Zayna Khayat: Language, Mindset and the Future of Care

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjasa Zajc.

[00:00:22] If we want to change the mindset in healthcare and healthcare delivery, we also need to be mindful of the language.

[00:00:30] And this is one of the topics that I addressed with Zayna Khayat, an applied health futurist,

[00:00:37] helping people and organizations make sense of forces, trends and shifts propelling healthcare to a very different future from the past decades of status quo.

[00:00:47] We discussed the importance of language in healthcare, challenges in moving care to patients' homes, diverse aging models and how to age well,

[00:00:56] and the need for healthcare providers to focus on results and value-based healthcare.

[00:01:04] Enjoy the show. And if you haven't yet, do check out our newsletter. You can find it at FODH.substack.com.

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[00:01:50] Now let's dive in today's discussion.

[00:02:09] Zeyna, hi, and thank you so much for joining me for a discussion on Faces of Digital Health.

[00:02:15] We're going to definitely touch upon the future of healthcare, which is something that you like to think about.

[00:02:21] You have keynotes on this topic.

[00:02:24] You are an expert and super interested in how healthcare is changing, how we are moving into care at home,

[00:02:32] and the whole shift to home care and instead of sick care, we're going to life care.

[00:02:39] So actually taking care of us on the broader spectrum.

[00:02:42] But one of the things I remember talking to you about in the past is also the focus on language.

[00:02:50] You like to say that if we want to change healthcare, we need to change our mindset,

[00:02:55] which means that we also need to change the language because language defines the way we think.

[00:03:01] And when we had this discussion, I said, I always hate when my medical exams say smoking denies.

[00:03:10] I'm not smoking.

[00:03:11] That doesn't mean I deny the smoking.

[00:03:13] And you said, yeah, patient failed the treatment.

[00:03:17] The patient didn't fail the treatment.

[00:03:18] The treatment failed the patient.

[00:03:20] So what's your current favorite word and least favorite word?

[00:03:26] Yeah.

[00:03:27] So look, I love that you're opening with this topic of language.

[00:03:31] Absolutely.

[00:03:32] I always say the biggest barrier to the future of health that everyone deserves is how we think.

[00:03:37] And it starts with language.

[00:03:39] So it's a very powerful lens.

[00:03:41] And it's actually not that hard to get big impact by being very conscious of our language.

[00:03:47] In other circles, some call this linguistic relativity, social anthropology.

[00:03:51] But the language creates a new social reality.

[00:03:55] And it really, as you said, has the capacity to expand the mind.

[00:04:00] And I think our words we use contain so much significance that otherwise gets lost,

[00:04:07] both in the positive and the negative way, like your smoking example.

[00:04:10] So I actually keep a list of words that at a minimum, I think we need to retire and then even ban.

[00:04:20] That's an extreme version of retirement.

[00:04:23] And so right now I'd say this is on my list, the word innovation, which is a bit crazy because I teach a course called health innovation.

[00:04:31] I'm here in the Netherlands right now at the health innovation school.

[00:04:34] But I just think we overuse that word and therefore it means everything and nothing.

[00:04:38] And it pollutes the word patient centered.

[00:04:42] That's just, oh, we're going to feel good about ourselves because we took this patient that we ignored anyway.

[00:04:46] And now we've put them in the center and we feel really good about it.

[00:04:50] Social determinants of health.

[00:04:52] I think it's used for everything all the time.

[00:04:55] And therefore it just becomes this thing yet.

[00:04:58] It's huge.

[00:04:58] And so I just think we need different language for that.

[00:05:02] Bedside seniors.

[00:05:03] And I'm going to provoke.

[00:05:05] I don't know that I agree, but some are calling for the word care to be retired because it carries this paternalistic implication of doing something to someone or for someone.

[00:05:19] And therefore you lose the big momentum shift of people powered health care, moving from caring to training coach enabled.

[00:05:29] So anyway, one link you could put for your readers, which they might like is there's a design thinking firm called Bridgeable that made a thing called jargon.

[00:05:39] So jargon is like words that everyone uses that different.

[00:05:44] So it's called jargon for health care.

