Health Care Goes to the Mall

It's either auspicious or ironic: decades after other retail industries, health care is coming to the mall.

These are not, generally, good days for the malls.  We've all seen strip malls that were never finished or that have simply fallen on hard times, but in recent years those stalwarts of American shopping -- enclosed malls -- are sharing that fate.  Credit Suisse says that 20-25% of the 1,100 U.S. malls will close over the next five years.

Analysts talk about "zombie" malls, whose anchor tenants -- like Sears, JC Penny, or Macys -- have pulled out, creating an exodus of other tenants.  The malls themselves still stand, but their largely deserted storefronts and scarce shoppers mean they're dead but they don't know it.

Malls took off the mid-20th century, mostly in the suburbs and especially once they started to be enclosed.  The location, convenience and range of choices were unbeatable.  

Still, the concept started to seem dated by the 1990's, so the "lifestyle mall" was born.  They usually are not enclosed, try to recreate the feeling of a walk-able city center, and typically include destination restaurants and entertainment options like movie theaters or comedy clubs.   

Now that lifestyle concept is further evolving.  The Wall Street Journal predicts that "the mall of the future will have no stores."   They cite malls filling empty spaces with churches, schools, even offices or apartments.  E.g., Ford is leasing 240,000 square feet at a suburban Detroit mall for new offices.

The New York Times had a similar report on the changes to malls.  As one developer told them, "Dining and entertainment is the new anchor — not Sears, not Macy’s."  

One of their examples was how Austin's first enclosed mall had closed, and now is reopening as a new campus for a local community college.  It will ultimately serve as many as 20,000 students, and will also include 1,200 residential units as well as some retail.  

One thing that many agree upon: malls of the future will include: health care.

Another Wall Street Journal article focused specifically on health care moving to malls, and included several examples:

• Dana-Farber Cancer Institute has leased 140,000 square feet of a 286,000 square foot Boston-area mall, which also has several other health and wellness tenants.
• The Maury Regional Cancer Center has been in the Columbia Mall (Columbia, TN) since 2012.
• The Biggs Part Mall in Lumberton NC has Southeastern Regional Medical Center as a key tenant.
• UCLA Health operates primary care centers in the Village at Westfield Topanga.
• Vanderbilt Health has been part of the One Hundred Oaks mall in Nashville TN since 2009.

The portfolio manager for One Hundred Oaks mall told WSJ, "We have been very pleased with the performance of [One Hundred Oaks mall], driven in large part by the built-in traffic generated from the Vanderbilt University Medical System."  No wonder, the mall had been failing, and now Vanderbilt Health leases half of the mall's space. 

  

Other examples include Cedar Sinai (The Runway at Playa Vista -- LA) and Prime Healthcare (Plymouth Meeting -- Philadelphia), according to Bloomberg.  

Healthcare Dive profiled the WSJ article, and added that 57% of hospital exces in a recent survey listed improving access to ambulatory and outpatient care as their top priority, and that JLL Corporate Solutions recently urged health care organizations to adopt a "patient-centered" real estate strategy.

How much more "patient-centered" could it be than to locate in malls?

Johns Hopkins Medical President Gill Wylie told Bisnow that he watches retail vacancies for opportunities: "We do urgent care and primary care.  So I'm sitting there thinking, 'Gee if all these Staples end up closing, there might be space out there.'"  They've already snapped up four former Blockbuster locations for urgent care facilities.  

Mr. Wylie said he also pays attention to big department stores and malls, citing their infrastructure, parking, and ADA compliance as givens.  

JLL Managing Director Matt Coursen told Bisnow:

In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care centers off campus.  The on-campus environment should be reserved for acute care  and intensive care surgery centers that traditionally make hospitals more money.  Don't put anyone on campus that doesn't have to be there.  

