It seems like every other physician I meet these days has a tech-powered start-up in the works, or an idea for one.
Take Joseph Kvedar, MD, profiled in our December 2012 issue as one of the HealthLeaders 20. Founder and director of the Center for Connected Health at Partners HealthCare in Boston, no sooner did that honor fall on his shoulders than he launched his start-up, Wellocracy. It's a side project while he continues as director of the Partners Healthcare nexus for all things connected health.
"For some time, I've felt like our ability to really get connected health adopted has been limited by our view of it through the lens of patient care," Kvedar told me at the 2013 International Consumer Electronics Show. "I had really thought with great interest about a way to reach consumers, so that was always in my head. And then another observation over the years was that patients, although we sometimes had to coax them to participate in telemonitoring programs, once they get on they didn't want to come off. Patients find it very comforting. They've connected in. They feel cared for."
Since October 2012, the Center for Connected Health has provided connectivity between patients' home monitoring devices and Partners' electronic health record. Patients can now view their home monitoring data in Partners' patient portal. To my knowledge, this is a first in U.S. healthcare.
"Now we're getting to the point where we can sense, collect, monitor almost anything about you, and lots and lots of people are doing it. So if I want to get in the business of tracking my own activity, I pity the person who doesn't have a guide to help them," Kvedar says.
So was born Wellocracy, a combination of self-help book and social media-driven online support group that Kvedar formed with the help of self-help author Carol Coleman. There's also an activity tracker, the Pebble, although the Wellocracy idea plays well with many of the other activity trackers out there.
"[Carol] and I conceived of this project a little over a year ago, and said, Wouldn't it be great if we could get activity tracking and health tracking out of the 'quantified selfers' and into the land of everyday folks," Kvedar says.
The key, he says, is to include tools designed to help people understand their own motivational psychology, matching their activity tracking to an app or a service they can get now. For some, that motivation will be a data-driven service such as EarndIt. For others, it will be a social connection, such as forming their own Facebook group, thereby involving their Facebook friends in coaching them to be more active.
"You don't have to turn your life upside down to use tracking to be more healthy," Kvedar says. "You use the time you already have more wisely, whether it's parking your car further away from the mall, or taking the stairs, or taking a conference call walking around your office. They're all ways that you can be more active if you just think about it, and the beauty of the tracking ... is it will give you that continuous feedback while you're doing it."
The first Wellocracy ebook, Move to a Great Body, published last December, will be followed by ebooks on sleep and diet, hypertension, and possibly one on genetics, Kvedar says.
All this prompted me to ask him at what point payers will offer substantial rewards (i.e., lower premiums) to those who prove they are taking better care of themselves through programs such as Wellocracy.
"I think that's a great question," Kvedar says. "I'm going to switch gears and use a different example in my portfolio of examples, and that's Healthrageous. That's a company that we spun out of our Center a couple years ago. All these approaches have the same things in common: the feedback loops, and the social stickiness factor and so forth, but they're bringing that product line to health plans and employers. They have one particular relationship that speaks exactly to your point, which is a relationship with a large payer in California. The people that are enrolled in that particular insurance product, in order to maintain a low premium, must be on the Healthrageous platform, and demonstrate that they're healthy."
So how does all this affect Kvedar's day job at Partners?
"It's a passion that I have, so you tend to do things and not think a lot about them when you really believe," he says. "I really believe that if we got more people tracking, we'd be a healthier society, and I want to test that hypothesis. With the advent of new payment models and the consolidation between the payer industry and the provider industry, providers will start to take on more wellness programs, and if they do, then we will have a firsthand, well-above-the-curve, knowledge base of how consumers adopt this stuff, based on this project."
How will a world of sensors will tackle the daunting problem of mental health?
"There's probably 20 companies out there building various sensors that can detect levels of emotion, and it's really the early, early, early days," he says. "It's like the body tracking sensors were 15 years ago." He points to biofeedback—"not a new concept"—as a harbinger of what's to come.
"Whenever we at the Center have done projects to give people the freedom to make good choices, inevitably they make good choices," but they want to be connected back to their healthcare providers, Kvedar says. Whether through the clinic, the Web, the app, or the ebook, technology is the great change agent for Kvedar and other leaders of his stature.
As a young emergency room physician, Martin Kohn, MD, thought he knew most everything. But once in a while, quiet whispers in his ear were the difference between success and a life-threatening medical decision error.
"What saved me and my patients more often than not were three nurses in that emergency department who had been there forever, and were very diplomatic. I could be sitting there struggling because we were doing stupid things like 24-hour shifts," Kohn says. "I'd be struggling with something and one of the nurses would come up and say, Marty, did you think about such and such?"
Now, Kohn is leading the team at IBM that will bring a technology-powered version of that little voice to clinics starting at the end of 2013.
"In some ways I view Watson as that friendly, helpful nurse who by experience knows these things, and just whispers quietly over your shoulder," Kohn says. "Nobody else has to see it."
In case you missed it on the TV game show Jeopardy, Watson is a set of massively parallel probabilistic algorithms able to break apart and parse natural language in different ways, and to suggest possible answers to questions.
In healthcare, Watson is being trained and tested first in the oncology clinics of Memorial Sloan Kettering Cancer Center, located 30 miles away from IBM's development laboratories in Yorktown Heights, New York.
For months, I've nosed around for more details about Watson's role in healthcare, but those hospitals that are working with IBM are under strict nondisclosure agreements, and are press-shy. But last week, Kohn made a lap around Silicon Valley, speaking at the FutureMed conference and then at an event hosted by Triple Ring Technologies, a startup incubator. I caught both talks.
Both audiences were peppered with physicians, such as one from Stanford Medical School, who I chatted with at Triple Ring. He remarked to me that he wasn't overly impressed yet with Watson.
I would expect physicians to be wary of Watson. Reports of its projected diagnostic prowess have fed fevered speculation that artificial intelligence is at long last about to make doctors obsolete, will turn healthcare over to a set of algorithms, and will allow technology to replace a clinician's gut instinct.
But Kohn and IBM insist that's not Watson's role. A second effort with healthcare payer Wellpoint, touted by that company last week, may place Watson in a more centralized decision-making role, allowing or disallowing requested procedures based on Wellpoint's own use of Watson to scour medical literature to support or challenge a doctor's diagnosis or recommended treatment.
