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Who ‘owns’ the healthcare consumer of the future?

Who ‘owns’ the healthcare consumer of the future? | Healthcare and Technology news | Scoop.it

CVS and Aetna are merging. Amazon, JPMorgan Chase, and Berkshire Hathaway are forming a joint venture aimed at reducing health care costs and improving outcomes. Cigna is acquiring Express Scripts. The proposed mergers promise a revolution that could fundamentally alter the current healthcare landscape and the relationships between providers and patients. With these giant corporations betting big on healthcare, a logical question to ask is: What’s behind it all?

 

The answer is simple: ownership of the healthcare consumer experience, and by extension, the consumer.

Digitalization and healthcare consumerism

In the past few years, Amazon has reshaped the relationship between consumers and marketers. It has forged itself into being the preferred destination for consumers seeking convenience. Now, imagine Amazon applying this power to the healthcare sector. The company already offers a wide range of the over-the-counter drugs in their health and wellness section. Going from there to selling prescription drugs is not a big step. However, that step could become a big leap in terms of the shift in consumer loyalties if consumers are provided the option to order their 90-day medication refill and have it delivered to their doorstep (maybe even by a drone).

 

Recognizing the threat, many health systems are taking measures to digitalize their relationships with consumers by focusing on something they have long neglected: convenience. Virtual visits and e-visits are now becoming commonplace. A young mother of three no longer has to bundle her kids into the car and drive an hour each way to her hospital for a routine follow-up that takes all of fifteen minutes in the physician's office. A senior citizen in a wheelchair on multiple chronic-care medications no longer needs to "check in" by getting physically to a physician's office. They can both do their visits through secure messaging, or if required, through a virtual real-time consultation.

 

The above is just one example of how digitalization could reshape relationships between consumers and providers.

Data, analytics, digital

Here is another scenario that is already starting to play out. Consider a patient with high blood pressure. Technology is enabling patient-generated health data (PGHD) from wearables and sensors that include blood pressure, heart rate, glucose levels, and medication adherence to be transmitted seamlessly into the patient’s electronic health record (EHR). The combined data is being analyzed for trends and insights and made available to everyone involved in that patient’s care, enabling care teams to manage the patient more effectively. The patient can still control who can see the information by following an e-consent process through an app right on the mobile device. If a patient opts to participate in clinical studies, that person can be matched automatically with relevant opportunities. Both the individual patient and the population improve their health outcomes as a result.

 

Data-driven advancements are arriving in the form of both precision medicine and healthcare consumerism. Advancements in precision medicine are expected as the relationship between data from wearables, sensors, social determinants and other emerging sources is better interpreted through advanced artificial intelligence (AI), and yielding better outcomes. We are in the early stages of a new push toward patient-centered, consumer-directed care that is demonstrating strong growth potential.

 

What we are also starting to see is some redistribution of the in-person visits between traditional providers and emerging ones. As an example, CVS and Aetna are betting that consumers may prefer to visit one of their many walk-in clinics for minor conditions instead of waiting to schedule an appointment with their primary care physician in the hospital down the road. Urgent care is already shifting out of hospitals, and in many cases, going virtual altogether. The rise of companies such as Teladoc and Doctor-on-demand is clear evidence of this.

Bricks and mortar is not going away

None of this suggests that the traditional healthcare setting is fading into obscurity. Health systems, especially those with strong brands in their local and regional markets, have an unassailable lead today as trusted healthcare partners in their communities. Many of them are already making big investments in digitalization programs that will enable consumers to get the best of both worlds, namely a virtual experience for routine healthcare and urgent care needs, and an in-patient experience for acute care needs. For a high-quality patient journey, these two worlds must be tightly integrated. Only traditional hospitals can provide that truly integrated experience today.

The future of healthcare consumerism is not an either/or

If Big Data’s relationship to precision medicine has been on a more or less predictable trajectory, the explosive growth of healthcare consumerism has opened up options for healthcare consumers seeking convenience in addition to the quality of care. The healthcare leaders of tomorrow will ideally sit at the intersection of these two critical aspects of healthcare delivery. A reputation built on high-quality care alone will no longer be enough; neither will a reputation for slick user interfaces and transactional convenience.

 

A friend, who is also the CIO of a large health system, recently suffered a heart attack during a race. As he felt it coming on, he wisely checked himself into the medical tent from where he was rushed to a nearby hospital. A stent was put into his chest that saved his life. Imagine a scenario where with the help of real-time, advanced analytics and AI technologies, his imminent heart attack could have been predicted. Imagine, too, if he had not had access to one of the most experienced and qualified cardiologists in the country to attend to him during the emergency. Digitalization can ensure that the cardiologist's knowledge, wisdom, and experience are still accessible no matter the current physical location of the patient.

 

Ownership of the healthcare consumer experience requires a mixture of convenience and quality enabled by a robust data and analytics capability. No one sits precisely at that happy intersection today. However, the race is already underway to get there.

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Digital health’s last mile problem

Digital health’s last mile problem | Healthcare and Technology news | Scoop.it

In my book, The Big Unlock, I describe the four major categories of technology providers as Custodians, Enablers, Arbitrageurs, and Innovators. Each of these categories of providers has staked a claim to reimagining the digital future of healthcare.

 

First, the Custodians: These are the big electronic health record (EHR) vendors like Epic and Cerner who have the data and the workflow. As systems of record, they enjoy the long-term strategic commitment of the health systems they serve and are the first port-of-call whenever a health system decides to enable new functionality for enhancing the patient and caregiver experience. 

Systems of record have certain limitations and are arguably weak in several areas, such as advanced analytics, which is critical for a digitally reimagined healthcare experience. Along came the Enablers to address this problem. Big technology firms such as Google, GE Healthcare, Microsoft, Salesforce and IBM’s Watson Health business have built technology stacks that integrate multiple emerging and traditional data sources, including EHR systems, and have incorporated some proprietary data sources as well, such as images in the case of GE Healthcare.

