, Director of Research, Deloitte Center for Health Solutions, Deloitte LLPSarah Thomas is a director with Deloitte Services LP and the director of research for Deloitte's Center for Health Solutions. Sarah has experience in public policy, ranging from reimbursement to addressing issues such as quality in Medicare, Medicaid and the private health insurance market, including health insurance exchanges and marketplaces.She has more than 13 years of government experience.


Imagine health care without technology

by Bill Copeland, Vice Chairman, U.S. Life Sciences & Health Care Leader, Deloitte LLP

Try to imagine not being able to read. Howard Wainer, an American statistician, poses this challenge to his statistics students when he teaches his introductory course. To him, the idea of statistics to those who learn it is similar to learning how to read or swim. He goes on to explain that, while it is difficult to learn these skills, once you do, you cannot imagine a time that you were unable to read or swim.1

Try to imagine health care without technology. No MRIs, X-rays or even stethoscopes. For me, it’s difficult to imagine—technology has brought the health care industry a long way. However, despite the massive investments many organizations have made on information technology (IT), it is not doing all the things we want it to do—systems do not talk to each other, and use of these systems for new analytic insights is just beginning.

Stakeholders across the health care system are working to correct this disparity. While there may be frustrations around Meaningful Use and challenges with adopting electronic health records, the support behind health IT continues to grow. Even with this support, however, challenges still remain.

My colleague Sarah Thomas and I recently had an opportunity to address some of the most pressing IT challenges facing the health care system. In June Senators Ron Wyden and Charles Grassley, who represent the Senate Committee on Finance, sent a letter to stakeholders from across the health care continuum asking for comments and feedback on the state of data transparency in the health care system.

Their request was backed by some eye-opening statistics:

  • The amount of information that is stored digitally has grown from 25 percent to 98 percent worldwide since 2000
  • Five quintillion bytes of digital data existed in 2003—as much is generated every two days now2

We responded to this request from Senators Wyden and Grassley by discussing two questions that are critical to the health care system:

How can the federal government encourage a “culture of interoperability”?
Interoperability is a patient safety issue. Some estimate that anywhere from 8-14 percent of medical records have information attributed to the wrong patient.3 In order for the health care system to move toward greater interoperability, advancements in technology are not enough—even with the unprecedented rate of progress that has taken place in the last decade. The federal government could inspire this culture of interoperability by:

  • Offering incentives to providers and other stakeholders to agree upon and implement standards that are flexible enough to meet the broad scope of needs of individual stakeholders in the system
  • Encouraging vendors (e.g., electronic medical records) to expose their data model and agree to use the same standards (both existing and future) for use in collaborations, roadmaps and coalitions related to interoperability
  • Identifying and promoting the use of best practices to build interoperability into a system early in development
  • Broadening Medicare and Medicaid incentives for health IT from technology adoption and use alone to include successful interoperability

How can the government encourage consumer engagement in health care?
Patients want their doctors to use health IT, but more can be done to advance patient engagement. Deloitte’s 2013 Survey of Health Care Consumers found that seven in 10 consumers say they would prefer a physician who uses health IT over a physician who does not.4 Mobile apps, telehealth and other nontraditional care delivery models are enhancing overall consumer engagement in health care, but more can be done to advance the consumer engagement movement in health care and capitalize on consumer interest. The federal government could lead the way toward greater consumer engagement by:

  • Advancing more pilot testing in the area of telehealth to help ensure this evolving model of care does not introduce new sources of error into clinical processes
  • Creating demonstration projects that reduce regulatory barriers to telehealth technologies and guide stakeholders on how to develop and refine telehealth programs to improve health outcomes and reduce costs by making care more efficient and convenient
  • Driving reimbursement reforms to achieve quality outcomes against evidence-based standards through its role as both a payor and a provider
  • Further incentivizing and setting the example for the use of value-based insurance design as a way to create incentives for consumers in Medicare Advantage and the private health insurance marketplaces to make health care decisions that are cost-conscious

The Deloitte Center for Health Solutions’ surveys have found system-wide discontent with health care. Consumers do not believe the system is providing value, nor is it meeting their needs.5 Employers are also looking for more: 52 percent want greater transparency around prices, and 46 percent want clear, accessible information about care provided by doctors.6 These findings suggest that there is great potential for new product ideas at the intersection of information technology and consumer demand for transparency.