[00:05:46] And they have some really good stuff about how to bring the humanity back into health care innovation.

[00:05:51] It's a great point.

[00:05:52] I'm definitely going to check that out.

[00:05:54] If I just may comment briefly, the whole discussion about banning care reminds me on chronic patients versus people with something.

[00:06:06] That's also something I think endocrinologists are the first one that mentioned this for people with diabetes.

[00:06:13] Yeah.

[00:06:13] So it's a huge topic for many, probably an unnecessary topic in the sense that health care has so many problems that, you know, when you've got clinicians that are overworked and you put them in courses on how they're now supposed to talk differently to patients because, yeah, the patient experience is important.

[00:06:35] You can understand that from their perspective, this is the last thing that they would start changing if they wanted to.

[00:06:43] So how do you see that?

[00:06:45] Yeah, I think so.

[00:06:47] Hearing you talk about that again, I think we finally stopped calling someone a diabetic.

[00:06:53] I think that's clear.

[00:06:54] That's a faux pas.

[00:06:55] But we do call them chronic disease patients versus people living with or affected by disease X, Y and Z.

[00:07:03] So that reminded me there's another call to ban or retire the word patient.

[00:07:11] So on the one hand, some are like, no, some clinicians will say patient if you take its Latin origin means to suffer.

[00:07:19] So it reminds you this person I'm working with is suffering and I'm here to help alleviate the suffering.

[00:07:25] So how dare you take that away?

[00:07:26] On the other hand, it just carries all the past of being patient as a patient and waiting for something to be done to or for you.

[00:07:35] So my pushback on that we have bigger problems to solve and people's lives to save.

[00:07:41] So I'm not going to don't add language to my plate.

[00:07:45] Again, if we go back to the purpose of language, creating mindset and our social reality, if your goal is a great experience and good outcomes for these people who you're called to serve and the words you use affect that.

[00:08:04] Then it's inconsistent.

[00:08:08] Right.

[00:08:08] And this doesn't go.

[00:08:09] It doesn't take much to be intentional about the language you're using to help you get the results you want.

[00:08:15] And language can really make a difference.

[00:08:17] I love your creativity with language.

[00:08:20] When we had a discussion at Health Europe, you said that we are observing a retailization of health care or consumeration of health care and the clarification of retail.

[00:08:33] So what is your new favorite word or what do you think are some of the words that you use in terms of how health care should look like already today but might look like in the future?

[00:08:45] So you're asking about what words I'm enjoying using now and I am very intentional.

[00:08:49] I actually keep a note of I call it the new lexicon for health care.

[00:08:53] And so whenever I hear something, I plop it in there.

[00:08:57] So I'll just skim just to see fun employment instead of unemployment.

[00:09:04] Systemness as a descriptor and adjective when your default is to understand and think about the system implications of things.

[00:09:13] The immune as we understand the role of immunology in pretty much all biology.

[00:09:18] So there's this new data set called the equity, equity in tech.

[00:09:23] Prescription poop.

[00:09:25] That's this whole gut microbiome.

[00:09:27] And for people with IBS, you transplant poop from one healthy person to the other.

[00:09:31] So it's called prescription poop.

[00:09:34] Gymtimidation when you go to the gym.

[00:09:37] Anyway, I've got thousands of them.

[00:09:39] I should write a blog about them.

[00:09:42] So I think they're fun for just, again, your brain just shifts a little.

[00:09:46] And I think that's how we start the process of new mindset.

[00:09:50] If we go from mindset to care delivery, as it is currently still called, what are some of your favorite examples of how technology is reshaping care delivery and aiding the pressing needs?

[00:10:04] I know that you like to call yourself a realist, not a futurist.

[00:10:08] So what are some of the things that do inspire you and you already noticed in clinical practice?

[00:10:15] There is so much.

[00:10:17] I'm reading and scanning probably like you, Tasha, every day.

[00:10:20] And then my mind gets blown repeatedly, sometimes in a day.

[00:10:25] The two that I get excited about right now fall into two camps.

[00:10:28] I think one is a set of technologies that are just democratizing access or at least closing the gap of access.