 

These big technology stacks include inbuilt advanced analytics capabilities that can deliver insights to power digital health experiences. Google’s Deep Mind, for instance, recently analyzed eye scans from over 125,000 patients to build an algorithm that could detect diabetic retinopathy, the number one cause of blindness in some parts of the world, with over 90 percent accuracy. The company claimed the accuracy of the analysis was on par with board-certified ophthalmologists.

 

The Arbitrageurs are mostly technology agnostic consulting firms such as Accenture and Deloitte, as well as India-heritage firms such as Wipro and Infosys, that rely on information and labor-arbitrage models to build digital experiences from scratch using the preferred technology tools that exist in health systems.

The Last Mile problem

All three categories of technology providers described above have stopped short of building ready-to-deploy digital health experiences, which leads us to the Last Mile problem in healthcare. Despite the powerful computing and data analytics infrastructure that big technology firms have invested in, there is a shortage of viable, proven digital health experiences for health systems and their key stakeholders in healthcare delivery i.e. patients and caregivers. The challenge – and the opportunity – has fallen to the fourth category of technology providers, namely the Innovators.

By definition, the Innovators are typically startups that have come up with a whole new way of addressing an existing problem with technology-enabled healthcare experiences, or for filling a gap in the current healthcare experience with technology. Digital health startups raised an estimated 11.5 billion in 2017, and money continues to pour into the sector, despite the slow pace of exits. Despite the promise, a report by IQVIA indicates that while over 318,000 health apps and 340 consumer wearable devices are now available worldwide, 85 percent of the apps had fewer than 5000 installs. The few apps that did reach critical mass demonstrated strong clinical evidence, robust integration with the established workflow integration, and high user ratings – prerequisites for any digital health solution looking to break into the health systems marketplace.

Addressing the bottleneck

The need for last mile applications is enormous, and yet the innovation ecosystem has not built and implemented viable applications fast enough and at scale to meet the demand. Common challenges include:

  • Extended cycles to hit prime time usage: most health systems follow a traditional approach that takes promising new solutions through the phases of a free pilot, paid pilot, and enterprise adoption. The process could take years, and many solutions remain in "pilot purgatory" for an extended period, often failing to break through to enterprise adoption. Health systems need a newer, more agile model, to assess and deploy promising solutions more quickly and efficiently
  • Too many standalone solutions: the digital health landscape is littered with thousands of point solutions that stand in isolation, with no established connectivity to systems of record which is the price of entry for any new solution. Health systems are loath to sign up dozens of point solutions and take on the burden of integrating and managing these solutions. They prefer to default to the many solutions that EHR vendors have built or are actively building (or claim to be building) that effectively make stand-alone solutions redundant, despite the superior experience architectures that startups are known for. A potential approach for startups is to align with one of the big Enabler companies who, through established relationships with health systems, can create a pathway to adoption and growth.
  • An absence of scale: No single platform addresses all the needs of a digital health enterprise today, unlike the mature enterprise resource planning (ERP) systems of the manufacturing and financial sectors. There is a significant opportunity for Enables companies to build ready-to-deploy innovation ecosystems through partnerships with digital health startups. However, Enabler platforms too have increased and are at risk of becoming too fragmented to present a real alternative to health systems looking for scale and velocity in the digital transformation journeys.

The digital transformation of healthcare is in its early stages, and the gold rush is underway. Wanted: creative approaches to solving the Last Mile problem and unifying the fragmented ecosystem of point solutions and stand-alone technology enablement platforms.

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Reimbursements red herring, trust, and key infrastructure needs for Telemedicine success  

Reimbursements red herring, trust, and key infrastructure needs for Telemedicine success   | Healthcare and Technology news | Scoop.it

Telemedicine is a growing part of modern healthcare and could play a pivotal role in the U.S.’s efforts to streamline and expand preventative services. Virtual, video-based doctor’s appointments can help alleviate the general practitioner shortage and encourage preventative care. They also offer a cheaper, more convenient alternative to in-person appointments for many patients. Unfortunately, there’s a lot of hype and misinformation being reported so I was pleased to see that TechnologyAdvice (TA) surveyed 504 U.S. adults about telemedicine and their willingness to use such services. I think the results shed important light on where healthcare providers and telemedicine vendors still need to gain acceptance with patients so I reached out to Cameron Graham, Managing Editor at TA to see if he can give us the facts on the ground. Cameron heads market research for healthcare IT, business intelligence, and other emerging technologies and is uniquely qualified to help shed some light on the subject. Here’s what Cameron said:

 

1. It’s not just about reimbursements

Despite the promise of telemedicine, the vast majority of Americans still aren’t using such services. One oft-cited reason for this is the lack of insurance reimbursement for many telemedicine procedures. While some private insurers will cover telemedicine, many only cover select types of visits or specific applications. Medicare, for instance, covers face-to-face interactions, but only when the originating site (point of care, not the patient’s home) is in a Health Professional Shortage Area (HPSA). Although coverage is slowly improving in many states, the American Telemedicine Association gives just five states (plus DC) an A grade in coverage and reimbursement.

 

However, the current hodgepodge of reimbursement rules is not the only thing holding back telemedicine from widespread use. An equally important factor is likely Americans general comfort with video-based platforms and their trust in remote appointments. According to our study, less than half of adults (44.9%) said they would be comfortable conducting a doctor’s appointment over video. Only 35.3% of respondents said they would choose a video appointment over an in-person one. Until patients are more comfortable with the notion of remote care, it is unlikely that telemedicine will gain significant traction.

 

In order to facilitate acceptance of telemedicine among Americans, providers and vendors need to work on educating patients about the benefits of such systems. Telemedicine vendors, in particular, should help patients navigate the complex reimbursement rules currently in place, and promote the cost-savings of remote appointments. By doing so they will not only gain brand awareness among patients but will be able to recruit patients as advocates for more comprehensive insurance reimbursement policies.