My youngest daughter was born at the turn of the century, and incredible to me, cannot imagine life without computers or the Internet. The U.S. health care system could one day move to one in which my grandchildren can only picture the system as one where systems connect with each other and consumers use tools that help them find the highest value services, plans and providers. 

Read the entire Health Care Current here and subscribe at: www.deloitte.com/centerforhealthsolutions/subscribe.

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1 SAS Institute Inc., “Analytically Speaking – Interview with Howard Wainer,” http://www.sas.com/apps/webnet/webcast_viewer.htm?index=wc_jmp01sep14bc
2 Senators Ron Wyden & Charles Grassley, Letter to Stakeholders on June 12, 2014, http://www.finance.senate.gov/imo/media/doc/Wyden Grassley data transparency letter5.pdf
3 ONC, “Patient Identification and Matching Final Report” February 2014. http://www.healthit.gov/sites/default/files/patient_identification_matching_final_report.pdf
4 Deloitte Center for Health Solutions, “Survey of U.S. Health Care Consumers,” 2013
5 Deloitte Center for Health Solutions, “Survey of U.S. Health Care Consumers,” 2013
6 Deloitte Center for Health Solutions, “Survey of U.S. Employers,” 2013

Bill Copeland, Vice Chairman, U.S. Life Sciences & Health Care LeaderBill Copeland is the U.S. Life Sciences and Health Care Leader for Deloitte LLP and the sector leader of the practice's health plans group. Bill helps companies and governments better address the direct challenges and extended ramifications caused by new developments with ICD-10, electronic health records, health insurance exchanges and accountable care organizations.


Blurring lines and radical transformation: M&A in life sciences and health care

by Phil Pfrang, Life Sciences and Health Care Financial Advisory Leader, DTTL

Without question, the life sciences and health care industry is transforming radically; both blurring the lines between providers, health plans, and life sciences companies and breaking down the traditional geographic borders that have historically defined industry participants. Deloitte Touche Tohmatsu Limited recently completed a global survey of M&A trends in the life sciences and health care industry in collaboration with the Economist Intelligence Unit (EIU) to explore the drivers behind this transformation and the factors that are top of mind for life sciences and health care companies as they react to market forces. A number of key findings emerged from the results of the survey.

What factors are driving M&A activity?

Respondents to the survey identified increased financial and competitive pressures as the number one driver of M&A activity. From the great patent cliff impacting biopharmaceutical companies to the competitive pressures facing medical device manufacturers to the impact of health care reform globally, participants in the life sciences and health care market are feeling increased financial and competitive pressures and one way to deal with those pressures is to seek additional economies of scale through M&A. The pace of change within the industry through disruptive technologies, new approaches to the delivery of care, such as personalized medicine, and the emergence of new delivery models, is putting further pressure on life sciences and health care companies to innovate. And often times the fastest way to innovate is through acquisitions.

What geographic regions are likely to see the greatest level of investment and from where?

The results of the survey indicate that life sciences and health care companies expect to direct future investment through M&A activity toward high growth markets at the expense of lower growth markets. Specifically, Asia Pacific was identified as the number one outbound investment market for companies based in both Western Europe and North America. In fact, Western European companies, arguably companies operating in one of the slowest growth markets globally, indicated that only 31% of their M&A investments would be directed toward their home geographic territory. Almost two-thirds of the outbound M&A investment for Western European companies would be directed toward Asia Pacific, arguably the fastest growing life sciences and health care market. 63% of companies based in Asia Pacific indicated that their primary target market for M&A would be right at home in the Asia Pacific market.