Like the famous HAL computer in the movie 2001: A Space Odyssey, Watson has had to learn by starting with basic stuff. When its objective was to beat human Jeopardy champions, Watson marshaled 12 terabytes of stored data, including questions and answers from previous Jeopardy games, to help decide which information was most relevant in forming an answer to each new Jeopardy challenge.
In healthcare, sometimes there is no one right answer, so Watson is being trained to return a list of possible diagnoses based on input ranging from the patient's own story, ordered tests, experiences of similar patients, and peer-reviewed medical literature, which is weighted most heavily.
To date, Watson has ingested more than 600,000+ pieces of medical evidence, two million pages of text from 42 medical journals, and clinical trial data in the area of oncology research.
Like a good journalist, Watson also learns which sources are reliable, favoring those sources' results over time, and discounting those results that come from less reliable sources. The term "artificial intelligence" is a bit of a misnomer, because Watson doesn't generate new ideas itself, but instead relies upon accessing existing information.
What makes the Memorial Sloan-Kettering test fascinating is that the institution already has 15 years of electronic health records on five million encounters, Kohn says. Over time, this kind of data will become some of the most valuable assets of any healthcare system, and for the first time, it will be powering an AI system to help make decisions.
To those who protest that Watson will simply be too much technology for too little gain, it's worth remembering that the amount of medical data available doubles every five years. In 2010, the National Library of Medicine cataloged 700,000 new articles. "I didn't read them all," Kohn quips. "There's information out there that we could use that we can't get to. Businesses that can process that information are two times as likely to succeed."
Kohn is IBM Research's chief medical scientist for care delivery systems. He co-authored IBM's white paper on the patient-centered medical home. But he is also a graduate of MIT, with engineering bachelor's and Master's degrees. He speaks both geek and doc—and both are definitely required for this "grand challenge," as IBM terms it.
If Watson can help providers prevent "avoidable" adverse events, it might prove to be a prudent investment. But for the time being, Watson will only be available to the largest healthcare organizations. Small practices won't be able to afford it, at least not until someone offers Watson in some sort of pre-packaged offering in the cloud. That will take some time.
Remember that natural language free-text analysis is just one piece of the analytics puzzle. Analysis of structured data and images, offers its own separate benefits to healthcare. And improving healthcare is a lot harder than winning a Jeopardy game.
But techniques such as Watson may also crack some of healthcare's harder nuts, such as how to decide on a course of treatment when multiple chronic diseases are present. For instance, should the physician treat congestive heart failure at the risk of making the same patient's asthma worse?
In some cases, only a massive speed-read of all available literature may be able to help suggest answers to that question and others like it.
Meanwhile, the debate about the role of AI in healthcare is just getting started. I expect a vigorous set of put-downs of Watson in the comments on this column. But just as I wouldn't have bet against Wikipedia or Google, I'm not going to bet against this technology's value either. After all, even Wikipedia and Google have assumed a certain role in today's healthcare technology puzzle, even if it's only to advise patients while they wait for their specialist appointments. (And what doctor doesn't use Google in his or her research?)
In the near future, even the medical experts will find themselves more dependent on and appreciative of ever more technology-fueled answers as well.
Subtitled "The Healing Edge," the book contains a surfeit of stories supporting the idea that innovation isn't the sole province of the wizards at Apple or Google. Rather it can emerge from the good ideas and brainstorms of designers working in close concert with healthcare providers.
I spoke with Berkowitz last year, and he seems to know everybody who's anybody in healthcare IT. As such, he's a natural choice to edit this 311-page compendium, along with Chris McCarthy of Kaiser Permanente's Innovation Learning Network.
An experimental model for solving problems
The first thing I learned was that innovation can be the result of a methodology. The most common one found in the book is PDSA, which stands for Plan-Study-Do-Act, an experimental model for solving problems. You may encounter PDSA in variations such as Lean (for efficiency challenges), Six Sigma (for quality challenges) and Human-Centered Design (for experience challenges).
Kaiser describes this last methodology in Chapter 2, where McCarthy describes Kaiser's Innovation Consultancy as "an internal design firm staffed by creative people who are part design, part strategy, and part healthcare."
Sounds like a fun and important place to work, especially since the Center is inspired by design firms such as Ideo and PointForward.
Identifying patterns used by technical innovators The Kaiser methodology parallels that of tech innovators such as O'Reilly Media, which has made a veritable industry out of identifying patterns used by technical innovators. It's through work such as this that the Web 2.0 paradigm was popularized, and we're now seeing insightful pattern recognition being applied to healthcare innovation.
It's a shortcut to spreading innovative ideas more quickly than simply reciting case study after case study.
Having said that, there are case studies aplenty in this book. We learn, for example, that patients at Kaiser wanted to have nursing shift changes happen at the bedside, so the EHR system was modified to allow that to happen.
Low-tech prototyping The book also discusses the notion of "low-fidelity prototyping, a way to use simple methods to prototype enhanced tools and applications. "It turns out that approximating the tool in another system, such as the [Microsoft] Access database and paper print-outs, can allow for increased efficiency, cheaper cost, faster development and more creativity than trying to do so in the EHR system itself," writes McCarthy and his co-author, Christi Dining RN, director of Kaiser's Innovation Consultancy. Other prototyping exercises involve use of egg timers and simple alarms set on iPod touches.
It's that kind of combination of low-tech, just-enough-technology thinking that we are going to need to get healthcare to where it needs to go. If providers continue to simply turn over a huge list of requirements to vendors (or the government), we're likely to get more overpriced, overproduced technology that doesn't accomplish the mission of making healthcare safer, more effective, and more convivial.
Pathways to process efficiencies Sometimes innovation simply involves applying a good idea from one part of healthcare to another part of healthcare. By now everyone has heard of Atul Gawande's use of checklists in the operating room. In Chapter 3 of this book, Berkowitz describes application of checklists to primary care and care coordination.
This thinking was rolled into the Inflection Navigator, an EHR enhancement that allows physicians to choose "pathways" to activate care coordinators when significant new diagnoses are made. The first three pathways chosen for Inflection Navigator were hematuria, atrial fibrillation, and cancer. Other pathways will follow.