 

2. Trust is a key component of effective telemedicine

Americans are not only hesitant about scheduling telemedicine appointment, they are also sceptical about diagnoses made through video platforms. Forty-five per cent of respondents said they would trust a virtual diagnosis less than one made in person. An additional 29.3% said they simply would not trust a virtual diagnosis. This suggests there is a distinct lack of trust among Americans in the quality of medical services that telemedicine platforms can provide.

 

Much of this scepticism is likely due to a lack of familiarity with the services. It also reinforces the fact that telemedicine providers must earn patients trust before they can effectively increase adoption rates. Once that trust is established, it appears people are far more likely to consider using remote appointments. While initially, only 35.3% of respondents said they would choose a virtual appointment over an in-person visit, 65% of respondents said they would be more likely to conduct a virtual appointment if they have first seen the doctor in-person.

 

It’s unlikely that providers or vendors will be able to dramatically change such preferences given the personal nature of many medical visits. However, increased awareness about the qualifications of physicians could make potential patients more comfortable about conducting preventative care via video. Incorporating a rating system, or minimum quality threshold for participating physicians is one potential solution.

 

3. Personal and professional infrastructure is key

The personal infrastructure for telemedicine is already in place across much of the United States, in the form of video-enabled smartphones. According to the latest PEW research, 64% of Americans own a smartphone. In theory, this provides them with the basic means to access remote, video-based health care. Smartphones will likely serve as first means of exposure to such services for many people.

 

More advanced, capable systems (such as dedicated telemedicine kiosks) however are far from established. Aside from a few test programs in select areas, there is no nationwide, professional infrastructure or technology for telemedicine. This hinders adoption and limits the use of telemedicine to basic, preventative care that can be conducted entirely remotely. Dedicated kiosks can greatly expand the use-case for telemedicine, by incorporating sensors, multiple cameras, and other advanced technology. Further investment from telemedicine vendors and insurance companies could help to boost the nationwide profile of telemedical services and expand access for many Americans.

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Health IoT creates huge opportunities for public health and software companies 

Health IoT creates huge opportunities for public health and software companies  | Healthcare and Technology news | Scoop.it

Connecting smart biological sensors to the internet is not a new idea. There are already dozens of products in the market that continuously monitor blood glucose and heart function, for example, and enable secure remote management for clinicians and caretakers. The safety of life implications are enormous, and the commercial opportunities untold. Some analysts predict a $100 billion-plus market for the healthcare segment of the “internet of things” (IoT).

 

What is new and emerging is the physical scale of the devices on the one hand, and the need to aggregate, reconcile, and consolidate those data streams for downstream clinical care services. Advances in semiconductor device manufacturing will relentlessly drive down the price and the size of these electrophysiological sensors, literally to the nanometer scale, which will ultimately be able to do more than detect, they will be able to intervene. At the same time, our ability to make sense of the torrents of information is catching up to our ability to create them.

We believe that these are tremendous opportunities for public health and software companies like ours. It is why we are investing so much of our own resources to promote the open design, secure exchange, and value-added analysis of health data systems. Perhaps the largest inhibitor to a promising future of longer, healthier, less expensive life are the software merchants and device manufacturers who still and astonishingly insist on keeping data closed, isolated, and trapped in proprietary systems. We believe this is about to change too.

 

The interoperability troubles with electronic medical records are legion, and we won’t waste our page space or your attention lamenting the deeply ignorant and the nearly criminal. The immortal words of Forest Gump’s assessment about doing dumb things find purchase here.

 

What we can do, however, is find clever ways leverage of IoT as yet-another, and maybe decisive, the fulcrum of connected care. For what is today true in isolation – progressive plans, concerned parents, engaged patients – will soon-enough be more the ubiquitous standard of coordinated care; that coordination will reach deeply into pocketbooks as well as bodies.

We know that there are legitimate concerns about individual privacy and device safety and that some people would literally rather die than compromise on either. We respect that, even as we actively promote more automation and digital services in health care.

 

Some of us believe that the existential benefits of independence and longevity outweigh the potential risks of intrusion and malfunction, some of us don’t. The point is that everyone should have the choice and that no one should be coerced or manipulated into choosing one side of the argument. Fear mongering (about privacy) and fabrication (about intrusion) are forms of manipulation. In the case of health care, they cost lives and money.

 

Let’s, instead, imagine a world of seamless, secure, and reliable health data interoperability. Let’s find a better way to safely liberate data at its source – labs, pharmacies, hospital and clinics, insurance claims, as well as implantable and wearable devices – pass it through hygienically sealed pipes, and receive it in places where it does the most good. That may be during a clinical care or remote telemedical encounter (to give you the best possible advice based on evidence and your personal health history), it may be when you pick up your medicines (to check for interactions with other medicines), or it may be to help your insurance company help you (because they have always had a bird’s eye view of your services, and they can’t kick you out for pre-existing conditions anymore).

 

Because of changes in the law, it may be with a loved one or trusted caretaker. It may be you.

The data could be as simple as a reminder message about an upcoming appointment, a warning message that a clinical value seems out of range, or an answer to a securely-texted question to your doctor. We have imagined that future and it is, as Ray Kurzweil likes to say, near.

 

There are two challenges, and they are slowly receding.

The first is that the data holders are still reluctant to share, even though it isn’t “their” data.  This will become less of a problem, as forward-looking providers like VA and DoD have shown, as well as payers like CMS, Aetna, and HCSC among many others have demonstrated.  All are outspoken supporters of the Blue Button program, now in its fifth year, and still growing.

 

The second falls squarely on our shoulders:  we need to make the user experience attractive, convenient, and useful.  The health IT community has made terrific strides recently – we-two have worked on the InCircleand a soon-to-be-announced medication management app, for example –  and there are many companies that target data-driven patient-provider interactions, including AmericanWell and covers health.

 

The beautiful thing is that IoT fits so neatly into this conversation. The goal, of course, is to help us achieve our best-possible health. The best way to do this is with data. And the best data is coming at us in ever more granular packages, from patient-hosted sensors that monitor, detect, interact, and intervene. Weaving those into the tapestry of your personal health history is the next vanguard of coordinated and managed care.