While the big life sciences and health care companies that operate in North America, Asia Pacific, and Western Europe all indicated significant investment abroad, the smaller companies based in geographic regions such as the Middle East, Africa, Eastern Europe, and Latin America indicated they were much less likely to invest abroad. In fact, only about half of that group indicated they were likely to invest outside of their primary geographic home base and even then, most indicated that their investments would be in “adjacent geographies where cultural and language differences were less significant." For example, Western Europe was identified as the primary outbound market for companies based in the Middle East, Africa, and Latin America – very different from the strategy of the rest of the world, including even Western Europe where only 31% of companies actually based in that region identified that as their primary target market for M&A.

What are the greatest challenges associated with international expansion?

The survey also asked respondents to identify the greatest challenges with respect to international expansion and the results seem to align closely to the geographic orientation discussed above. The number one challenge identified was related to knowing the market and regulation, which are arguably the same thing. Life sciences and health care is one of the most highly regulated industries and the ability to navigate those regulations is key to the success of any international expansion strategy. Clearly, the larger companies based in North America, Western Europe, and Asia have the scale and depth of resources to navigate the complexity of global regulations.

In the coming years, life sciences and health care companies will face a wide range of pressures – from regulatory to economic – and keeping pace will require alternative business models, additional skills, greater efficiencies, new paths to innovation, and creative strategies for growth. The firms that learn how to embrace change, move faster, and tolerate risk will be the ones most likely to flourish.

Read M&A trends in life sciences and health care: Growth at the global intersection of change to explore the full findings.


Phil Pfrang, Partner, M&A Transaction Services, Deloitte & Touche LLP

Phil Pfrang is DTTL financial advisory leader for the Life Sciences and Health Care industry. He has assisted clients with more than 600 completed or proposed transactions in a broad cross-section of industries. He has served many of DTTL's most important strategic and private equity clients. Phil has extensive experience in international and cross-border transactions.


Attention passengers: The Open Payments database is now live

by Harry Greenspun, M.D., Senior Advisor, Deloitte Center for Health Solutions, Deloitte Services LP

I fly a lot, so I’ve gotten pretty good at managing travel disruptions. Despite storms, strikes, technical malfunctions and even volcanoes, I generally find a way to arrive close to where I need to be relatively close to when I need to be there.

Therefore, when I woke up in Chicago on Friday, September 26 to the alert that O’Hare and the nearby airspace was shut down, I was confident I could find my way home to Washington, D.C. that night. Between using my airline’s website, monitoring a third-party flight status site that pulled data from the Federal Aviation Administration and exchanging emails with my friend Jim (a commercial pilot), I was quickly able to ascertain that my flight would not go, but another might. After securing a reservation on that flight, I was able to track and monitor the status of the inbound aircraft, re-arrange calls and meetings and update my rides to and from the airports. Ultimately, I arrived home about 90 minutes later than originally planned, which allowed me to keep my normal evening schedule of eating dinner with my family and walking the dog. In this instance, faced with real-time decisions, I was able to access the data I needed to take action.

Four days later, last Tuesday, September 30, 2014, I got the alert that the Centers for Medicare & Medicaid Services (CMS) Open Payments database, a next step in the governments march toward transparency, had gone live. Intended to “give the public more information about the financial relationships between physicians and teaching hospitals and applicable manufacturers and GPOs,” the site includes a broad swath of data:

  • Information about financial relationships between physicians and teaching hospitals and medical device and pharmaceutical manufacturers and group purchasing organizations (GPO) that might exist (including names and locations for each in the relationship)
  • The nature of the payment being shown, such as consulting fees, gifts, food and beverage, research and grants
  • Whether the payment is associated with a specific drug or medical device, and if so, the applicable name1

Reaction to the release mirrored the prior release of Medicare data on physician payments (see the My Take, “Seeing past the blind spot: is transparency in health care enough?” from the January 28, 2014 Health Care Current). While some groups lauded the increase in transparency, others raised concerns about accuracy and whether users could take the data out of context or confuse the payments for research with marketing and entertainment relationships. The next day, the headline in my inbox read “Open Payments website reveals $3.5 billion paid to docs, hospitals.”2