According to Berkowitz, the system has increased process efficiencies, ensured consistent use of care standards, and provided financial benefits for patients, providers, and payers, and the book goes on in some depth to describe these benefits.
A more-focused workflow Also featured in the book is an EHR overlay system for coordinating care in use at MedStar Health, the largest not-for-profit health system in the mid-Atlantic region. I learned that MedStar was the birthplace of what eventually became Amalga, a health information system now offered by Microsoft.
At the heart of MedStar's innovation-fueled transformation was a realization that clinicians cannot be counted upon to remember which forms to open and complete in order to perform EHR tasks. I liken this to expecting taxpayers to remember which tax forms they'll need to download and fill out in order to file their annual income taxes.
MedStar and others have pioneered efforts to focus workflow onto a single screen, although much, much more needs to be done in this area. These single-screen prompts also need to be customized to the particular role a given clinician provides in care. Designing those customizations is the tricky kind of detail that is essentially to the success of innovative health information technology, and that this book describes.
Stories from smaller multi-specialty physician groups also find a place in this book. For instance, there's Southeast Texas Medical Associates (SETMA), designated by the Office of National Coordinator for Health Information Technology as one of 30 exemplary practices in the U.S. for clinical decision support.
The screen shots reproduced from SETMA's IT system are a little daunting to me, but then again, they are tracking 200 quality metrics. Still, you can see that ultimately, clinical decision support dashboards are well under construction and in use at many HIT systems today.
In this column, I've just skimmed a few of the many highlights of Innovation with Information Technologies in Healthcare. It takes its place on my bookshelf alongside books such as Connected for Health, which describes how Kaiser implemented its EHR. I'll be writing about that in the future.
For now, hats off to Berkowitz and McCarthy for one of the most useful aggregations of HIT lessons learned that has been assembled thus far.
Are healthcare payers ready to reimburse for m-health and mobile phone apps? This week, the conclusion of my healthcare-focused conversation at the International Consumer Electronics Show with Reed Tuckson, MD, UnitedHealthcare group executive vice president and chief of medical affairs.
HLM: What role do you think technology is going to play in mental health?
Tuckson: I think we are especially excited around the telepsychiatry services that are going on in mental health. We recognize the real issues of availability of supply, of trained mental health workers, and we clearly understand also the logistics of geography.
Telepsychiatry is really becoming an established, recognized field, and it is also encouraging that patients actually are not intimidated by not having a person in the room geographically and spatially with them, and seem to respond well to the technology.
HLM: So you've been reimbursing for it widely for a long time.
Tuckson: Yeah, just as we have been reimbursing for synchronous video communication on the clinical side. We reimburse the same for synchronous video on the clinical side as we do for whether you were spatially in the room.
HLM: Do you have an ultimate vision of where all this is going?
Tuckson: We are obviously bullish. On the other hand, we are appropriately cautious. We do not get seduced by technology for technology's sake, and we recognize that while there are lots and lots of mobile apps being rolled out every day, the number of people that are using them is still fairly small.
... I like my FitBit; it works well, and it gives me that immediate feedback that I really want, and it gives me information in an interesting way that's not intimidating. But the ultimate vision, the ultimate excitement will be when we can take that technology and move it in a more integrated way with other things so that the combination of factors gives you a much better chance to move the needle to actual change in behavior.
If things are not moving the needle to change behavior, then it's just all been fun, and it's been interesting, but it doesn't mean anything. The only thing that matters is success. Our vision is interconnected, coordinated stitching together from the individual/personal into the clinical care delivery system in a meaningful way at scale. All of that then leads to people making personally appropriate choices and changing their behavior.
Are we excited about it? Bullish? Yes. Are we also recognizing that we don't have money in our society to waste, that the consumer is paying a lot of money for healthcare, and will be paying more for healthcare?
We're going to have to obviously make sure that any of the things they're doing that are discretionary add value. If things do not add value to healthcare, then they're not going to survive. They shouldn't survive.
HLM: Do you feel your colleagues in the industry are tuned into this as you are, or does the industry as a whole have more work to do?
Tuckson: I think the industry as a whole has more work to do, but the key thing is, again, we're going to have to find a way that people come together. One of the things that's going to be very interesting in the future as we try to figure out where we go is, what happens when we start to go from the pure consumer space more into a medical space?
If the app that we're using to advance wellness now has to start moving into the space that may be associated with diagnostics, or disease monitoring—titrating of actual behavior—to start to look clinical, now we're starting to get to a whole 'nother area, which is going to be then subject to regulation, to regulatory oversight. All these are the issues that are there, and what we want to see is, How do all the participants in this space begin to see how these things connect?
HLM: Scanadu delayed its launch so they can get FDA approval, so it can be used in a medical setting.
Tuckson: At some point, you get precise about what you're trying to do, and you want it to be demonstrable to have a real impact on human health. When you do that ... you make claims, and a consumer has to purchase something based on claims of reliability, that it will do what it says, [and] a physician's office has to say that in fact this thing that a patient is doing, if I'm going to incorporate it into my clinical paradigm, I need to understand its reliability, its trustworthiness and its appropriateness.
So you want there to be appropriate regulatory oversight. All these things have to be sorted out. What I would say is, let's not let those challenges slow down the train of innovation. We've got a lot of room to get to, and a dynamic dialogue. The alternative hypothesis is almost unimaginable, which is, we do nothing, we don't innovate, we don't develop new ideas, we continue to have this extraordinary increase.
HLM: Or we wait for the clinical trial system to work, which takes forever.
Tuckson: If we don't do something, all we know is next year, the obesity rate will be higher, the percentage of people who get no exercise outside of going to work will go beyond 26% to—what? 30? That the [percentage] of diabetics go from 9.5 to—what? 13?
At the end of the day, the null hypothesis doesn't work. So let's get us moving. Let's keep at it, and then let consumerism take over. Let the consumer tell us what they want and how they want it, what works for them. If we're in this era of patient-centered care, let's take it for what it means.
Let's all figure out how what we do connects into meeting the comprehensive, holistic needs of the patient, and continue to ramp up the interventions for those needs as the patient changes. As they get healthier or less healthy, as their disease challenges change, as their social environment changes, let's keep giving them what they need so they can make the choices and the behaviors that we want.