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mHealth Scores High With Consumers in Boosting Medication Adherence 

mHealth Scores High With Consumers in Boosting Medication Adherence  | Healthcare and Technology news | Scoop.it

Consumers are looking to mobile health tools, such as mHealth apps and wearables, to improve their medication adherence.

A recent study of some 800 prescription medication users, conducted by Russell Research for Express Scripts, finds that roughly half believe mHealth technology would help them become more adherent – and one-third of those would be more likely to use them if the tools were set up for them.

 

With experts suggesting at least half of the nation’s medication users aren’t taking their drugs as prescribed – costing some $300 billion a year in avoidable healthcare expenses, or $1,000 per person – medication adherence is a significant issue and one that healthcare experts have vowed to tackle more aggressively.

“This survey shows that while patients with chronic diseases know that medication is critical to their treatment and health, they don’t always act on that knowledge,” Snezana Mahon, PharmD, vice president of St. Louis-based Express Scripts Clinical Solutions, said in a press release. “Given the huge cost of nonadherence to an individual patient’s health, as well as to the country as a whole, it’s essential for patients and clinicians to work together to find solutions to help overcome barriers to adherence.”

Those taking medications would seem to agree. Almost half of those surveyed said taking their drugs as prescribed is the most important part of their health regimen, a percentage higher than those selecting a routine check-up (30 percent).

And they seem interested in improving their habits: 56 percent said reminders would more likely help them improve adherence, and 19 percent said those reminders would definitely help them.

That’s where mHealth comes in.

 

“The three main drivers of non-adherence come from cost, clinical or behavioral reasons,” said Kyle Amelung, PharmD, BCPS, a senior clinical consultant on Express Scripts. “All three can be solved for through mobile health tools.”

 

Younger consumers are particularly interested in mobile health technology: 74 percent of those between the ages of 18 and 34 believe such tools would help them, and half would be more likely to use the technology if it was set up for them. Among those age 35-54, the percentages were 62 and 46, respectively.

 

“We believe success comes from getting within the patient’s flow and reminding them about their health when and how the patient prefers,” Amelung said. “Most people view mobile devices as a personal productivity tool that can be used to check the news, connect with friends or get the score of the game. Incorporating these devices into taking better care of yourself is a logical position – but people still don’t want to be ‘nagged’ by family or friends about their health.”

 

That point was also made in the survey: 27 percent said they would most not want to be reminded to take their medications by a health device, while 40 percent said a spouse or partner would be most bothersome and 31 percent said the same of a friend. In each case, respondents felt that they’d be nagged by those prods and end up resenting the reminders.

Amelung emphasized that mHealth alone won’t solve the medication adherence issue.

 

“The key to mHealth tools is partnering them with a live clinician that can oversee the data, flag high-risk patients, and intervene as appropriate,” he said. “Technology is not the solution; technology is the means to an effective solution. To truly affect change, any proposed solution must be partnered with live clinical support to answer any questions and provide specialized guidance to the patient.”

 

The survey also shed some interesting light on prescription habits.

More than half of those surveyed feel they’re doing better at sticking to their prescriptions than others – including 60 percent of seniors. And more respondents were unconcerned about missing a medication (31 percent) than were extremely or very concerned (29 percent).

 

Among other results:

  • 67 percent would be motivated by a reward to take their medications as prescribed.
  • 82 percent would be motivated to take their medications by a financial reward, while 15 percent chose points toward a merchandise purchase and 3 percent selected a charitable contribution.
  • Only 33 percent understand the financial significance of medication adherence; 35 percent believe the annual cost to healthcare runs about $150 billion (or $500 per person), while 19 percent put that figure at $25 billion ($75 per person) and 12 percent said the cost was around $8.3 billion, or $25 per person.
  • 44 percent cited side effects as the primary reason for not taking medications as prescribed; 28 percent picked inconvenience and 21 percent said they stopped taking their drugs because they were feeling better and felt they didn’t need to continue the prescription.

Amelung said some of the survey’s results surprised him.

“One of the most surprising findings was that two-thirds of those polled say they are more likely to take better care of their health and adhere to their medications when rewarded for their efforts,” he noted.  “We all want to be in optimal health, but this data point supports the long-standing belief that only the potential of better health outcomes is not sufficient in getting patients to make the best decisions and take the appropriate actions for their health.”

“In today’s world, the distractions of the moment often get in the way of pursuing what’s in the best interest of our care. We sometimes forgo scheduling or keeping doctor appointments. We skip necessary lab tests or our annual flu shot. Many of us forget to refill our medication or we don’t remember to take it every day.  … For most of us, engaging in the right daily behaviors to improve our health is a challenge because these actions fall out of our normal routines and habits – and so, we skip them. Knowing that there must be something more for the patient to obtain and that financial rewards are an effective way to motivate patients, we can offer specific carrots to incentivize healthier actions and lead to decrease costs in the healthcare system.”

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Empowering Patients through Decentralized Information Governance 

Empowering Patients through Decentralized Information Governance  | Healthcare and Technology news | Scoop.it

Health care will be transformed if we empower patients and physicians through access to information. Don Rucker is right to focus attention on APIs to enable the transformation. A year and a half into the new administration and the massively bipartisan 21st Century Cures Act, the Department of Health and Human Services (HHS) is having to navigate between the shoals of highly unpopular Meaningful Use regulations and the apparent need for regulation to undo the damage of market consolidation that they caused. From my perspective, it looks like HHS is doing a good job.

Prediction is a dangerous game but it’s necessary for investments that depend on health information technology. Nowadays, pretty much everything in healthcare depends on information technology, particularly if we need effective quality measures to enable transition to value-based healthcare.

Based on Verma’s most recent remarks, it’s safe to predict that HHS will use the power of the $900 Billion purse as a way of avoiding regulation as it tries to break down the oligopoly of the consolidated “integrated delivery networks” and their even more consolidated EHR vendors. What’s more interesting is to anticipate how Rucker’s recent remarks about Persistent Access will be translated into decision support information for patients and physicians that will actually drive the practice innovation Verma is talking about.