In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at: https://www.bisnow.com/washington-dc/news/healthcare/healthcare-providers-see-opportunity-in-growing-retail-vacancy-75207?utm_source=CopyShare&utm_medium=Browser

In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at: https://www.bisnow.com/washington-dc/news/healthcare/healthcare-providers-see-opportunity-in-growing-retail-vacancy-75207?utm_source=CopyShare&utm_medium=Browser

In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at: https://www.bisnow.com/washington-dc/news/healthcare/healthcare-providers-see-opportunity-in-growing-retail-vacancy-75207?utm_source=CopyShare&utm_medium=Browser

In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at: https://www.bisnow.com/washington-dc/news/healthcare/healthcare-providers-see-opportunity-in-growing-retail-vacancy-75207?utm_source=CopyShare&utm_medium=Browser

Interesting perspective.

Fady Barmada, of Array Advisors, led the conversion of New York City McDonald's to an urgent care center, and noted that: "Health systems know that, by co-locating themselves with well-used and well-attended retail facilities, they can increase the visibility of their facilities and become platforms for the creation of unique and interesting programs."

But moving to retail locations won't, in itself, make health care organizations more patient-centered.  To do that, they'll have to make the patient experience easier (if not always enjoyable), give them clear choices, and truly treat them like valued customers.

Moving is easy.  Changing is hard.  

Read more at: https://www.bisnow.com/washington-dc/news/healthcare/healthcare-providers-see-opportunity-in-growing-retail-vacancy-75207?utm_source=CopyShare&utm_medium=Browser

Good Ideas From Unexpected Places

How about this: in Harvard Business Review, two leaders at Johns Hopkins suggested that hospitals could learn something about buying equipment from -- drum roll, please -- the airline industry.

You don't often find many people defending airlines these days, much less holding them up as good examples of anything (except, perhaps, about what not to do, what with overbooking, cramped leg space, plenty of add-on fees, and, of course, dragging paying passengers off planes).  That their recommendations make sense probably says more, though, about how poorly health care often does things than how well airlines do.

The point that Peter Pronovost and Sezin Palmer make is that "hospitals purchase technologies without requiring that they communicate with each other."  They have lots of high tech equipment, each with lots of important data, but the equipment is generally not interoperable (of course, even the same types of equipment often aren't interoperable -- EHRs being the prime example).

As they say, "health care is woefully underengineered."  This leads to all sorts of workarounds and double-entry, which at best make patient care more difficult and at worse threaten patient safety.  They urge that heath care take advantage of system engineering to truly integrate technology, workflow, and clinical practices.

Hard to argue.

Their great quote:

We don’t expect airlines to build their own planes. They buy them from experienced system integrators such as Boeing or Airbus. There’s no reason that hospitals shouldn’t have a similar model. 

For example, they suggest that, instead of building hospital rooms and then filling them with equipment that don't communicate, hospitals could buy hospital room modules that come with fully integrated devices.  It could be not just rooms, but clinical units, whole floors, even a "hospital in a box," each coming already integrated.

The approach goes beyond hospitals, of course.  For example, aircraft engines increasingly tap into the Internet of Things (IoT), so that they can be continuously monitored and problems addressed before they become serious.  That is something that health care talks about a lot, in terms of monitoring our heath, but so far has failed miserably at.

Of course, the airline industry still uses air traffic control systems that are decades old, their baggage tracking systems still manage to lose your bags, and it seems to take a suspiciously large number of keystrokes to rebook you if your plane gets cancelled.  So the airline industry could use some systems engineering of its own.

Upon reflection, the two industries are not as dissimilar as they might seem on first glance.  In both cases, we literally put our lives in their hands, hoping that the people and equipment all function correctly.  Both are very capital-intensive.  Both use some technology that is decades old as well as some cutting edge technologies.  Both have seen rapid consolidation of service providers, leading to less competition.

And neither has a great track record about doing exactly what they promise to do exactly when they say they're going to do it.

Health care or airport waiting room?