HLM: Arianna Huffington said 44 million healthcare apps will be downloaded this year. You've got to leverage that.
Tuckson: Some will survive. Some won't. Some should. Some shouldn't. Let the marketplace go forward, but let us all try to at least engage the person. ... I wrote a book called The Doctor in the Mirror. The thesis of the book is in the title. Look in the mirror, and you will see the best doctor you'll ever meet. That's you!
Who knows you better than you? Who makes more decisions every day about your health than you? Who loves you more than you? The reaction to that book has absolutely astounded me, because the people that I talk to now who have read it are almost overwhelmingly reminding me of the importance of empowering people to make choices and decisions.
Now you and I, we sort of take that for granted. [But] the majority of people still do not have the message that you can and should take charge of your health, in every area. So we've got to keep having that conversation. Then, once you have people engaged and excited, then you're saying, I've got this tool, or they will find a tool and say, This meets my needs, I've decided to take charge of my health. Now how do I do it? Oh, here is an aid. It fits into my normal lifestyle.
Tuckson: You asked about a vision for the future, and what really gets me excited. Move the health out of the health ghetto and into your life. I was at a conference in New Orleans where I first got this. I was in my hotel room. I had conference call after conference call. I finally said, I've got to get out.
I go to my smart phone, I put in an app, AroundMe. It tells me which are the coffee shops, or anything, around me. A map comes up that shows me how to get there. I go outside and I walk. I take steps, I go somewhere. I get inside of the coffee shop, and I pull up an app that tells me the nutritional content of what's in the store. I figure out the one that's best for me. I'm getting ready to order. I love the song that's playing. I hold up my phone. There's an app that tells me the name of the song. Then it asks me do I want to buy it? I buy the song, I buy my food, I go back to my hotel.
When I finish my last conference call, I go to the gym to work out. I put on the song I just downloaded. My heart rate goes up 20% more than it was before, because I'm moving to the rhythm. Which part of that was health, and which part of that was living? That's when it hit me. Now I got excited, because instead of my deciding now, I'm going to go do health, no, no, no. I'm just going to go do living. The health happens.
HLM: I was looking at a feature on UnitedHealth's website called My Cost Estimator. Would you ever consider making that social—so if I'm checking my cost estimator, my friend who is with UnitedHealth and she's checking hers, and we want to compare notes, we could decide to share up what we're estimating and costing out, and have kind of a social aspect to it. Under our control, of course—it's our data, and you're part of that ecosystem. Does that look like something that would be a part of this?
Tuckson: I applaud you for an intriguing idea. I think as we would evaluate that, the issue is that we believe in transparency. We think the information ought to be available for people to make appropriate choices and decisions. We think that people should have information first about the quality of the care that's provided, and one of the key elements of care provider quality is patient experience with care, and the satisfaction they have with care—which is very much a social issue, and as people start to say, 'well, how were you treated when you went to such and such a health group or physician?'
So the fact that you would have that kind of social conversation about it would be interesting. If people were to share and begin to understand the differences in costs based on health benefit design, that would be very useful.
Now, of course, knowing that there will be differences in that, vis-à-vis the employer's benefit plan offering and the risk profile of an employer, that might make it a little bit different—so there may not be that ability to do direct one-to-one comparison—but at the end of the day, having more people have more of an informed conversation on the quality and cost effectiveness of care delivery is certainly something that we desire, so thank you. We'll continue to think about that.
This year's International Consumer Electronics Show featured a healthy dose of healthcare, with United Healthcare one of the biggest exhibitors at CES's Digital Health Summit segment. I spoke with Reed Tuckson, MD, UnitedHealth group executive vice president and chief of medical affairs.
HealthLeaders Media: How disruptive is it for you to be here with this huge booth at CES when we're used to seeing you at something like HIMSS?
Tuckson: I can't tell you how excited I am to be here, because we've just finished releasing in early December the “America's Health Rankings” annual report, and yet again, it shows this really frightening increase in the risk factors that are leading to and also increasing documentation of preventable chronic illness, especially as we look at hypertension and diabetes. I am so tired of the same old tools, the same old strategies and approaches. We have got to bring innovation into this space where we're helping people make better choices and decisions, so being here makes all the sense in the world, because we really are trying to be a part of recruiting an army of innovation in this space.
Now given that you've mentioned that we are also normally at places like HIMSS, we clearly see our value added as being the integrator—being able to connect the guidance, the tools, and the data flows that come from the individual digital health world as consumers into a more holistic, integrated, interoperable database. That connects with the delivery system that connects with the care management, care coordination, and takes all of that experience, that data, that feedback, and then continues to refresh and refine personal identification of risk and closing gaps in medical care. So the more that we take the data from the different places, pull it, stitch it together, reanalyze it, and then repump it back out again in ever-more precise, more meaningful, more actionable chances for individuals to take better engagement over diminishing risk factors, and the more you can connect the delivery system to identifying gaps in care that you can then close, the better it is. So for us, the two worlds of the more traditional HIMSS clinical data world and the consumer wireless digital revolution are becoming more holistic in our mind, and we sort of see ourselves as pulling all of that together. So I don't see it in any way as dichotomies. I don't see it as being dyssynchronous. For me it's synchronous.
HealthLeaders Media: I went to South by Southwest last year, and Aetna was there giving a big talk and exhibiting. Are payers leading the charge here? What about the providers? Should Kaiser have a booth at CES next year?
Tuckson: I think that it's hard for delivery systems per se to be in this space, because they've got a lot on their plate now. The opportunity that at least we see is being a facilitator, an intermediary to help make all that happen for all the players. We are clearly seeing our role as, first of all because of our Optum company, very much involved in sharing the aggregated and analyzed data back with the delivery system for action by them. We also see our role as being helpful in developing and integrating the software necessary to make that data actionable and useable at the point of care delivery, so we have to help them in that regard. So we see our role as sort of enablers to getting all of that done.