 

Today, the information available to physicians and patients at the point of care is centrally governed by hospitals and by EHR vendors. A service seeking to present a piece of information such as therapeutic alternatives, quality ratings, out-of-pocket expenses, and research or clinical trials opportunities, must run a gauntlet of censorship by both the hospital and the EHR vendor. A thoughtful paper on how preemptive genomic testing has significant impact on subsequent treatment decisions shows the evolving connection between medical science and information governance.

The barriers to providing independent decision support when it matters most, during the physician-patient encounter, are immense. Let’s list some of them.

An independent information service

  • Must be “certified” by the hospital even if a particular physician wants to get it
  • Must be “certified” by the EHR vendor before it’s even accessible to the hospital certifiers
  • Involves up-front certification costs that are incompatible with open source or other non-profit information sources
  • Can’t access the complete patient’s record in the EHR
  • Requires the physician to sign-in to a separate system with a separate password
  • Is not covered by insurance, or, if covered, is subject to pre-certification delays that the physician won’t put up with
  • Is unaffordable because each EHR and each hospital presents a different integration challengecan’t get investors because the EHR vendors will demand unspecified rent on access to the physician-patie t relationship or, in many cases, actually demand access to the intellectual property itself.

The task ahead for HHS is formidable. Regulation that drives patient empowerment at the point of care (when the physician is about to sign that order that drives $3.5 Trillion of healthcare costs) is inconceivable under the US healthcare system and out of reach for even the nationalized health systems in other rich countries. The proprietary EHR vendor business model means EHRs must control the “app store” as the driver of future growth. Separately, the Accountable Care Organization business model for hospitals drives them to control their physicians and restrict access to “out-of-network” providers regardless of what’s best for a particular patient.

But there is hope, particularly if CMS, ONC, and maybe even the VA orchestrate their actions. The hope lies in the upcoming definition of “information blocking” as mandated by 21stC Cures.

HHS can and should define information blocking in terms of independent decision support at the point of care.

Access to independent decision support at the point of care is an outcome rather than a process. It’s easy to tell if it’s blocked without resort to heavy-handed regulation of the API technology. No new legislation is required because HIPAA, HITECH, and 21stC Cures already enable patient-directed information sharing via API at no significant cost. Patient-directed APIs are also directly accessible to the physician, subject to patient consent.

Technically, what’s required is that *every* API of an EHR be supported as a patient-directed API. That’s not much to ask since the EHR vendors are already building the APIs to use in the app stores they need to stay competitive. What’s also required is what Rucker calls Persistent Access which is what FHIR calls Refresh Tokens and is already widely implemented in the Apple Health APIs. Finally, what’s needed is the ability for a patient to direct information anywhere we choose, without censorship or delay, via the API. (Note that patient-directed exchange is different from patient access rights that require information to flow through personal health records. PHRs have largely failed in the marketplace.) Under HIPAA, patients have this right to patient-directed use for in-person requests to send patient records using paper forms, but this right to uncensored patient-directed exchange needs to be made accessible via the patient portal and linked to the FHIR API. The technical term for this is Dynamic Client Registration and it’s a unimplemented security capability of the FHIR API.

Patient-directed APIs can impact the physician-patient encounter in real time when one or both parties have a smartphone, although ideally the independent decision support will also be available in the EHR as long as the physician and the patient approve.

I’m calling this prescription for empowering patients Decentralized Information Governance. It’s completely consistent with both Verma’s and Rucker’s vision. Because it’s also consistent with current law, it can be implemented by Medicare, Medicaid, VA, and All of US immediately by joining the Health Relationship Trust (HEART) workgroup and implementing our profiles in the VA BlueButton 2.0 and CMS MyHealthEData projects.

The key is for all of us to reject calls for centralized governance of information services by government, academic hospitals, or global corporations (Facebook, Google, etc…) that have all proved resistant to regulation in the digital age. We must also reject the idea that new information governance bureaucracies like DirectTrust, or CARIN Alliance, or some government-controlled Recognized Coordinating Entity can be invented to ensure that our incredibly valuable health information drives open medical science. Decentralized information governance explicitly gives each patient the power to choose which patient interest groups, community organizations, or congregations one trusts to control access to his or her health records for both clinical and research uses.

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How blockchain can address the two biggest challenges in healthcare IT

How blockchain can address the two biggest challenges in healthcare IT | Healthcare and Technology news | Scoop.it

A recent study on blockchain adoption in health care by Blackbook Market Research indicated that a large percentage of payers surveyed, and a small but growing percentage of providers, were either considering deploying or were in the process of implementing, some blockchain solution sets. Blockchain appears to have moved from the awareness and education phase to actual deployment of solutions.

 

“Blockchain can solve two of the biggest problems in health care today," says Lidia Fonseca, CIO of Quest Diagnostics, a leader in lab testing services. She is referring to the gnarly issues of interoperability and data quality. While data quality has long been an issue in health care, the interoperability challenge is a legacy of the massive digitization of patient medical records over the past eight years which have left us with proprietary electronic health record (EHR) systems that don't "talk" to one another. The result is inefficiency and waste, as stand-alone information systems slow down processes and create redundant work. 

Taking a look at the healthcare blockchain pioneers

Some technology solution providers, including IBM and Change health care, along with a number of other companies listed in the Blackbook Research study, have made initial moves in establishing blockchain capabilities and launching solutions. Federal agencies such as FDA and CDC have expressed interest in applying blockchain to find solutions for public health issues.

 

Amazon, with its long-awaited entry into health care, recently announced the launch of blockchain templates for health care, aimed at making it easier for developers to create blockchain-based projects and deploy blockchain networks via open source frameworks. In a sense, Amazon has started the democratization of the blockchain-enabled application development, something we saw before with machine learning algorithms in the wake of the big data and analytics hype a few years ago.