[00:10:36] So given demand far exceeds supply, a lot of people are waiting months, hours, years for stuff they should have available to them because they pay for it.

[00:10:46] But it's just not available because we have such a labor intensive model.

[00:10:50] We did last five minutes without saying the word, but AI that literally just gives back what I call pajama time to clinicians and just gives them back minutes, if not hours in a week to spend on doing whatever they need to fill up their cup or to give better care.

[00:11:09] Those get me really excited.

[00:11:10] It's low hanging fruit of cognitive tasks getting replaced by a machine or making your ability to do those cognitive tasks extremely faster.

[00:11:19] So call them scribes, any of these AI co-workers called co-bots.

[00:11:25] I like all those applications for many clinical contexts.

[00:11:29] And then the other big area is, okay, imagine we fill the access problems and everyone has what they need when they need it.

[00:11:37] But the quality of that care is much subpar than it should be because it's been unintelligent today and very crude and very analog and very set on industrial era models of care.

[00:11:49] So technologies that are making when care happens, it way better than the old way.

[00:11:56] And that's why I look at virtual reality.

[00:11:58] I just think it's finally popping in terms of a digital tool that can achieve what its current clinical counterpart does better, smarter, faster, and cheaper.

[00:12:11] And the metaverse or the medical metaverse and all those applications for things like pain management, anxiety, those kinds of things.

[00:12:23] I'm really liking what I'm seeing in those areas.

[00:12:27] So AI and VR.

[00:12:28] I must say that for a long time, I was fascinated to learn what VR is used for in healthcare.

[00:12:35] But when it comes to medical education, I never really quite grasped how is this better than the other ways.

[00:12:43] Is it just a more fancy way of learning?

[00:12:46] So it was super interesting at HIMSS Europe when we heard a presentation about this app that's still available online.

[00:12:54] So I think you can access it where you basically get into a VR set to drill yourself on what happens if the airplane has some sort of an emergency or there's a crash happening on the airplane.

[00:13:08] And if you fly often, you just never listen to those instructions that they give you.

[00:13:16] And many people don't really know how to react if something actually happens.

[00:13:22] But when you train yourself in VR, when you actually feel that experience, the memorization is so much better.

[00:13:31] That kind of explains to me how this is better in practice.

[00:13:36] If we go from the low-hanging fruits to more difficult things, which are related to policy and systemic changes,

[00:13:46] telemedicine subsided after the pandemic more than we hoped it would in 2020 or 2021.

[00:13:53] But what did change is this shift toward virtual wards or moving into home care, doing more things at the patient's home.

[00:14:03] And when you were still in one of your previous positions working in home care with CE Health,

[00:14:08] you were one of the first ones that provided at-home chemotherapy.

[00:14:13] I was hoping that you could go back in history a little bit and share how you made that happen.

[00:14:20] Because I imagine for such procedures, somebody would say it's not safe enough.

[00:14:26] Then the big problem would be how is this going to be reimbursed?

[00:14:29] Who's going to be paid?

[00:14:30] How is the payment going to be made?

[00:14:33] So how did you tackle all those challenges?

[00:14:35] Can you take us through some steps of what you still remember?

[00:14:39] Yeah, so let's start.

[00:14:40] Let's add to our list of what I think should be words we sunset.

[00:14:44] I think telemedicine, right?

[00:14:46] Because again, it locks our brain into the modality of the day.

[00:14:51] When we invented this word, it was the telephone.

[00:14:54] Just like you weren't born yet, Tasha.

[00:14:56] But back in the day, if you went to work but you weren't at work, it was called telecommuting,

[00:15:01] believe it or not.

[00:15:01] We don't talk about telecommuting anymore.

[00:15:04] We talk about maybe remote work.

[00:15:05] So I just think telemedicine, again, still implies it's really the same care.

[00:15:10] You've just separated place from care and you've done it over telephone.

[00:15:16] Whereas the idea of care at home or care anywhere, it's not just decoupling place from the exact

[00:15:24] same business model, care model, payment model, et cetera.

[00:15:27] First of all, virtual care decouples place and often time.

[00:15:34] So virtual care is care agnostic to place and or time, which is where you get your asynchronous.