Would I expect small practices or even fairly large medical groups to be here yet? It is very tough for them to make the health IT decisions, the capital investments in all of that world right now. I think what I would see our opportunity is to help make it easy for them as we go through this transition period. The other thing about it is that what you also see, at least for United, is that we are trying very hard to be product-agnostic. The delivery systems, especially the large integrated hospital and medical systems, have a harder time being flexible and fluid. They get locked into systems. We want to be the ones that help make it easy for you, depending on whatever system you use, to feel that the data flows, the engagement flows, the interoperability flows, and the coordinated care delivery flows, so that's probably the space that companies like ours can better occupy.
HealthLeaders Media: Is this the year we're going to see employers say, 'Hey, you do this, you wear this, you're going to get cheaper insurance'?
Tuckson: Absolutely. We're already seeing it now, and the curve has got to go up. I think it'll go up, because we're going to be able to have more data to be able to prove to employers that it works, and secondly, we're going to have to convince employers that for the tipping point to occur, it's going to take employer engagement in terms of being cajolers, leaders, cheerleaders, information disseminators, but then ultimately building incentives into the benefit package. We're doing it at our company. We're seeing, with our own employees, that the consumer-directed health plans are really taking off, showing great results.
But then, it's not good enough just to say, Okay, here is your consumer-directed health plan. You've got to give them two things. Number one, you've got to give them the opportunity to engage successfully in turning around those modifiable risk factors—thus the digital health revolution—and secondly, you've got to give them the health cost estimator, because you want them to be able to know how much is out of pocket when they make health choices. So granular data around costs and granular and actionable information around modifying preventable risk factors. Those are the two things that we get excited to bring forward, and hopefully that will all convince and get enough employers to get us to the tipping point.
HealthLeaders Media: You've got a whole bunch of other people here at CES showing technology to help people get healthy. They're all cranking out data, and the patients might be UnitedHealth customers, they might be Kaiser customers. Who knows where they are. But how do you know which patient you're dealing with, whether you have the same patient in your system twice? We don't in this country have a national patient identifier. This seems like a big issue.
Tuckson: I think it is obviously good to have tools to help you to be precise, but we are not intimidated now by the challenge and ability to know enough about unique people to give them back information that's reliable and trustworthy. We're operating at massive scale with very granular information about people, and we have not faced an overwhelming hurdle in that regard.
HealthLeaders Media: How many million do you serve?
Tuckson: At least 35 million people insured, and 75 million touched in one way or another. We feel pretty good about that.
HealthLeaders Media: My sense is that payers have it under control better than the providers do.
Tuckson: I think we may well. But I'll tell you what I'm excited about is, we're now being able to not only accumulate information about the person, claims, pharmacy, and labs, but we're also including health risk assessments, biometry, data from care management, and care coaching. We're also getting closer to really being able to meaningfully include EMR data and health information exchange data. What boggles the mind for a non-propeller head is that there are these people in companies like ours who have the ability to smash together these very disparate data sets and make sense out of them. So I think we're probably much less anxious about some of the hurdles and more positive about what we're able to produce.
This article appears in the December 2012 issue of HealthLeaders magazine.
Can a wiki share and standardize order sets? R. Dirk Stanley, MD, MPH, aims to find out.
"The fact that they're not standardized across the country leads to enormous costs and inefficiencies in healthcare," says Stanley, chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass. "For example, if you have a doctor who's moonlighting, you know if you have a doctor from hospital A that you need to fill a shift in hospital B, if the doctor doesn't know what order set, kind of how the clinical functions operate, then it means you basically have to retrain the doctor on your clinical functions, but that's a lot of time and a lot of money."
Informally, order sets are finding their way from provider to provider through several routes today. Incoming residents are a source. Another is occasional informal exchange of order sets on the online forum run by the Association of Medical Directors of Information Systems.
Stanley recently began meeting with colleagues all along the Interstate 91 corridor in New England to help build a structure for sharing information.
"If you invent safety belts, is it really fair that you keep the patent for safety belts all to yourself?" Stanley says. "If you know you have something that can help improve care and improve safety and reduce costs, why wouldn't you share it with other people? I figure if I can share things with other people, then maybe they'll help share their lessons with me, and together we can actually reduce each others' operations costs and improve each others' safety."
Like the highway itself, Stanley's wiki-powered I-91 Informatics Group is a shared project that benefits everyone, Stanley says. Order sets are only one area of interest. Stanley sees it as a way to share protocols, documentation, policies, and procedures. "When a carpenter builds a house, there are standard tools that every carpenter knows how to use and maintain," he says. "I'm hoping that together we'll be able to write the book on how to manage the tools and make them better and make them more affordable and safer."
The consortium's barn-raising attitude is partly born in the high cost of purchasing order sets from companies such as Zynx and Provation, Stanley says. "Even when you get those canned products, you have to review; for example, do we have this drug in our formulary?" Stanley says. "In hospital A, they might use levofloxacin, and in hospital B they might use ciprofloxacin. If the standardized order set has levofloxacin, but you don't have that on your hospital formulary, then you have to fix the order set. Usually somebody still has to go through line by line to ensure the proper functioning and safety of every single order in the order set, and what you start to learn is, even when you get one of those canned solutions, it's still a lot of work."
Because EMR vendors are also offering their own order set suites, contractual restrictions and competitive considerations make efforts such as Stanley's an uphill battle. "Do you know how hard it is for me to call another health system and request their clinical content?" says Marc Chasin, MD, MMM, CPE, system vice president and chief medical information officer for St. Luke's Health System in Boise, Idaho. "When they've spent so much time and money developing their content, why would they give it away?" Thus, the sharing Stanley envisions may be a crowdsourcing and barn-raising strategy used by smaller providers to compete more effectively with their bigger rivals.
This article appears in the December 2012 issue of HealthLeaders magazine.
The data is out there. We only have to decide to use it.
Everywhere we go, we leave "data exhaust." It starts when you wake up and check your phone. Now there's a record that this guy's no longer asleep. Like little bread crumbs, we are our own life recorders. Our phones know where we go and how long it takes to get there.
On the Internet, our intentions are exquisitely captured by a series of privacy-bending technologies that watch our surfing and searching history and tailor ads personally to us. I can't tell you how ads for vendor-neutral archives find me even when I'm checking ESPN, but given what I do for a living, I can hazard a guess.