 

A group of large healthcare enterprises, including large payers such as Humana and United Health Group (UHG), along with Quest Diagnostics, UHG subsidiary Optum, and Multiplan Health recently came together to launch a blockchain pilot program to solve for one of the most significant data challenges in health care today – provider data management. Provider data, a fundamental enabler for all manner of healthcare transactions, is a key building block for processing claims and maintaining up-to-date provider directories. Today, most provider data is stored in siloed and independent databases. Provider data quality is estimated to be a $2.1 billion problem today, according to a report by CAHQ, a non-profit alliance focused on creating shared initiatives to streamline the business of health care. By streamlining the inefficiencies in provider data maintenance, participants can have a "single source of truth." It is estimated that up to 75 percent of provider data management costs can be eliminated using blockchain solutions.

What it will take for blockchain initiatives to succeed

While blockchain is coming of age in health care, we’re still in the early stages of the hype cycle for blockchain. The initial mania around bitcoin, the very first use case for blockchain, is now giving way to more carefully considered use cases for business with tangible benefits. Healthcare, a sector that generally lags in the adoption of technologies, is currently in a wait-and-watch mode; notwithstanding the high levels of interest among payer organizations, the Blackbook survey also points to low levels of interest among health systems, citing the undetermined cost of blockchain solutions as the major issue that stops health system executives from committing to a timeframe for deploying the technology. Our best hope is that the early pilots will bring tangible proof points and provide more confidence to the industry in the technology.

 

Health care is a team sport and so is blockchain. The more participants there are in a blockchain network, the better it is for the network and the industry. Pilot programs such as the provider data management initiative by Quest Diagnostics and others will need a much higher level of participation across the industry to reap the benefits of the network effects.

 

As with most transformative technologies, the big challenge is usually not the technology; it’s managing culture and workflow changes, driving collaboration, and an execution focus. In blockchain, there is an added dimension of a commitment and willingness to work across company boundaries, which is an entirely new paradigm for most health care enterprises.

In a unique development, a group of health care industry executives has come together to launch a peer-reviewed blockchain journal to share both the positive and the negative experiences with blockchain in health care.

 

The potential for blockchain to improve health care operating efficiencies is significant. High-value use cases include revenue cycle management, supply chain, clinical trials, and provider data management. The initial pilots will need to demonstrate the real benefits of the technology and lead to higher adoption of blockchain in the coming year.  

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No dilemma for innovators in healthcare

No dilemma for innovators in healthcare | Healthcare and Technology news | Scoop.it

The big trends in healthcare today are rising consumerism, a shift to value-based care, emerging data sources, and the use of advanced technologies for improving care delivery and reducing costs. There is unprecedented innovation opportunity in the digital transformation of healthcare.

 

At a recent industry event, I moderated a panel discussion on innovations in health care with a group of technology innovators and healthcare veterans. We all agreed that technology-led innovation was accelerating rapidly, but the innovation landscape had a set of unique challenges as well. In this post, I share some of the key thoughts from the discussion.

The market landscape for healthcare innovation

In the past few years, we have seen several significant changes in the market for technology-led innovation in health care. Here are some important trends.

 

  • A shift towards the virtualization of health care. Many routine health care services are now available on your smartphone – a perfect example would be urgent care visits or routine consultations. According to one report, there are over 300,000 health apps in the Apple and Android stores. However, only a small number have reached critical mass, indicating that consumer preferences for virtual care are changing slowly.
  • Huge amounts of venture capital pouring into digital health: $11.5 billion in 2017, according to one report. The first quarter of 2018 has seen continued investments in digital health, serving as a validation of the promise of digital health innovation and the opportunities in the digital transformation in health care. At the same time, many of these startups are struggling, exits are not keeping pace with expectations, and a few that have raised very large amounts of money, such as Outcome Health, have gotten into trouble for trying to find short-cuts to growth and profitability.
  • Innovations from big technology firms are also struggling to gain traction. Recent troubles at IBM’s Watson Health business which has reportedly laid off significant numbers of employees in the face of market and organizational challenges indicate a deeper problem for the business model itself.
  • New data sources such as genomics, wearables and social determinants are driving a whole new way of managing patient populations. Unstructured data, such as clinical notes, is now the new goldmine that people are digging into, with the help of emerging technologies such as AI. Other emerging technologies, like blockchain, are still in early stages but with great potential. However, data interoperability, especially with the big electronic health record (HER) systems like Epic and Cerner, remains a challenge.
  • We are in the early stages of breakthroughs such as gene-editing with CRISPR (powered by massive data analytics capabilities) that are likely to transform healthcare, along with an explosion in smart sensors and wearables. Other technologies, such as augmented reality (AR) and virtual reality (VR) are in very early stages but show enormous potential in transforming the way healthcare is delivered in the future.

Health care’s innovation focus and the players

A recent survey by Modern Healthcare indicates that health care consumerism is the no. 1 area for innovations, followed by clinical practice, or care delivery, and payment reform or alternate payment models. Most respondents in the survey felt that innovation was accelerating.

 

Data from Rock Health, a venture capital (VC) firm, lines up with the survey responses. While disease diagnosis and treatment remain significant focus areas, consumer empowerment is emerging as a strong funding category, confirming the rise of consumerism in health care. As healthcare shifts progressively away to virtual care delivery models, interest in telemedicine, remote monitoring, and alternate care delivery models continue to drive innovation.

 

It’s not just VC firms that are funding and driving technology-led innovation in health care. We are seeing health systems getting into the innovation game themselves by setting up funds.

 

Examples include Partners Healthcare, UPMC, Intermountain and Mayo Clinic, to name a few. While these funds are relatively small, the opportunity for promising startups with innovative solutions to accelerate the path to product validation and market acceptance improves with the support of the sponsoring health system.

 

We are also seeing some non-traditional partnerships emerging. The big announcement earlier this year by Amazon and Berkshire Hathaway, and the more recent announcement by a consortium of healthcare companies to invest in blockchain technology are examples.

