HIMSS’19: Real Value in Telehealth and Virtual Care

This is the second in a series of blog posts recapping HIMSS’19; you can read all our coverage here.  

My primary purpose at HIMSS’19 was gathering information and ideas for our upcoming report on the front door to care. This report will take a close look at the evolving ways patients first enter the healthcare system. Whether from retail health, telehealth, remote patient monitoring, or remote care apps, HIMSS was full of changing ideas and approaches. The conference had a utilitarian focus, looking less at generic or abstract buzzwords to get people excited, and more at what can be done right now to engage providers, payers, and ultimately patients.

My biggest takeaways:

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them.

Health systems have invested a lot into controlling referrals and leakage. While the PCP remains the central organizing hub of most healthcare, the growth of retail and remote health could lessen the PCP’s centrality in traditional referrals networks.

Unlike the Teladoc model, which employs contracted providers to provide a turnkey outsourced telehealth service, newer entrants offer operational platforms and back-end systems so HCOs can staff and run their own telehealth programs. This allows them to retain control of the patient experience. It’s an easier model for an HCO to understand and use, but whether they adopt such solutions before their competition is an open question.

Behavioral health might finally get its due through Virtual Care apps.

Between shrinking reimbursements and scarce providers, behavioral and mental health care have been the first service line on the chopping block for a while now. PCPs have become the go-to provider for too many behavioral health needs, occupying increasing amounts of time and stretching their expertise thin.

Several of the telehealth and remote health platforms I saw last week had behavioral health components. There were a few well-executed apps dedicated to mental health and wellness, mainly with a CBT/DBT focus and some with solid clinical results. Helping PCPs manage this care and mitigating the effects of comorbidities on patients is an important part of addressing PCP workload and job satisfaction, as well as patient engagement. These virtual care offerings can help struggling PCPs get their patients the help they need, while still working within tight budgetary and scheduling restrictions.

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them. The question is whether health care systems will recognize that in time.

Performance improvement services are becoming a core component of analytics products

With my background in healthcare performance analysis and improvement, I wanted to see how analytics is evolving to become more effective and efficient.

The future of analytics platforms looks less like pre-built dashboards or reports and a lot more like what Visiquate offers. Its embedded employees work directly with customer end-users to execute Agile-inspired improvement sprints supported by their analytics and reporting. Vendors are coming to grips with the challenge of operationalizing analytics for value and performance improvement. The value proposition behind both improved reporting software and process improvement is pretty well understood. Figuring out how to fit it all into an annual budget in an era of shrinking margins is the real hard part here.

Leveraging data to produce specific, actionable recommendations remains a challenge.

A fascinating conversation about AI at the Geneia booth on Tuesday afternoon summed up the current state of AI and machine learning in the clinical world. While access to existing and new kinds of data is increasing and the ability to integrate it is getting more sophisticated, AI and ML still aren’t the clinical tools many expected them to be. Only imaging, an area where the datasets are complete and the challenges are well understood, has really begun to heavily leverage AI/ML. Everywhere else, the barriers to gathering appropriate context and rendering predictive clinical recommendations have yet to be overcome.

Stay up to the minute.

Did You Know?

HIMSS’19: Maturing Market Drives Pragmatism

Even the exhibit hall was calmer with vendors focused on solving specific problems instead of the latest buzzword

Frankly, I was dreading attending HIMSS this year. I’ve grown tired of the hype, the noise and just how little we have accomplished as an industry in the past few years. We have not contained costs, but have increased clinician burnout. We have made only a modest impact on quality, but the lack of interoperability has hampered care coordination. I had become increasingly cynical every year as we approached the big event, dreading more of the same, which is never a good thing.

Yet at the outset, while waiting to board my flight to Orlando, I started meeting many a compatriot in healthcare IT. This did not stop until I landed back in Boston five days later. Those brief meetings always included a hug, checking in with how each other is doing personally and then proceeding to talk about the industry – in that order. I have worked in a wide range of industries over the course of my career, only in healthcare have I experienced such genuine warmth and caring. These brief encounters renew my spirit pushing that cynicism back for this industry is more than just a business, it is about health, and it is about life.