On the other hand, you can easily shop for flight choices and prices (although airline pricing may just rival health care pricing for its inexplicable variations), can book your airline ticket and pick your seat using your smartphone, and on-board entertainment options are becoming fairly sophisticated.

The equivalents in health care pale by comparison.

Health care can do better.  John Nosta writes in Psychology Today that healthcare innovation is "in the ICU."  In other words, in serious trouble, but not dead yet.  He believes the underlying technologies are there to spur innovation, and that "an inflection point is at hand."  He cites in particular a survey done by Klick Health, which found that consumers don't think that health care is very innovative, but they wish it was.

Specifically, health care was at bottom of 18 industries in terms of which respondents felt was the most innovative (17%), but top of the list of ones that they thought should be (40%).  Ninety-one percent believed innovation will positively impact healthcare over the next five years.  Ninety percent also felt technology would have a positive impact on their health, with 70% believing technology will help them personally manage their health.

Contrary to oft-mentioned concerns about technology interfering or even replacing the physician-patient relationship, the Klick respondents felt that it would benefit from innovation, such as in better diagnosis and treatment.

Health care all-too-often sees itself as unique, and tries to solve problems using health care people applying health care solutions.  That may be necessary in many cases, but it can't be the only approach.  There are too many other industries, using too many interesting business models, process improvements, and technologies, to limit problem solving to "traditional" health care models.

Suzanne Fox, the former CTO for HHS, recently told Washingtonian: 

The most successful groups I’ve seen in terms of the innovation work I oversaw at HHS or discussions I’ve been a part of in other settings, the more diverse groups, the better the innovation becomes.  You’re going to want to hear from people who haven’t yet developed the muscles for a certain way of thinking about health care, who are going to maybe have that outside idea that’s creative.

So, if we're going to innovate in health care, we need to flex those non-health care muscles.  We need to break down barriers.  We need to listen to diverse voices and ideas.  We need to apply ideas that we might not normally think would apply to health care.  We need to beg, steal, and borrow good ideas from wherever they come.

Even if that means learning from the airlines.

Fidgeting May (or May Not) Be Good For You

I swore I wasn't going to write about fidget spinners.  Just a toy, just be the latest fad -- the Rubik's cube of this generation, or perhaps the Pokémon Go of this year -- with no broader implications, for health care or anything else.  Yet here I am, writing about them after all.

If you know any children, you already know what a fidget spinner is.  You may even have one yourself.  They seem to be everywhere lately, even in the hands of President Trump's youngest son as he exited Marine One recently.

What that says about us is not quite clear.

Although they generally share the same three-prong shape (there's also a newer variation, a fidget cube), fidget spinners come in all colors and prices -- one writer listed some 62 variations.  They can range in price from a cheap as a dollar to several hundred dollars.  

You can even turn your mobile phone into one, if you really want to.  Or get the app.  

CNN reported that fidget spinners accounted for the top 15 most popular toys on Amazon, and fidget toys and fidget cubes combined accounted for 49 of the top 50 spots.  If you don't get their appeal and think they're just silly, well, kids probably don't think you're cool anyway.

One of the early rationale for fidget spinners was for children with ADHD (attention-deficit/hyperactivity disorder).  The theory was that they allowed them to focus better by giving an outlet for their extra energy.  Their benefits supposedly also applied to adults with a wider range of mental health concerns, such as PTSD or anxiety.  

Unfortunately, the basis for any of these claims appears dubious.   There is some research that gross motor activity did help improve working memory for children with ADHD, but it was not focused on fidget spinners and using them probably would not qualify as gross motor activity.  Clinical psychologist Scott Kollins warned NPR: "It's important that people don't get into trying these fads when we do have treatments that can help these kids."

And, while ADHD diagnoses have exploded (which some have blamed on Big Phama's desire to sell more drugs), most of those children you see with fidget spinners almost certainly don't have ADHD.  They just like to play with it. 