 

Despite health care's reputation as a slow follower of technology, the innovation ecosystem is buzzing. In my book, the Big Unlock, I refer to four categories of technology solution providers: The Custodians such as the EHR vendors, who have the data and the workflow; the Enablers, which are big companies like Google, Microsoft, and Salesforce who have invested in health cloud infrastructures that can be rented for building digital health experiences; the Arbitrageurs, which include global consulting and technology services firms who rely on information and labor arbitrage for developing and delivering technology solutions; and finally the Innovators, which include the hundreds of startups and VC-funded companies who are developing entirely new ways to deliver health care. Every one of these categories is innovating in their own way.

 

At the heart of the innovation ecosystem is a final category of innovators, namely the healthcare enterprises. Leading health systems are innovating with health care delivery models and pricing/contracting models and are using technology to enable their digital transformation.

Into the great wide open

Despite all the activity and the fierce competition, there is good news for innovators; the market is wide open, and there is no single dominant entity in the digital health innovation landscape. Each of the categories of technology providers I refer to have their unique strengths and many would like to become that one dominant solution provider of choice.

 

While it does not seem likely that we will see a dominant digital health innovator in the near term, the window of opportunity for innovators is narrowing. As the high value “white spaces” get filled up and the risks of failure increase, VCs are committing larger and larger amounts of funding to more mature companies in the hope of a successful exit. New entrants in the innovation landscape will either need to find new white spaces or build “better mousetraps” to challenge well-capitalized incumbents on their turf. At the same time, as the pace of exits picks up, VC firms will look for new investment opportunities for their liquidation gains. For now, it’s best for digital health innovators to operate with an abundance mindset. It’s an “all you can eat” world out there. 

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Could Apple Store-like digital health retail stores be popular? 

Could Apple Store-like digital health retail stores be popular?  | Healthcare and Technology news | Scoop.it

Here’s why I think the time is right. Rumour has it that CVS, Walgreens, Kroger, and many other pharmacies carrying digital health and wearables product draw in-store customers. If that’s the case, could we drive more sales of telemedicine, remote monitoring, chronic care apps, and other digital health products by creating specialty stores in which we had trained sales people that knew how to combine products, services, and solutions from a variety of companies and educate consumers, caregivers, and patients about their use? What if some smart pharmacies, smart health insurers, and smart health systems got together and put together healthcare management retail stores in malls, similar to an Apple Store or a Microsoft Store?

 

In a fee for services (volume-driven) world, selling healthcare products and services to individual institutions is certainly time-consuming but reasonably straightforward. In an outcomes-driven (fees for value) world driven by shared risks and shared rewards, selling healthcare solutions across multiple disciplines, multiple stakeholders, and multiple institutions is much harder and even more time-consuming. That’s because there’s no easy buyer to identify. Population health is all the rage but our current 3+ trillion dollar healthcare industry was never devised nor incentivized to work together as a team for a long-term patient or population benefits (it’s reimbursed mainly for episodic care).

 

Our country’s healthcare industry is more about sick care and episodic transactions rather than longitudinal care. But, since we are moving to population and outcomes-driven care where the patient is more responsible for their own care management and payment, it would seem patient education and digital health tools are more important than ever. So, perhaps we need to get together and innovate around how we’re going to present next-generation solutions from across multiple innovators and showcase them to patients and their caregivers.

 

Using the Apple Store as a model, let’s imagine a Digital Health Store where we can have computers, wearables, tablets, phones, medical devices, remote monitoring, care quality, and other cool devices sitting in one place where shoppers can see how things work together and salespeople are trained to talk about chronic care. Even Amazon, who basically killed the large bookstore retail model, is giving retail bookstores a shot.

 

If the Digital Health retail store idea is reasonable, we could even think about allowing people to shop for insurance — on existing insurance exchanges — through a guided expert in store. There are tons of way of monetizing these stores.

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Apple’s EHR: Why Health Records on Your iPhone is Just the Beginning? 

Apple’s EHR: Why Health Records on Your iPhone is Just the Beginning?  | Healthcare and Technology news | Scoop.it

Americans on average will visit a care provider about 300 times over the course of their lives. That’s hundreds of blood pressure readings, numerous diagnoses, and hundreds of entries into a patient’s medical record—and that’s potential with dozens of different doctors. So it’s understandable, inevitable even, that patients would struggle to keep every provider up-to-date on their medical history.

 

This issue is compounded by much of our healthcare information being fragmented among multiple, incompatible health systems’ electronic health records. The majority of these systems store and exchange health information in unique, often proprietary ways—and thus don’t effectively talk with one another.

 

Fortunately, recent news from Apple points to a reprieve for patients struggling to keep all of their providers up-to-date. Apple has teamed with roughly a dozen hospitals across the country, including the likes of Geisinger Health, Johns Hopkins Medicine, and Cedars-Sinai Medical Center, to make patient’s medical history available to them on their phone. Patients can bring their phone with them to participating health systems and provide caregivers with an up-to-date medical history.

 

Empowering patients with the ability to carry their health records on their phone is great, and will surely help them overcome the issue of fragmented healthcare records. Yet the underlying standardization of how healthcare data is exchanged that has made this possible is the real feat. In fact, this standardization may potentially pave the way for innovation and rapid expansion of the health information technology (HIT) industry.

 

Growing agreement upon a standard way to store and exchange electronic healthcare information is what made Apple’s foray into health records possible in the first place. Fast Healthcare Interoperability Resources (FHIR) emerged four years ago as an interoperability standard for electronic exchange of healthcare information. It is a standard framework for the sharing, integration, and retrieval of clinical health data and other electronic health information. Enough agreement upon such a standard for health information exchange has promoted modularity.

 

How modularity fast-tracks innovation

A system is modular when all its components fit together in a standardized way, whether physically, mechanically, chemically or in this case digitally. This standardization enables people to design one component without having to know how everything else in the system works. An everyday example of this is the USB port. It is a standard cable connection interface upon which any number of products can connect—whether it be a keyboard, a charger, external memory, or any other device that can meet the specification. This differs from interdependent systems, in which the design of parts are customized, nuanced, and how they work together is not widely known. Thus, a designer has to know how the whole system works to be able to design any part of it.