HIMSS’19 Reflections

For the last eleven HIMSS conferences I have attended, there has always been one buzzword or acronym that virtually all vendors on the exhibit floor would latch onto, whether they could deliver those capabilities or not. There was no such word or acronym this year. The hype, the buzz may be behind us, which is welcomed by this analyst and I’m sure most in attendance.

I also noticed that conversations were less about whiz-bang features. Instead, conversations focused on specific problems that can be solved and value delivered to an organization. The industry is quickly moving beyond being strictly regulatory-driven (albeit CMS’s NPRM dropped Monday at HIMSS goes against that) to a more pragmatic market, which is a healthy sign of a maturing industry.

It was clear this year that the EHR war for buyers is over. Those EHR vendors offering a fairly limited, EHR-centric product with few extensions (e.g. analytics, RCM, PHM, etc.) were eerily quiet. EHR vendors with broad capabilities had their fair share of visitors, but the discussions focused on the extension apps and equally important, how to extract value from those significant EHR investments.

In speaking to one of the largest EHR vendors, they were surprised by the interest in PHM among their clients, which has been tepid in recent years. Clearly, CMS’s recent moves to get provider organizations to get serious and start taking on downside risk are being felt. But this vendor went on to say that most prospects simply want someone to tell them what to do to be successful. For companies like Aledade and Evolent this must sound like mana from heaven.

Some quick outtakes from HIMSS’19

  • Acute and ambulatory have been by and large taken care of, yet we still do a very poor job as an industry addressing the “community of health.” Good opportunity for a truly visual, intuitive platform.
  • Ada Health, a Berlin-based small company using AI for self-triage is just entering the US market and has landed Sutter Health as its lighthouse customer. Keep an eye on them – they are interesting.
  • Significant shift among provider-centric vendors who are now signing large deals with payers. Still plenty of mistrust between providers and payers, but if incentives are aligned – it can work.
  • Collective Medical out of Utah has been operating in stealth mode and racked up several payer and provider clients. Compelling value-prop but they will have to move fast as several much larger vendors are looking to do something similar.
  • Many a large health IT vendor does a poor job at data aggregation and digestion (normalization) and are seeking partnerships with a number of small innovative companies that focus on this problem.
  • Apervita, a company that has been around for several years with a business model I never was fond of has completely changed direction. I like what I saw at HIMSS this year. Their work with NCQA is pretty impressive.

The Wrap

HIMSS this year reflects a maturing market. With any maturing market, conferences like HIMSS begin to lose their luster, despite their own self-promotional hype. But what HIMSS does well is to bring together a broad cross-section of the industry and remains a fabulous place to reconnect and network. Does it need to be three and a half days (plus!), I do not believe so. In five years, HIMSS will still be here, but the high water mark was likely last year (barring any major federal incentives a la HITECH). The tide is going out.

HIMSS’19: What to Expect, What I Hope to Find

Next week, most of the healthcare IT industry will descend on Orlando to attend HIMSS’19. This is my 12th year attending HIMSS, an event for me that is more about networking and confirming assumptions than actually learning anything new.

For years now, HIMSS and the multitude of vendors exhibiting there have feasted at the trough of federal largesse ($35B plus), via the HITECH Act passed in 2008 to foster adoption of EHRs. The HITECH Act was successful, driving EHR adoption from the low teens to over 90% today. Though some may question the value of that investment, I personally believe that over time (another 7-10 years) we will reap benefits that far exceed that initial investment.

However, now that we’ve reached that level of adoption, the market has plateaued. Sure, there were hopes of a robust EHR replacement market, but that never materialized. Then there was the hope for huge gains (profits) to be made on the shift from volume to value through the sale of PHM solution suites. That didn’t pan out too well either as the fate of the ACA was left in the lurch with a change in administrations. Also, quite frankly, PHM is a complex sell, requiring significant change management that few healthcare organizations were ready to commit to and few vendors had the services to support.