[00:15:40] Because when you're still making virtual care or telemedicine be about a clinician and a patient

[00:15:47] at the same time, you're still now still time sharing in a labor intensive visit based model.

[00:15:52] And if we don't emancipate from that, we will not modernize health care.

[00:15:56] So I'll say that.

[00:15:57] Going back to SE Health, 118 year old nonprofit health charity in seniors care and home care.

[00:16:04] Yeah, we were the first in Canada, at least, to do at home chemotherapy more than 50 years ago.

[00:16:10] It's still not the standard of care, though.

[00:16:13] The standard of care is you make these poor patients who have cancer drive to the big city

[00:16:17] and do their chemo one, two times a month, sometimes a few times a week.

[00:16:23] So it's a very minor use case, very similar to dialysis.

[00:16:27] The evidence shows that about 40% of hemodialysis could be done at home, but only about 5% is.

[00:16:34] Because the business model is locked into a hospital-based or clinic-based dialysis.

[00:16:40] That's the same with chemo.

[00:16:41] It does not need to be done at a clinic.

[00:16:43] So when we did it, I think in general, even these virtual wards, care at home, all these movements,

[00:16:50] unfortunately, I would say they're happening because there's a business driver driven by

[00:16:56] the entity that wants to capture the value.

[00:16:59] So for a hospital, you imagine if you're an urban area, you can't grow.

[00:17:03] You can't build another wing.

[00:17:04] Your economics of running your operations are very poor because they're extremely inefficient

[00:17:09] organizations.

[00:17:10] So most are running at a deficit.

[00:17:12] So you're looking for ways to still deliver on mission because that's your contract with

[00:17:16] society that when people are sick, you're going to take care of them.

[00:17:19] So it's an asset-light model to take it out into the home because now distance isn't a constraint.

[00:17:27] It's not really being done primarily for the purpose of creating a better value care,

[00:17:33] better experience of the patient.

[00:17:34] It's really because the business model doesn't work.

[00:17:37] And in the U.S., it's a growth reason.

[00:17:39] They need revenue.

[00:17:41] And if you're in four walls, you can't grow.

[00:17:43] So you grow by growing into the community.

[00:17:45] So because that's the driver, if you don't have a business imperative, it's not going to happen.

[00:17:51] And I think until we obsess about creating an experience for patients that meets their needs

[00:18:00] before the hospital, then we're not going to have it at scale.

[00:18:04] One thing that I am curious, so when we talk about these at-home applications of medications,

[00:18:10] especially dialysis, do patients have anything to say in these decisions?

[00:18:15] So, for example, can they buy their own devices and then do the dialysis at home?

[00:18:21] What are the factors that impact who has access and who doesn't?

[00:18:24] Yeah.

[00:18:25] So first of all, anything that is this concept of care anywhere,

[00:18:29] it's always you have to add for those who are able and those who want it.

[00:18:34] Some people, even with home dialysis, because we used to also do home dialysis,

[00:18:38] they didn't want it, even if the technology was available and it makes their life easier.

[00:18:43] Because for them, they actually loved coming to the hospital four times a week

[00:18:48] because they said, I feel like somebody's caring for me for those few hours.

[00:18:52] Great.

[00:18:53] Great.

[00:18:53] But don't deny it from the people who do want it,

[00:18:56] who don't have a car to drive to your hospital four times a week,

[00:19:00] who don't have a caregiver to take time off work.

[00:19:03] So that's just one.

[00:19:04] Then the next is, is it available at a cost that's acceptable to society?

[00:19:08] Is there a payment model that works?

[00:19:10] So sometimes the technology isn't available,

[00:19:13] either because there is no payment model for it.

[00:19:16] That's the case with a lot of remote monitoring in some jurisdictions.

[00:19:20] In the case of home dialysis, there is a payment model for it.

[00:19:25] But the other barrier is electricity is expensive in my house and water.

[00:19:29] You need good quality water to go through the machine in the home.

[00:19:34] And that's a barrier for some people.

[00:19:36] Stairs are a barrier because you have to carry this thing up and down some stairs.