Curious, I decided to look for myself, utilizing the CMS Data Explorer. It took me a few tries, and the help of one of our policy analysts, but I was eventually able to get an 11 MB spreadsheet that contained many lines of information, physicians’ names and companies. The immediate question that came to my mind was, once any concerns about the site and context are quelled, will patients begin to take notice? Aside from the catchy headlines, consumers’ interest in and use of publically available data has historically been quite low. Deloitte’s survey of U.S. health care consumers found that only one in eight consumers say they referred to a score card or report card to compare doctors in the past year.3

If consumers really do begin to take notice, in my opinion, it could open up additional areas for individual organizations and the industry to address:

  • What will be the impact on policies at institutions? Conflict of interest policies are nothing new, and many organizations (both by regulation and by choice) have adopted strict rules around relationships and disclosure related to business interests, self-referral and other sources of undue influence. However, other organizations may lack this rigor, and the release of this data could serve as a call to action.
  • How will the information impact innovation, public-private partnerships and industry-sponsored research? As noted, a major category of payments highlighted is for clinical research, and those who take the time to examine the data closely will hopefully be able to tell the difference between that and payments for meals and entertainment. Still, some may be concerned that their appearance in the database may ultimately be misinterpreted and their level of trust undermined. As a consequence, will institutions begin to reconsider their relationships with incubators, consortia and other platforms for research and development?
  • What about other new entrants? While the data reflects payments from pharmaceutical and medical device companies, many other industries are pushing their way into health care and seeking relationships with physicians. While many types of firms may currently fall outside the scope of this program, technology firms, retailers, developers and others represent a vast new frontier of potential influences to physician behavior. Will physicians begin to prescribe use of these new devices (e.g., mobile apps)? If so, will that bring those types of products into the regulatory spotlight?

As I sat in O’Hare airport, even in an evolving situation, I had the information I needed to respond. As health care consumers become savvier, using the experiences they gain from other industries, they may expect to have information and tools to support their health care decisions. The health care industry, and new firms wishing to enter into it, might have a competitive advantage if they pay more attention to consumer perception and decision making.


Read the entire Health Care Current here and subscribe at: www.deloitte.com/centerforhealthsolutions/subscribe.

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1 CMS, “Open Payments Data in Context, http://www.cms.gov/OpenPayments/About/Open-Payments-Data-in-Context.html
2 Jaimy Lee, Modern Healthcare, “Open Payments website reveals $3.5 billion paid to docs, hospitals,” September 30, 2014
3 Deloitte Center for Health Solutions, “2013 Survey of Health Care Consumers

Harry Greenspun, MD, Senior Advisor, Health Care Transformation and Technology, Deloitte Center for Health Solutions, Deloitte LLP

Harry Greenspun, MD is a director with Deloitte Services LP and the senior advisor at the Deloitte Center for Health Solutions. He has held a diverse range of clinical and executive roles across the health care industry, giving him a unique perspective on current and future challenges.


Medical devices and additive manufacturing: A natural fit

by Glenn Snyder, Principal, MedTech Practice Leader, Deloitte Consulting LLP

The disruptive potential of additive manufacturing (AM), often referred to as “3D printing,” is undeniable. We’re on the ground floor of a new technology that offers the promise of enormous change in the way we design, create, market, and distribute products.

Many would agree that life sciences and medical technology (medtech) companies are uniquely positioned to take full advantage of cutting-edge AM technologies and prospective funding sources to build potentially game-changing business models.

The medtech industry already stands at the forefront of this transformative change. Medical applications account for a significant portion of the AM market; about one-sixth of system-related revenues according to a 2013 study by Wohler Associates.1

AM capabilities align well with the growing needs of the medtech segment. We think it’s a natural fit. Medical devices and tools tend to be small: hearing aids, surgical implants, dental crowns. They are also value-dense, combining high value with relatively small physical volume. Finally, medical devices benefit from AM-enabled custom-tailoring to improve patient fit and clinical efficacy.