There is one and only one place each year where the tech-minded assemble to swap stories and gawk at the latest manifestations of the digital fishbowl that is our total lives today. So I too found my way to Las Vegas for last week's Consumer Electronics Show, which also featured conferences-within-conferences on digital health, fitness technology, and technologies for seniors.
I've watched these mini-conferences incubating for the past four years, but this was the year they blew up. That's good—it means they're growing like crazy.
This was the first year that one of the biggest exhibitors at the Digital Health Summit was a healthcare payer. You heard that right—United Healthcare had a huge booth at CES, not to be outdone by Aetna, which grabbed the spotlight at last year's South by Southwest Interactive.
The HIMSS conference this was not. United's booth was dominated by a stage where "Dance Dance Revolution" songs blared and booth staff, attendees, and even United Healthcare Executive Vice President and Chief of Medical Affairs Reed V. Tuckson worked up a sweat before our interview with some fancy steps.
Tuckson is a man possessed by the mission of getting sedentary America out of its easy chairs—and away from the big-screen home entertainment systems the consumer electronic industry puts out in ever-increasing numbers.
I tried to make sense of how this consumer electronics inflection point is affecting healthcare. Late in the week, it hit me, while I was talking to a marketing blogger (a veteran of the Seattle grunge scene who used to let the band Nirvana practice in her basement after they got famous).
The business of leadership, of getting people to change, is the business of storytelling. Tuckson and other leaders of his caliber are shaping the stories that will persuade people to take care of their health, even when some part of them is resisting.
It's the kind of dynamic that turns an inane viral video like PSY's "Gangnam Style" into an enticement to exercise, via a game like Nintendo's "Just Dance 4," where the app store features this song and daughters beg their fathers to download the song, and then work out to it for hours.
Health has to become a lot more fun, and technology is making it happen. One of the most popular workout apps for mobile phones last year was called "Zombies, Run!" If you don't run—really run—zombies in the game catch you (and eat your brains, no doubt). Yes, it's ridiculous, but like PSY's song, it changes behavior.
There was much talk at the Digital Health Summit about wiring all these innovations together, in a long chain that connects patients, providers, payers, public health officials, and research. Such wiring has only just begun, and will take some years. But it's coming.
Then there's the cutting edge, and boy, are there some wild things going on right now at that front.
A company called Salutron is building watches with an inexpensive set of sensors for collecting all sorts of vital signs right on people's wrists. A recent acquisition lets Salutron marry talent and inventions from two sources: DARPA sensor research and technology that is already present in exercise equipment in gyms throughout the country.
This will give the watches the ability to accommodate all manner of wrists, so the devices can deal with sweat, physiological differences, and the kind of real-world quirks that trip up so many kinds of consumer and even medical technology.
And on the far, far cutting edge at CES was Fulton Innovations, which at first didn't appear to have anything to do with healthcare. That's often how it starts at CES.
What caught my eye was a consumer packaged goods box, with ink on one part of the box that was blinking. Fulton uses something called the Wireless Power Standard to deliver a little electric current to a polymer-based ink printed on the box in order to illuminate it.
I spent a few minutes marveling at this, talking to company officials. Then they told me something relating to healthcare that blew my mind.
The same polymer-based ink process could create a temporary tattoo that could be used to collect certain vital signs from the wearer via wireless power, and deliver them to a compatible reader or maybe even appropriately outfitted mobile phones. Fulton hopes to have a demo later this year.
The implications are big. Printing remains one of the cheapest ways to distribute products. Ink-based printing still scales to huge numbers at unbeatably low cost.
This sort of unexpected innovation is what makes CES an event without parallel, and why the healthcare industry is increasingly attracted to it like a moth to a flame. Some technologies shown there never come to fruition, but what's a few moths getting burned?
A final wild story came from a guy I met in a hallway. Researchers at MIT have demonstrated that they can amplify motion in a video using variations in the frequency of color changes in a sequence of video frames, to quote their words. Users can specify the frequency range and degree of amplification desired. The technique works best for changes which are regular and re-occurring, such as heartbeats.
This technique can also be used to amplify changes that occur only once if the variation is wide enough. The system was originally intended to amplify changes in color, but turned out to be so sensitive in terms of motion amplification that the researchers reworked it to include the motion enhancement aspects.
Bottom line: video of people's facial features or the subtle pulsations of veins and arteries on their necks, collected from cameras on tablets, might be relevant in assessing changes in Grandma's health—without requiring a sensor, a patch, a temporary tattoo, or even a phone, just a camera.
Technology is hurtling toward healthcare at increasing speed. My challenge is to tell the stories of these innovations to quickly disrupt existing care systems and move the needle on healthcare costs.
Also at CES, I met Alan Greene, MD, chief medical officer of Scanadu, which is developing a noninvasive vital sign reader, akin to some of the patches that are making their way onto the market. Green demonstrated it to me by simply holding it to the temple of his head for a few seconds. But Scanadu has chosen to keep its product off the market until they can receive FDA clearance for use as a medical device.
That takes guts—and investors with lots of patience. There already are dozens of companies delivering non-FDA-approved, minimally tested gadgets with all sorts of health-improving claims. Quick bucks are being made, consumers will be angered, and probably new controlling legislation will at least be introduced and possibly passed.
But even at CES, in the heart of get-lucky, 24-hour Las Vegas, some healthcare technology innovators are waiting for the sure thing, and the right data, to really move the needle.
Inevitably, when the subject turns to the pitfalls of bad health IT, you will find Scot Silverstein, MD, ready to comment. He has been writing about health IT difficulties since 1998.
Silverstein is an adjunct professor at Drexel University who I recently interviewed for an upcoming HealthLeaders magazine story on physician resistance to health IT.
A recent Silverstein blog post caught my eye for the following statement: "It is impossible for people, especially medical professionals, to be 'ready' for a system that 'is not ready for them.'"
I wanted to learn about the good doctor's thinking and so I gave him a call. We spoke for two hours and it felt like scratching the surface of issues that healthcare will be facing for a good while to come.
If health IT has a canary in the coal mine, it is Silverstein. His Drexel website and contributions to the Health Care Renewal blog are the places to go to examine the voluminous literature about health IT's many shortcomings, errors, and challenges.