[00:19:40] So there's many reasons why creating hospital at home or some of these modalities at home

[00:19:45] is not feasible, either because the patient doesn't want it,

[00:19:49] it doesn't meet their needs appropriately, or it can't happen for a bunch of barriers.

[00:19:53] But that doesn't mean it's not available for a lot of people.

[00:19:57] And I think that's what I was trying to push in my platform as the futurist in this large home care

[00:20:03] organization is how do we create business models for pretty much anything at home,

[00:20:09] including, by the way, surgery at home, radiology imaging at home, ICU at home,

[00:20:14] almost anything that work for the people who want it.

[00:20:18] And then instead of by default making the good care being the facility-based care

[00:20:24] and the scraps going to the home.

[00:20:27] As someone with experience in redefining how we can reshape how to age well,

[00:20:33] you also co-authored a book on this topic.

[00:20:36] What do you expect will happen to care homes in the future

[00:20:40] if we actually transition to life care instead of medical care?

[00:20:43] Because one thing I'm always skeptical about when it comes to technology aiding aging

[00:20:49] is that even if you have a device that detects falls,

[00:20:53] if there's nobody that can come to help you,

[00:20:57] so if my parents live on the other side of the ocean because I moved,

[00:21:02] that information doesn't really help me much.

[00:21:06] I think we have to be careful to not automatically equate aging in place

[00:21:11] or aging in the place of choice.

[00:21:13] With technology.

[00:21:15] Technology is coming at a fast pace.

[00:21:17] As we wrote a whole chapter of this in the book,

[00:21:20] The Future of Aging, called Geron Technology.

[00:21:22] That's another one of the fancy words.

[00:21:24] It's allowing us to do things we literally just couldn't do before.

[00:21:27] Just like for everything in our life, we can do things we couldn't do before.

[00:21:32] But let's go no tech or low tech.

[00:21:34] There are models where you age in the place of your choice without having to be warehoused

[00:21:40] in a nursing home or what you call a care home.

[00:21:43] In Canada, we call them long-term care homes.

[00:21:46] That is already the model in Denmark.

[00:21:48] That's already the model in Japan, which confronted an aging society 15 years ahead of the rest of us.

[00:21:53] Right?

[00:21:54] They've been in the super-agent category.

[00:21:56] So there are ways to do it that are not about tech.

[00:21:59] It's just about creating care models in the community instead of warehousing and facility-based care.

[00:22:06] The parallel, Tasha, would be mental health.

[00:22:09] Where did we used to put people who had a mental illness?

[00:22:12] In an asylum or a sanatorium.

[00:22:15] Right?

[00:22:16] We warehoused them in buildings.

[00:22:18] Those are all gone now.

[00:22:20] Other than for the very, very extreme people with psychosis who don't have any supports in the community.

[00:22:26] We will not have to put old people in buildings as the default setting.

[00:22:32] For some people, again, they're going to prefer it.

[00:22:34] Maybe they have no family.

[00:22:35] They need that level of care.

[00:22:37] Absolutely.

[00:22:38] But depending on the study, 20 to 30% of who's currently in a nursing home does not need to be in a nursing home at all from a clinical capacity.

[00:22:48] One thing that I really liked as an idea in the book is the idea of communities or various old people living together and helping each other out, which made sense.

[00:23:01] It's like a peer group, like college people living together.

[00:23:04] But then again, the older you get, the more you appreciate this living alone.

[00:23:10] And it was super interesting for me to hear when I talked to an American company that's trying to ease aging and create companionship.

[00:23:19] And the speaker I spoke with said that this kind of independence is a very strong American value.

[00:23:27] So this cultural context is super important to why people would not be interested in going in this sort of community care.

[00:23:36] I don't know.

[00:23:37] Any comments on that?

[00:23:39] I would just say much like our default setting is to create a perception that older adults is one mono segment.

[00:23:51] This monolith, just like all women.

[00:23:54] It's just not true.

[00:23:55] So everything is a segmentation.

[00:23:58] So that's not even I don't think that's true that it's the American.

[00:24:01] There's a segment of American older adults who want to be on their own.

[00:24:04] There's a segment everywhere.