The notion that fidget spinners are good for kids, or at least benign, is increasingly coming under attack.  Schools in at least 11 states have banned them, claiming they are at least distracting and possibly dangerous.  Imagine teachers trying to get kids focused on math while they are spinning away (and the rest of the class is texting under their desks), and the bans make a lot of sense.

Even worse, there are warnings about fidget spinners being a choking danger, a possible source of internal bleeding (due to the batteries), even a risk for lead poisoning.  Who knew they might be so hazardous?

Alex Williams, writing for The New York Times, has a different theory.  Mr. Williams argues that, while we once might have been the "Prozac Nation," suffering from depression, we now are the "United States of Xanax."  In other words, as social media consultant Sarah Fader told him: "If you’re a human being living in 2017 and you’re not anxious, there’s something wrong with you.”

He notes that as many as 38% of girls 13-17, and 26% of boys, have an anxiety disorder, and that anxiety far outpaces depression on college campuses.  

This should not come as a surprise.  After all, since 9/11, the 21st century has seen a never-ending threat of terrorism, wars in Afghanistan and Iraq, the Great Recession, widening wealth inequality, and hyper-partisan politics the likes of which we may have never seen before.  To not be anxious seems like not paying attention.

Mr. Williams cites the fidget spinner "as a perfect metaphor for the overscheduled, overstimulated children of today as they search for a way to unplug between jujitsu lessons, clarinet practice and Advanced Placement tutoring."   A mindless activity like them has great appeal. 

He also references another new source of anxiety: #FOMO, or fear of missing out.  We have to keep up with Facebook, Twitter, Snapchat, texts.  Staying connected can be an overwhelming, 24/7 task.  Our obsession with -- one could say addiction to -- our smartphones shows how we constantly have to be busy with something.

No wonder it isn't just children who are playing with them anymore.

There's nothing inherently wrong with fidgeting.  The Washington Post interviewed Katherine Isbister, a professor at University of California Santa Cruz, who is studying the fidget spinner craze.

Dr. Isbister told the Post that we evolved doing things with our hands, but modern life affords us less opportunities to do many of them.  She speculates that our digital devices rob us of the kind of "interesting tactile experiences" that fidget spinners provide.

Professor Isbister and her collaborator Michael Karlesky believe that fidget spinners "may shape cognitive state to support a user’s productivity and creativity in their primary tasks."  OK, then. They're collecting other examples of how and with what people fidget (and finding some interesting items!).

Fidget spinners may not have broader implications for health care, as I've previously speculated that other seemingly unrelated things like e-Sports, Pokémon Go, or Snap's Spectacles might.  They might not tell us anything more about the times we may live in than hula hoops told us about McCarthyism or the Cold Way did about the 1950's.  They may just, indeed, be a passing fad.

I think I still want one, though.  How about you?

Robots for Everyone!

Ready or not, there are robots in your future.  And some of them will be for health care.

There has been growing concern that the rise of robots, along with artificial intelligence (AI), will create huge impacts on jobs.  Within the last few months both McKinsey and PwC have issued white papers on the topic.  The former found that nearly half of jobs have the potential to be automated (although most not totally), while the latter expects 38% of U.S. jobs at at high risk of automation within 20 years.

Health care is not high on most lists of sectors whose jobs are soonest to be heavily impacted by robots, but it is on the list -- and it will happen.

The Pew Research Center asked people for their predictions about robots and computers taking jobs, and found a curious dichotomy.  While two-thirds expected those technologies to take over most jobs within 50 years, 80% thought their own jobs were safe.  They were more worried about their industry declining or jobs going to lower wage workers.

Even the ones who happen to be right about their job may still feel the impact.  Recent research suggests that robots not only take jobs but also reduce wages for the remaining jobs.