There is strong and growing financial interest in supporting new technological applications across the sector. In 2012, medical device revenues topped $121 billion, with forecasts placing growth at an annual rate of 5.4 percent.2

If successful technological application is the product of opportunity, timing, and resources, then the future of AM for medical product development and along the supply chain is exceedingly bright. However, medtech companies face critical business decisions; and those decisions, and how they develop operating plans based on them, will determine their level of success.

In our view, companies in the medtech space can follow one of four distinct tactical paths to incorporate AM into their business planning and manufacturing processes, with ascending levels of risk and potential profitability:


Path I: Those seeking to maintain their competitive footing, but reluctant to incur substantial risk or costs generated by AM adoption can opt for stasis, perhaps limiting their investment to adopting AM for rapid prototyping, production and custom tooling, or the creation of illustrative medical models.

Path II:  A second path centers on supply chain evolution. On this path companies take advantage of scale economies offered by AM as a potential enabler of supply chain transformation for the products they offer, perhaps finding new ways to deploy medical technologies, such as print-on-demand capabilities in hospitals and clinics.

Path III: A third emphasizes product evolution through greater commitment to areas such as mass customization and bioprinting. On this path, companies take advantage of the scope economics offered by AM technologies to achieve new levels of performance or innovation in the products they offer.

Path IV: The fourth path available to industry participants is broader and more inclusive, effecting evolutionary changes to both supply chain and product manufacturing. It’s an appealing approach for business leaders with a touch of daring, willing to adopt new business models with AM as a core component. But it does require forward-thinking companies whose leaders have an appetite for tackling risk and operational uncertainty.

The challenges facing implementation of an AM model might give some company leaders pause. Medtech manufacturers face tough regulatory pressures from the U.S. Food and Drug Administration and other oversight agencies. However, this oversight may not be as burdensome as it is for drug makers; cycles of innovation tend to be shorter in the devices sector, but new medical devices can take as long as 10 years to come to market.

We think federal oversight will likely intensify for AM products as these innovations are so new and the impact of 3D implants, including their structural quality and endurance, demand more intensive scrutiny. While the potential benefits of AM are many (it can spur additional innovation, improve patient access to life-saving devices, simplify and accelerate the supply chain and production process, and achieve considerable savings), are medtech companies willing to commit the time and resources to AM to overcome potentially burdensome regulations?

It’s a tightrope walk. Push too fast and it could turn out to be too costly in terms of time and resources. Respond too slowly and cautiously, and medical device manufacturers could find themselves well behind the competitive curve. Business leaders across the industry need to decide how they will proceed, assess the regulatory landscape, and plan accordingly.

To learn more, read 3D opportunity in medical technology: Additive manufacturing comes to life.

1 Wohlers Associates, Additive manufacturing and 3D printing: State of the industry, 2013, p. 14. 2Espicom Business Intelligence Ltd., The WorldMedical Markets Fact Book 2012, 2012.


Glenn Snyder, Principal, MedTech Practice Leader, Deloitte Consulting LLP

Glenn Snyder is a principal with Deloitte Consulting LLP, leading Deloitte’s medical technology industry practice. He advises clients in the areas of corporate growth, business model innovation and commercial strategy.


Applying a venture capital approach to accelerate cures

by Terri Cooper, PhD, Principal, Federal Health Sector Leader, Deloitte Consulting LLP

Seventeen years ago many of us were tuned into the O.J. Simpson trial and preparing our telescopes for the last viewing of Hale-Bopp until the year 4397. For some that may seem like a long time ago, but 17 years is the short end of the typical life cycle for a scientific discovery in medicine. Many medicines take anywhere from 17 to 23 years to make their way into the day-to-day practice of doctors and hospitals.1 And, the majority of initially promising discoveries – 86 percent2 to over 95 percent3 by some estimates – fail to even make it that far.

Given the complexity of the medical research and development (R&D) process and the careful testing that is required to be sure biopharmaceutical products are safe and effective, these facts may be easy to understand. But, for many, they are not easy to accept.