 

In the case of the FHIR standard, the manner in which digital healthcare information is exchanged is modularized—the rules of the road are established and easy to follow. Adoption of this bit of digital standardization, by an influential group of healthcare providers, is what allowed the third-party giant, Apple, entry into the modular electronic health records game. Even though their experience in healthcare is limited, the standard lays out the rules well enough for them (and other third parties) to participate in the HIT market.

 

We’ve learned in the past that the creation of and agreement upon standards can expand industries by creating a new ecosystem in which third-party players can add value. In fact, the preeminent example of this type of ecosystem creation is Apple itself, and their AppStore.

 

Along with their AppStore, Apple created a set of standards that specified how third-parties (from companies to individual hobbyists) can more easily create applications that make use of the information on their phone and the Internet. These apps were made available to Apple’s network of users and developers were paid according to the amount of revenue the app generated by Apple (based on usage). Over the span of 10 years, Apple has paid AppStore developers $86.5 billion (paying out $26.5 billion in 2017). The rapid expansion of the market for creating substitutable apps in return gave everyday users the ability to harness information in any number of more convenient, simple, and potentially meaningful new ways.

 

What does this relatively recent and still unfolding story mean for HIT? It means that as opposed to merely viewing your health record, standardization may also allow for the creation of new tools that actually make use of your health record in new, meaningful ways. For example, developers may create an app that helps patients understand their risk of a cardiac event base pulling specific data points from the health record. In short, applications can be created by third party creators for use by the patient that make their healthcare data more accessible, easier to understand, and more actionable.

 

In this way, not only does modularity stand to make healthcare data more accessible to providers, researchers, and public health organizations (current consumers of health data), but to a new market—the patient. Standardization mediated by the adoption of FHIR opens up the market for innovators outside of the traditional health IT industry. These new players can then compete to reach everyday people (just as app creators did on Apple’s AppStore platform), with useful tools that empower them in their struggle for health.

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A Path to Putting Patients at the Center 

A Path to Putting Patients at the Center  | Healthcare and Technology news | Scoop.it

I remember when visiting a city required paper maps and often actual guidebooks. Today, I tap on a map app on my phone, enter my destination and review options for getting from point A to point B. In recent years, these applications have expanded to integrate ride-sharing, bike-sharing, and public transit information. Map apps provide two key real-time data points to help me compare the different options: the time it will take to get to my destination and the cost.

Behind those data points are elegant algorithms that analyze traffic patterns and conditions, as well as the real-time data exchange between multiple apps through modern, Representational State Transfer (RESTful) application programming interfaces (APIs). What makes our smartphones so powerful is the multitude of apps and software programs that use open and accessible APIs for delivering new products to consumers and businesses, creating new market entrants and opportunities. There is nothing analogous to this app ecosystem in healthcare.

ONC’s interoperability efforts focus on improving individuals’ ability to control their health information so they can shop for and coordinate their own care. While many patients can access their medical information through multiple provider portals, the current ecosystem is frustrating and cumbersome. The more providers they have, the more portals they need to visit, the more usernames and passwords they need to remember. In the end, these steps make it hard for patients to aggregate their information across care settings and prevent them from being empowered consumers.

Just as consumers can see the time to destination and costs using their map apps, they should be able to see quality indicators and costs of their care. As Health and Human Services (HHS) Secretary Azar recently stated, “putting the healthcare consumer in charge, letting them determine value, is a radical reorientation from the way that American healthcare has worked for the past century.” I certainly recognize that issues around pricing for healthcare services and measuring quality are complex, but I am confident that ONC’s efforts will complement new policies across HHS to encourage transparency, leverage Medicare and Medicaid to drive value-based transformation, and reduce regulatory burden on the health system.

As part of ONC’s role in coordinating health information technology (health IT) nationally, we are working with innovators to develop modern APIs that support the use of mobile apps to help individuals manage their own health or the health and care of a loved one. A robust health app ecosystem can lead to disease-specific apps and allow patients to share their health information with researchers working on clinical trials to test a drug or treatment’s efficacy, or monitoring outcomes like those in the National Institutes of Health’s All of Us Research Program.

ONC took a practical step to accelerate the use of APIs in healthcare with the 2015 Edition of the certification criteria adopted as part of the ONC Health IT Certification Program. Specifically, the 2015 Edition includes updated technical requirements that were not available in the prior edition and—to the benefit of the provider and the patient—to support further innovation in APIs and interoperability-focused standards. The 2015 Edition includes “application access” certification criteria that require health IT developers to demonstrate their products can provide application access to core medical and patient information via an API.

The 21st Century Cures Act (Cures) builds on ONC’s 2015 Edition and calls for the development of APIs that do not require “special effort” for developers to access and exchange health information. ONC will address this requirement through rulemaking expected to be issued later in 2018. Ensuring that APIs in the health ecosystem are standardized, transparent, and pro-competitive are the central principles guiding our work. These goals should allow new business models and tools that will expand the transparency of all aspects of healthcare. New tools should allow patients to comparison shop for their healthcare needs like they do when hailing a ride.

In recent years, the health IT industry has made positive strides. The HL7 Argonaut Project, a private sector initiative, has been developing a core set of Fast Healthcare Interoperability Resources (FHIR) implementation specifications. These specifications will enable expanded information sharing for electronic health records and other health IT solutions based on modern computing standards (i.e., REST, Javascript Object Notation (JSON), and FHIR). Boston Children’s Hospital Computational Health Informatics Program and the Harvard Medical School Department for Biomedical Informatics have been leading the development of SMART Health IT, an open, standards-based technology platform that already is showing success in enabling innovators to create apps that seamlessly and securely run across the healthcare system.

The convergence of these actions, the new authorities granted to ONC by Congress in the Cures Act, and efforts by HHS, the Centers for Medicare & Medicaid Services (CMS), the National Institutes for Health (NIH), and the Veterans Administration (VA) with the MyHealthEData initiative are helping promote more consistent data flows, inject market competition in healthcare, and return individual control of their care to the American public.

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