Silverstein completed a postdoctoral fellowship in medical informatics at Yale School of Medicine 20 years ago, but his experience with IT goes back to the 1970s, when building a computer involved using a soldering iron. His technology interests are diverse; he is also a ham radio enthusiast licensed at the highest level ("extra" class) by the FCC. In the 1990s, after years of practicing medicine and the post-doc, he joined Yale's faculty and began building electronic health record systems, including for King Faisal Specialist Hospital in Saudi Arabia, "even though my name's Silverstein," he notes.
After helping implement clinical IT at Yale New Haven Hospital, Silverstein took a CMIO-type role at Christiana Care Health System in Wilmington, Del., at a time when the term "CMIO" hadn't yet been coined.
At Christiana Care, Silverstein architected clinical information systems for critical care areas such as invasive cardiology from the ground up, from data modeling all the way up to supervising the programming team. He also was the clinical leader of commercial health IT acquisition and implementation for other medical specialties.
During the dot-com boom, he worked for an IT vendor, and then got recruited by Big Pharma, to run Merck Research Labs' internal science research library and IT group supporting drug discovery.
Today, at Drexel, Silverstein teaches and also consults with both plaintiff and defendant attorneys on health IT-related issues. "I cannot work in the health IT industry anymore," he says. "If I could even get a job, I'd likely be fired in five minutes from pointing out the problems." In short, those problems are manifestations of what he calls "bad health IT," as opposed to "good health IT." (Editor's note: After publication, Scot Silverstein noted that the good health IT / bad health IT dichotomy was introduced to him by Professor Jon Patrick at the University of Sydney in Australia.)
Unfortunately, critics such as Silverstein are branded as anti-technology Luddites, or worse. "That framing of the issue is misleading," Silverstein says. "It is propaganda generated by the industry. Here's the proper framing of the issue. In fact, physicians are largely pragmatists. They will adopt technology when it's clear to them that it's both safe and effective and might actually make their patient care better. They'll adopt that readily, so much so that often times, one has to be careful of it being over-adopted, say cardiac stents, for example."
Silverstein says it is wrong to think of the tension in healthcare as being IT modernists versus Luddites. "It's actually IT hyper-enthusiasts, or what I call 'Ddulites,' Luddites with the first four letters reversed," he says. "I didn't invent that term. I found it on the Web somewhere in a different context, but I believe the proper framing of this tension between technologists and physicians is that of technology hyper-enthusiasts, who either are unaware of or deliberately ignore the downsides and ethical issues of healthcare information technology in its present state, versus pragmatist physicians who just want to get a job done."
What Silverstein is cautioning against—in a very timely fashion in my opinion—is a generally held belief that any health IT, even poorly designed or implemented system, must be better than a paper-based system. "The physicians have a moral and ethical obligation," he says. "They've taken an oath. They have all the responsibility. They have the obligations. They have the liability. They're the ones who have to deal with the downsides of the technology. The hospital or clinic is not a software beta-testing shop," Silverstein says.
The current healthcare IT ecosystem, with its rush to implement meaningful use and grab the limited government incentive dollars being doled out by HHS, is arranged to suppress reporting of bad outcomes, Silverstein says, with the health IT industry given extraordinary regulatory accommodation compared to other healthcare and technology sectors. For example, he echos previous claims that hospitals have signed "gag clauses" so that defects in health IT cannot be reported to anyone but vendors. "Because of numerous impediments to information flow such as this, as reported by FDA, IOM, and others, we do not know the magnitude of harms, and we need to study it further," Silverstein says.
Silverstein says a likely reason some doctors, such as those at the Contra Costa Medical Center in Martinez, Calif., have been able to speak out is that they are unionized. Non-unionized doctors who raise concerns can face reprisal, for example in the form of sham peer reviews, where hospitals can "pickle them for minor problems and blow things out of proportion," he says. Fearing such retaliation, many of these doctors stay silent.
"In summary, physician resistance to health IT is not due to backwardness, and physicians' resistance to hyper-enthusiasts pushing bad health IT without concern for the potential and actual downsides needs to be considered," Silverstein says.
Undoubtedly, there is a lot of good health IT doing good things. But Silverstein believes, and I agree, that not enough attention is being paid to bad health IT. I'm eager to hear your comments.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Richard Merkin, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"We noticed that when we identify high-risk patients, we could intercede and prevent a lot of unnecessary care... and hopefully reallocate some of those healthcare care dollars into cure dollars."
If you're trying to solve complex problems in medicine today, it doesn't seem like the thing to do would be to assemble a community of math whizzes who've never met each other, and ask them to team up, compete with each other, and outguess the medical community. But that's just what Richard Merkin, MD, CEO of the Heritage Health Prize is doing.
Start with cash: The $3 million Heritage Health Prize, a data-mining, predictive-modeling competition to reduce avoidable hospital visits, launched in April of last year. Add a tech-powered online community that, this past September included more than 1,500 participants assembled into 1,300 teams that had submitted more than 22,000 entries.
"We noticed that when we identify high-risk patients, we could intercede and prevent a lot of unnecessary care," Merkin says. "It became obvious that if we could identify with greater specificity and sensitivity, then we could really transform healthcare in the world, particularly starting in the United States, and hopefully reallocate some of those healthcare care dollars into cure dollars."
Using historical claims data, competitors predict which patients will be admitted to a hospital within the next year. They can tweak their algorithms once a day, and accuracy rankings are displayed on the leaderboard at www.heritagehealthprize.com.
Unnecessary care, like beauty, is sometimes in the eye of the beholder. To Merkin, telltale signs include patients who skip medications, or those living alone, who might end up going to an emergency room on the weekend, where the ED physicians might not have those patients' medical history, and if overly cautious, might run extra tests and admit patients for overnight observation.
The more such inefficient care can be found, healthcare providers can reallocate resources to call those patients on a daily or weekly basis and preclude some of that unnecessary care.
"Sometimes we have what we call high-risk physicians, who might only have 100 or 150 patients in their practice," Merkin says. "These would be all either complicated medically, socially, or suffering from mental illness." Such physicians could reach out to the patients, even giving patients their home number or a cell phone and saying to call any time. "It's almost like a concierge type of medicine, and just by having access to a doctor more often, and the doctor being more part of that person's life, we've noticed that hospitalizations, which is the most expensive portion of healthcare today in America, have come down considerably."