As I covered recently in a blog post, “The Ebola outbreak: A call to action for a translational approach to R&D,” the goal of translational medicine (TM) is to bring a greater number of biopharmaceutical products into health care delivery more quickly and successfully. However, the current TM process has been regarded by many as complex and protracted. Government agencies and nonprofits (“funders”) often lack a systematic business framework to select and fund TM projects for maximum potential investment return.

Venture capitalists (VC) currently play a major role in the U.S. economy, but there is more to be gained from them than just their investments. The VC model offers a framework for funders to integrate into their TM evaluation processes. VC practices for project identification and decision making, active project and portfolio management, and partnerships could help funders more effectively select and assess TM projects.

What core elements of VC could funders apply to their TM decisions?

Rigorous project identification and decision making: VCs use rigorous processes to assess and compare projects in a systematic and objective manner with respect to multiple factors. They seek out expertise before executing deals. By performing a similar business-centered project analysis, vetted with external multi-disciplinary experts, TM funders could undertake a more strategic project selection approach. Key questions for TM funders might include:

  • How should market considerations such as prevalence, burden of disease and available treatments be built into the vetting process?  
  • What is the potential of scientific merit in terms of novelty of pathway and level of innovation?
  • Does the project have technical merit with respect to the potential feasibility of moving along the TM continuum?
  • Is there commercial viability or reimbursement potential in the project?
  • What is the potential level of financial/social return on investment?
  • Does the project have potential for achieving positive impacts on health?
  • Are there multi-disciplinary experts both internal and external, such as advisory boards, available to help determine where and how to invest?

Active project and portfolio management: VCs have strategic plans and portfolios that are carefully selected to align with the organization’s goals. They often invest in multiple industry segments and take a long-term strategic view of their investments. They typically provide managerial and technical support, such as consulting services or business training. Through active project and portfolio management, TM funders may be able to develop a balanced portfolio with a long-term impact view where projects are funded in stages based on the achievement of milestones. Depending on the projected long-term return on the TM investment, management decisions could be made about whether the project could be licensed, sold, engulfed into another project, or receive additional funding. Key questions for TM funders might include:

  • Does project collection (portfolio) reflect an integrated, complementary strategy or vision?
  • Is the time length of a project balanced/assessed against its level of potential success?
  • Is overall risk managed by achieving a balance between high-return and low-return projects?
  • Are short- and long-term investment impacts assessed against other investment opportunities?
  • Could funding schedules be set to provide funding in series/rounds or stages based on meeting specific performance milestones?
  • What internal managerial and technical support, such as in the area of talent acquisition or business plan development, do the grantees require? Does the funder have the right in-house experts to deliver this support or do they need to be acquired?
  • Has the business plan development involved an iterative process with multiple stakeholders?

Collaboration and partnerships: VCs use their extensive networks to connect and facilitate collaboration among the start-up companies with which they have relationships. They also may identify and consolidate entities, such as those developing similar products, for greater efficiency and market positioning. A similar approach to partnerships/collaborations could provide TM funders a greater flow of data and effective practices. In this light, TM funders could consider questions such as:

  • What collaborative relationships, and grantee incentives to participate, might be established to facilitate the exchange of ideas and insights among similar projects?  
  • Does the funder have the right network of external experts to assist scientists in moving their project from lab to market?
  • Does a shared informatics infrastructure (for validating, evaluating, integrating, and sharing data among project stakeholders) exist or does it need to be created?  How could funders partner to improve, expand, or develop this infrastructure?

In 2013 VCs provided $29.6 billion worth of capital to more than 4,000 investments.4 In doing this, they provided millions of jobs and trillions in revenue. By looking to this framework, funders may be able to improve the pace, focus and adoption of high-impact TM projects to accelerate cures.

It’s been 17 years since millions of teenagers were flocking to the CD stores to buy the Titanic movie soundtrack. Meanwhile, heart disease takes 600,000 lives per year, cancer takes nearly 1,600 lives per day and every 67 seconds someone is diagnosed with Alzheimer’s.5 Improvement in the translational timeline is needed now.