The provider health IT market is going through a significant transition and it’s not going to be pretty. Clearly, the party is over and one has to wonder: Why does HIMSS continue to exist? Why are all these vendors here? Are we on the Titanic, seemingly blind to the economic icebergs that surround us?

But I digress.

What is important is that the EHR has become the central nervous system to provider organizations. Secondly, this market will continue to consolidate rapidly with few independent EHRs surviving the shakeout. Those left standing will attempt a number of different strategies to drive continued growth in a plateauing market.

  • Acquire other EHR vendors to gain market share (Allscripts, Cerner, CPSI, Harris)
  • All major EHR vendors are pursuing an extension strategy moving from EHR to supporting PHM, RCM, analytics, etc, though their capabilities in these adjacent areas vary wildly.
  • Expansion into new markets. Epic is looking to dentistry and insurance. Allscripts, life sciences and payers with Veradigm. Cerner, government and payers. All large acute/ambulatory EHR vendors are actively pursuing overseas markets, with Meditech particularly strong in Canada.

It remains to be seen how successful these strategies will be but rest assured, even if successful, no EHR vendor is completely safe from a future acquisition.

This sets the stage for what to expect at HIMSS’19:

  • All vendors will continue to tout the momentum they have in the market as if this market will remain forever on a hockey stick trajectory, but very few can back it up.
  • AI/ML will be just as pervasive this year as last, permeating all aspects of health IT, but likely very little demonstrable proof of scale.
  • A multitude of disease-specific, chronic management solutions but no vendor with a true portfolio of best-in-class solutions on a single platform. Resmed appears close to enabling such a platform for respiratory ailments.
  • More FHIR use cases.
  • Plenty of patient-centric this, consumer-centric that but all a head fake as it is really about capturing patient revenue via online bill pay and filling vacant appointment slots.

And what I hope to find at HIMSS’19:

  • An AI/ML company that has truly scaled its solution across an enterprise in at least two customer deployments.
  • Clear metrics from EHR vendors on the level of adoption and use of FHIR across their client base.
  • An engagement solution that is looking beyond the near-term volume/revenue needs of a healthcare organization to how to truly engage patients/consumers in their health e.g. Aetna/Apple’s Attain app.
  • How vendors are assisting their customers in achieving demonstrable, defendable ROI from their solutions. Health Catalyst stands out here.

May your trip to HIMSS’19 be a success, however you define it. And if you see us in the halls, do not hesitate to stop and say hello – maybe we’ll have a few quick on-the-fly notes to share.

Once again, it is that time of the year for our annual pilgrimage to HIMSS. While many attendees focus on the sheer size of the exhibit hall or packing their schedule full of meetings, we wanted to highlight the other major part of the event: education sessions. Below are this year’s recommendations from the Chilmark analyst team, organized according to our domains of research.

We plan to attend many of these sessions, so if you would like to meet up afterward, please feel free to email anyone on the team to coordinate meeting at the session to discuss the topic further.

Analytics

Communicate Value and Build Support for Enterprise Analytics

Tuesday, Feb. 12, 4:15pm – 5:15pm, Convention Center W304E

Speakers:

  • Chris J. Donovan, Executive Director, Enterprise Analytics, Divisions of Finance, Cleveland Clinic
  • Andrew Proctor, Senior Director, Business Intelligence, Medical Operations Division, Cleveland Clinic

Why AttendDescribes the experience that Cleveland Clinic has had since they embarked on an enterprise analytics endeavor since 2014. This session will provide insights into how to achieve strategic leader buy-in and the ‘why’ of particular use cases vs. focusing on the technological ‘how.’

Leveraging Data Analytics to Complement Value-Based Approaches

Wednesday, Feb. 13, 8:30am – 9:30am, Convention Center W308A

Speaker:

  • Nathan Riggle, Director of Analytics, Mercy ACO

Why AttendACOs are investing in various advanced analytics solutions with mixed results. This session will explain how to use data to develop the right growth strategy and clinical pathways to truly realize the benefits of these investments in valued-based contracts.