[00:24:05] And then there's a segment that wants to be co-housed.

[00:24:08] There's a segment that want intergenerational living.

[00:24:12] There's a segment that want to be in a nursing home.

[00:24:14] They love the nursing home.

[00:24:16] There's nothing wrong.

[00:24:17] So I just think this is a new skill set in all of health care is micro segmentation or at least some level of segmentation.

[00:24:28] It's not binary and nothing is one size fits all, which means then we need a stock of housing models that meet this mix of needs.

[00:24:36] Well, when one in five North Americans will be over 65 this year, it's the first time.

[00:24:42] That's 20% of the population.

[00:24:44] There is lots of room for lots of models.

[00:24:47] I know that you have to run in five minutes, but I do want to touch upon a practical thing as well.

[00:24:55] So when we talk about changes in health care and changing systems, you also work as a consultant and have designed organization models.

[00:25:07] So what's your advice?

[00:25:08] What steps can health care organization take to improve their organization and efficiency?

[00:25:13] What's a better way to doing things to the current way that things are done?

[00:25:19] Look, just quickly, because this could be a seven year podcast.

[00:25:23] My answer to this question, because that's what all of us have been working on hundreds of hours a year.

[00:25:28] Two things.

[00:25:29] One, be obsessed about creating the future you want instead of protecting the past.

[00:25:37] Okay.

[00:25:38] Obsessed, which then means set a normative vision or view or be head big, hairy, audacious goal.

[00:25:45] Some statement of what you want to achieve for whoever, your people, your staff, your patients, a certain disease.

[00:25:52] I don't care, but, but bold based on evidence, but bold and then be very flexible of how you get there.

[00:26:00] Obsessed with the result, flexible with how you get there.

[00:26:03] So that's one.

[00:26:04] Two then is self-impose on yourself, your org, accountability mechanisms where you call that pay for results.

[00:26:14] Outcomes based payments where, you know, your ability to get paid for whatever you do is contingent on delivering the results you said you want to deliver versus getting paid for procedures and services no matter what.

[00:26:27] You can do that forever.

[00:26:29] That's what we've been doing.

[00:26:30] We really don't know the value of what we spend trillions of dollars on in health care.

[00:26:34] But as a leader of an organization, be bold about an outcome you want for your population or your staff or whatever you want and be a leader in having some contingencies on your ability to get paid based on results.

[00:26:49] I think if we had more organizations that use that as their organizing system, I think we'd have a very different ecosystem for our patients right now.

[00:27:00] One last one.

[00:27:01] So outcome based payments and outcomes based care is the premise of value based care.

[00:27:10] What are some of the good examples that you already saw in terms of how to make that happen?

[00:27:14] Because many organizations, countries still struggle with setting kind of the KPIs and measurements to what is value, defining value.

[00:27:24] So what did you see that seems as a good practice?

[00:27:29] Look, this has been talked about a lot and it's not easy because we've been stuck in a business model that's been on a let's call it fee for service.

[00:27:36] But there are ways to do it.

[00:27:38] I think the accountable care organizations in the U.S. is a great example.

[00:27:42] Now, the evidence will show at the end of the day was their value created or not.

[00:27:47] So I don't know that picking on the numbers is the answer.

[00:27:51] It's more of the mindset of we're here to deliver a result versus get paid for procedures.

[00:27:57] And when you do that, then it's in your DNA to always be looking that way.

[00:28:02] And there are lots of case studies published on small scales with medical device companies or pharma companies when it's about a procedure or a technology enabled care model of risk sharing, gain sharing that does work really well.

[00:28:16] And then sometimes on a whole system level or organizational level.

[00:28:20] But usually for a specific population that you can wrap your arms around instead of like for the whole organization.

[00:28:28] But I think it's there.

[00:28:30] And again, as now everything gets digitized, therefore all data will be the friction and the cost of acquisition of information to know if value got created.

[00:28:39] It's going to be lower and lower.

[00:28:40] So I think we're going to see these start to take off a lot more because we'll have real time intelligence of what's working and what's not.

[00:28:47] And we didn't have that before.

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[00:29:12] Stay tuned.