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P.S. For more on how translational sciences can benefit medical research, see the “NIH awards $17 million for 3D tissue chips research” story below and view Deloitte’s recent whitepaper, “Path to 21st Century Cures – A Call to Action."

Read the entire Health Care Current here and subscribe at: www.deloitte.com/centerforhealthsolutions/subscribe.


Sources: 1 Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart, Germany: Schattauer Publishing; 2000:65‐70. 2 Westfall JM, Mold J, Fagan L. Practice‐based research: “Blue Highways” on the NIH roadmap. JAMA. 2007;297:403–6. 22 3 NIH. About NCATS. Available at: http://www.ncats.nih.gov/about/about.html 4 Recent Stats & Studies. 2014  April 3, 2014]; Available at: http://www.nvca.org/index.php?option=com_content&view=article&id=344&Itemid=103 5 Centers for Disease Control and Prevention, “Heart Disease Facts,” 2014; American Cancer Society, “Cancer Facts and Figures,” 2014; Alzheimer’s Association, “Alzheimer’s Facts and Figures”

Dr. Terri Cooper is a Principal of Deloitte Consulting and is the leader of the Federal Health Practice. She has two decades of experience working in various capacities relating to the Life Sciences Healthcare Business. For the past 18 years she has worked as a consultant to the industry. Prior to joining Deloitte Consulting she was a partner in the Global Pharmaceutical/Life Sciences Practice within IBM Business Consulting practices, where she had responsibility for leading the Global R&D Pharmaceutical/Life Sciences Practice. In her current client relationship role she has responsibility for product and service offerings in research and development to selected global pharmaceutical companies headquartered in the U.S. Dr. Cooper is a frequent participant at industry conferences where she frequently speaks on topics relating to the issues affecting pharmaceutical research and development.


The Ebola outbreak: A call to action for a translational approach to R&D

by Terri Cooper, PhD, Principal, Federal Health Sector Leader, Deloitte Consulting LLP

As of this week, the Ebola outbreak in West Africa has killed more than 3,000 people across Guinea, Liberia, Nigeria, Senegal, and Sierra Leone.1 It marks the largest Ebola outbreak in history. One clear focus throughout the outbreak has been on finding a cure. In light of this health crisis and the increasing concern about the rising prevalence of serious chronic diseases, it seems a perfect time to redouble our efforts on shifting to a translational strategy in life sciences—a strategy that could help bring innovative and cost-effective products to market more quickly.

Traditionally, the research and development (R&D) processes within the life sciences value chain –  discovery, development, and delivery –  have occurred in silos with limited sharing of data and effective practices from one step to the next, and little or slow looping back to earlier phases with insights and information that might inform future iterations of improvement and innovation at each stage. Today and through the current process, translation of scientific evidence from discovery into health care practice typically takes 17 to 23 years.2 Companies, governments, and people are losing time, money, and opportunities – opportunities to improve health outcomes around the world, as well as chances to revive the global competitiveness of the U.S. However, forces within the health care landscape, such as legislation, regulation and the rise of big data and analytics, are pushing stakeholders to look differently at how they approach the value chain.

Shifting to a translational approach – in which a more dynamic, integrated, and continuous process of data sharing occurs between the traditional steps in the R&D value chain – holds great opportunity for accelerating iterations of scientific discovery and development, implementing evidence in practice more efficiently and effectively, acquiring a deeper knowledge about product safety and effectiveness, and reducing overall R&D costs. It’s hard to think of anything that could be “lost in translation” if companies were to refine their R&D process in the ways that a translational approach suggests.

What would a translational approach to R&D look like?

Moving toward a system of translational medicine would create a continuous flow of data between the discovery, development and delivery processes of the R&D value chain. By increasing data sharing between these steps, a continuous and systematic process improvement cycle is established. That cycle can then provide critical information than might be typical for decisions arising along the value chain, resulting in the earlier termination of unsuccessful compounds, improved trial design and recruitment, better understanding of disease and care pathways, and improved post-marketing surveillance capabilities.

How can we move faster? 