If you are worried about your job, there's a website Will Robots Take My Job which allows you to calculate the odds your job will be replaced by a robot.  If you are a physician (0.42%), nurse (0.9%), or pharmacist (1.2%), you're probably feeling safe, but if you work on an assembly line (97%) or are a truck driver (79%), not so much.

And if you are a billing clerk (96%), pharmacy tech (94%), or personal care aide (75%), well, you might want to brush up that resume.

Robots are becoming more and more human-like.  China's University of Science and Technology have unveiled "super-realistic" robots that have facial expressions, can carry on conversations, even practice calligraphy.   A professor at Osaka University has created a robot named Erika that Bloomberg called the "creepiest robot ever built" because it is so lifelike.  

There are already hotels -- in Japan, of course -- that are staffed solely by robots.

Although sophisticated robots like in robotic surgery or nanobots are already here or coming (respectively), many see robots to assist with caregiving as filling one of the biggest health care needs.  Global Markets Insights, Inc. projects that the market for "healthcare assistive robots" will grow 19% annually from 2016 to 2024, and that's the early stages of the market.

Let's face it: there are a lot of shitty jobs in health care.  In many cases, literally.  Jobs that it is hard to find workers to fill, especially because they tend to be low wage jobs.  Taking care of people who can't take care of themselves is a hard job.  Doing it can be a calling, and thank heavens for the many people who do it cheerfully and tenderly.

There just aren't enough of them.

If you or a loved one has ever been in a hospital, you know that ringing for help rarely results in someone coming quickly.  If that stay is in a nursing home, the wait will probably be longer.  The staff isn't right there, there aren't enough of them, and there are often other people asking for help at the same time.  If you're in pain or simply have to go to the bathroom, the wait can seem interminable.

If only you had a robot aide, standing patiently next to you, ready to help...

An even bigger help would be robots you could have at home when you are disabled or incapacitated. Most people would prefer to stay at home instead of going to a hospital or nursing home.  Many Medicaid programs have worked diligently to try to keep vulnerable people at home instead of being admitted to nursing homes, but there's only so much having an aide visit a couple hours a day a few times a week can do.

But a robot aide living with you could be more effective, and might actually be cost-effective about keeping people out of nursing homes.

Think about it: they'd never need to sleep, go home to their family, or take a vacation day.  They'd never be in a bad mood or make a careless move.  Helping you would be their only mission.

We're not quite there yet.  There are some tasks that we're not quite willing to have robots perform, especially on already fragile individuals.  But if we're trusting robots to do eye surgery, helping with bathroom or other sensitive tasks is certainly achievable, in the not-too-distant future.

Bernadette Keefe, M.D., did a deep, deep dive on robots in health care (starting with what a robot is, their history, and their uses in other sectors).  She included several examples of caregiving robots, including:

• Zora, a "personal caregiver" from Softbank, interacts, moves, and helps with rehab.
• Robear, from Riken and Sumitomo Riko Company, can lift patients from a bed.  It is, however, still considered experimental.  
• Softbank's Pepper, which is intended as a companion.  Softbank claims Pepper can perceive and respond to human emotions.   

In addition, Toyota has a family of "partner robots" which includes a personal assist robot, a care assist robot, and Robina.  Not to be outdone, Honda has their own family of robots, including ASIMO, which they bill as "the world's most advanced humanoid robot."

Half of respondents to a Futurism survey predicted every house would have a humanoid robot, although there was widespread disagreement on the timing, with some thinking we were still decades out.  That may be pessimistic.  There's already Catalia Health's Mabu personal care assistant and the Aido "next generation social family robot," among others.

We're already getting used to personal home devices like Amazon's Echo, Google Home, and now Apple's HomePod, all of which can do a variety of virtual tasks  It is not at all far-fetched that'd we'll similarly get used to personal robots who can do physical tasks for us, including ones relating to our health.

With AI doctors and personal care robots, technology can at least help fill in current gaps in care, and maybe help provide better health care generally.

Bring on the robots!