Insurance companies have tried to figure out how to predict readmissions for years, but "they haven't necessarily included mathematicians and sophisticated data miners," Merkin says. "They may be able to identify a very small percentage of high-risk patients."
Even with the expansion of the care team to include social workers and dietitians, the patterns that predict readmission continue to elude caregivers, Merkin says. With the Heritage Health Prize, "the same kind of people that put us on the moon, the same kind of people that put Curiosity's rover on Mars, those are the kinds of people that are now working on these kinds of problems."
The history of prize-based scientific breakthrough stretches long back in time before the prize Charles Lindbergh won by flying nonstop between New York and Paris in 1927. In many cases, the winners of such prizes are building new industries, Merkin says.
Every six months, to encourage contestants, Heritage Health Prize awards some intermediate progress prize money. This also serves as a way of introducing contestants to each other and helping build the healthcare problem-solver community, Merkin says.
One of the perils of big data is the potential that data, having had its personally identifying elements stripped away, can be analyzed such that it becomes again attributable to individuals, threatening their privacy. With HIPAA concerns in mind, Merkin contacted experts who had helped Netflix overcome such concerns during its own data-mining competition. "Our No. 1 issue was keeping the privacy concern at the forefront," he says.
Any science or technology has potentially good and bad uses. When the final prize is awarded in April 2013, the science developed in its service will be made available to research institutions. "We want to make sure that people do not use it for any adverse purposes, so we were concerned initially that anyone could use it not for the betterment of mankind."
This won't be the last time Merkin takes the plunge into such initiatives. He brainstorms with agencies such as the National Institutes of Health and visionaries such as Craig Ventner on new challenges. One puzzle: How to store the genomic data of all 7 billion human beings on the planet. "I think that's equivalent to 25% of all the data that's ever been stored, so now they need new storage devices," he says.
Merkin's even talking to the Centers for Medicare & Medicaid Services, the Food and Drug Administration, and National Institutes of Health about additional opportunities that would help the agencies and regulatory processes perform more efficiently.
Merkin's interests may extend beyond healthcare, but they still train on the tough challenges. Sitting on the Jet Propulsion committee of CalTech's Jet Propulsion Lab, he was one of those experts who signed off on the sky-hook scheme that safely landed Curiosity on Mars. "A lot of the experts said that would never work."
Merkin delights in proving the experts wrong.
"Who would have thought that two bicycle mechanics would have flown over Kitty Hawk?" he says. "There's so much talent out there, and particularly now with technology and the Internet, there's going to be a billion people that didn't have access to education that are going to be able to solve problems and change the world."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Aurelia Boyer, RN, MBA.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"I try to find the right doctor or nurse or administrator—to partner with them—to make those kinds of things really happen, and I think it energizes the IT staff, because they're pushed closer to the actual hospital business than they would otherwise."
The demands keep coming: Decrease length of stay. Reduce admissions. Produce good quality measures for all to see, even as an industry struggles to agree upon which quality measures are most important.
But given a visionary CIO with a passion for data accuracy, accompanied by some physician champions, progress is possible. At New York-Presbyterian Hospital, astute use of data aggregation cut the number of deep-vein thrombosis (DVTs) resulting from venous thromboembolisms (VTEs) by nearly 50% in a 12-month period.
"It's not as simple as you think it's going to be when you start," says senior vice president and CIO Aurelia Boyer RN, MBA. "How are we going to decide who's at risk for DVTs? With a great advocate in a particular physician, we started looking at those things using Amalga."
Amalga, created by Microsoft and now offered through Caradigm, the company's joint venture with GE Healthcare, supports patient-centric analytics, a unified view of data across disparate systems, and perspectives both from the individual patient and across a population of patients.
Among the surprises: more upper-extremity DVTs than expected. Another analysis with a different group of physicians dealing with congestive heart failure resulted in a savings of $1.5 million, Boyer says.
"We were trying to prove that Amalga could do something for us in real time," she says. Typical analysis of quality measures was more retrospective. The secret to moving the needle on DVT was to catch problems before the patients left the hospital, she says.
"It's a multistep problem," says Boyer. "We had to find advocates who really wanted to say, 'What's in the EHR? How do we collect that data? Do we have the exact right data? Once we have the exact right data, do we make sure all the users fill it out perfectly?' "
Another quality improvement effort looked at external wound infections. "You wanted to look at chest tube drainage," Boyer says. "What became very clear, the nursing notes had to be very well filled out in order to have the right data. So if you said it was this kind of chest tube, everybody had to use the exact same words and the exact same criteria, and then we had to show the doctors the data every week, all the time."
So even when a physician documents a patient as being not at high risk for complications, if the data shows otherwise, the mandate is to "do something about that right now, today, not after the patient's discharged," such as being placed on an anticoagulant, Boyer says.
A physician or a service line administrator can champion the change in thinking, but one option not available is to put another layer of people on the problem, Boyer says. "We're working very hard to make it part of your everyday work, so that you do it right the first time, and we don't have to do this collecting of data later," she says.
"It is a culture change to say we can manage these things, and I think we are," Boyer says. It's the same thinking behind New York-Presbyterian's aspirations to be a Level 3 patient-centered medical home. Using a combination of EHR data and analytics, the hospital is targeting diabetes patients and several other diagnosis groups to reduce readmissions and emergency department visits.
As a registered nurse, Boyer has moved up through the management hierarchy of New York-Presbyterian during her 18 years at the institution. "Whether it's as a director of nursing and being administrator on call and having more and more responsibility, I have a fairly process-oriented view of the hospital," she says. "And I actually do this job really to have that impact."
Boyer also represents the kind of CIO who moves more into traditional CMIO roles than usual. "I may be more clinically focused," says Boyer. "I really interact with my IT team about patient care all the time. I'm doing some great desktop work with the guys, asking, 'Do you really understand how the clinicians use this desktop?' Then I try to find the right doctor or nurse or administrator—to partner with them—to make those kinds of things really happen, and I think it energizes the IT staff, because they're pushed closer to the actual hospital business than they would otherwise."