Speeding up the R&D process will require action on several fronts. Progress is occurring in many areas, but acceleration is needed to address growing health threats and recent declines in the global competitiveness of the U.S. Deloitte recently had the opportunity to engage with Congress on this process by producing a report, “Deloitte’s Path to 21st Century Cures: A Call to Action.” In it, we identify several ideas for achieving a translational approach to the R&D value chain: 

  • Increase incentives to use translational approaches in biopharmaceutical R&D by increasing or refocusing government funding; adjusting legal and regulatory frameworks and policies; and modifying reimbursement policies in ways that support increased collaboration and data sharing between the discovery, development and delivery phases.
  • Encourage multi-stakeholder collaboration and teaming models to strengthen cooperation and increase dissemination of scientific and market-derived information across the R&D value chain. Public-private partnerships and consortia could be leveraged to improve and accelerate research. Patient-centered care advocacy organizations could help coordinate and accelerate research through patient-focused research initiatives, patient education, or through patient reach via social networks. Improved regulator-industry communication could provide more timely and relevant guidance and inputs.
  • Leverage health information technologies and integrate data sources to gain new insights regarding consumer behavior, product safety and efficacy, and potential directions for biopharmaceutical innovation. Wearable and implantable medical and personal health devices, electronic health records, websites and email, mobile applications, and social networking are increasing the connectivity between patients, providers, and developers and creating vast amounts of data. This data could be used not just for monitoring, but also for predictive analytics at the population level and to drive development and improvement of drugs. Electronic medical records could be used to understand comparative (i.e., relative) benefits of a new product versus the standard of care or improve clinical trial recruitment. Social media networks could be leveraged to communicate treatment efficacy to patients.
  • Pursue the development of innovative study designs and advanced statistical methods that can increase speed-to-market for some product applications and provide valuable insights to cycle back to discovery and development. While randomized controlled trials will likely always be required for initial product approval, non-randomized observational and quasi-experimental studies that use real-world data collected for other purposes may be sufficient for determining safety and efficacy of supplemental applications. Stakeholders should also consider enabling comparative effectiveness research, leveraging clinical trial data, and accelerating biomarker and surrogate endpoint validation.
  • Strengthen adverse event reporting by establishing a broader system that incorporates a variety of detection sources and methods, such as electronic medical records, the internet, and social media networks, or uses validated biomarkers to identify an adverse event.

As Congress and the president call for increased funding and more resource investment in the area of Ebola research, we are at a point where speeding up life sciences innovation has never felt more urgent.

While there are challenges that need to be addressed, including balancing priorities, dealing with limited resources and protecting privacy and security, I believe overcoming them will be well worth the resources and effort that the strategic, organizational and operational change will likely require. And, the investments we make to strengthen data sharing and insight exchange across the R&D chain will have benefits beyond bringing more products to market faster. The collaborative and information connections we begin to put in place today phases could not only bolster life sciences R&D global competitiveness, they could also have a positive and lasting impact on business sustainability and growth for life science companies and improved health care quality and outcomes for consumers.

Read more in Deloitte’s Path to 21st Century Cures: A Call to Action.

Dr. Terri Cooper is a Principal of Deloitte Consulting and is the leader of the Federal Health Practice. She has two decades of experience working in various capacities relating to the Life Sciences Healthcare Business. For the past 18 years she has worked as a consultant to the industry. Prior to joining Deloitte Consulting she was a partner in the Global Pharmaceutical/Life Sciences Practice within IBM Business Consulting practices, where she had responsibility for leading the Global R&D Pharmaceutical/Life Sciences Practice. In her current client relationship role she has responsibility for product and service offerings in research and development to selected global pharmaceutical companies headquartered in the U.S. Dr. Cooper is a frequent participant at industry conferences where she frequently speaks on topics relating to the issues affecting pharmaceutical research and development.


[1] CDC, 2014 Ebola Outbreak in West Africa, accessed on September 26, 2014 http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html; [2] Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart, Germany: Schattauer Publishing; 2000:65‐70.

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