Interoperability

Five Best Practices for Improving Transitions in Care with HIE

Tuesday, Feb. 12, 10:30 – 11:30am, Convention Center W315A

Speakers:

  • Andrea Gelzer, SVP and Corporate CMO, AmeriHealth Caritas Family of Companies
  • Joe Miller, Director, Strategy and Innovation, AmeriHealth Caritas

Why Attend: This session should provide ideas about the value of HIE from a payer perspective.

Improving Care Coordination with Nationwide Data Exchange

Tuesday, Feb. 12, 1:30pm – 2:30pm, Convention Center W230A

Speakers:

  • Arthur M. Lauretano, CMO, Circle Health
  • Jitin Asnaani, Executive Director, Commonwell Health Alliance

Why AttendThis should be a good update on CommonWell, including its integration with Carequality. Hopefully, they will also talk about how TEFCA will affect both CommonWell and Carequality.

Care Management

Empowering Consumers with Data to Improve Chronic Disease Conditions

Tuesday, Feb. 12, 1:30pm – 2:30pm, Convention Center, W315A

Speakers:

  • Joshua Riff, CEO, Onduo
  • Mark Talluto, VP of Strategy and Analytics, Blue Cross Blue Shield Association

Why Attend: Self-directed care management utilizing digital health apps to address chronic conditions is still in its earliest stages. This session will talk about some of the new technologies that payers are using and the strategic partnerships they are forming help payers meet the needs of their members.

Bending the Cost Curve with Whole-Person Care

Tuesday, Feb. 12, 4:15pm – 5:15pm, Convention Center W300

Speakers:

  • Teddy Shah, VP, Advisory Services, Optum
  • Jeffery Arnold, Medical Director, Santa Clara Valley Health and Hospital System

Why Attend: Safety-net providers have a large number of Medicaid patients that often have unique requirements. This session will address how Santa Clara Valley Health and Hospital System in CA has implemented specific strategies to address the social, clinical and behavioral needs of their high-risk Medi-Cal beneficiaries.

Population Health Management

Public Health Extension of the Primary Care EHR

Tuesday, Feb. 12,  1:30pm – 2:30pm,  Convention Center W311E

Speakers:

  • Nivedita Mohanty, Chief Research Officer, AllianceChicago 
  • Fred D. Rachman, Chief Executive Officer, Alliance of Chicago Community Health Services

Why AttendVarious public health systems have not been linked to primary care EHRs limiting the efforts of broader population health efforts. This session will examine some of these issues and the progress that is being made by an organization in the greater Chicago area.

Population Health As Ecosystem Engineering

Tuesday, Feb. 12, 10:30am – 11:30am, Convention Center, W204A

Speaker:

  • Richard Biehl, MS-HSE Program Director, UCF College of Engineering & Computer Science

Why AttendBuilding a population health infrastructure is a complicated endeavor that requires a different approach than provider organizations are used to since there is a focus beyond the ‘four walls’ of their facilities. This session will examine how a new ‘ecosystem’ approach for population health contrasts with the traditional ‘system of system’ approaches.

Patient Engagement

Opening Keynote: Will Consumer-Directed Exchange Disrupt the Healthcare Marketplace?

Tuesday, Feb. 12, 8:30am – 10:00am, Convention Center, Valencia Ballroom

Speakers:

  • Aneesh Chopra, President, CareJourney
  • Seema Verma, Administrator, Centers For Medicare and Medicaid Services

Why Attend: Seema Verma, Aneesh Chopra, and Hal Wolf (moderator) will discuss how consumer-directed efforts are impacting healthcare delivery. If CMS is going to make any big announcements at HIMSS, it will be during this session.

Elevating the Patient’s Digital Experience

Tuesday, Feb. 12, 12:00pm – 1:00pm, Convention Center W311A

Speaker:

  • Aditya Bhasin, VP Software Design & Development, Digital Solutions, Stanford Health Care

Why Attend: This session will take a look at Stanford Health Care’s efforts to use digital health to transform the patient experience across their organization. It will provide a review of what has and hasn’t worked so far as well as recommendations on how other provider organizations might learn from their experience.

Payer-Provider Convergence

Providing Payer Insights to Clinicians at the Point of Care

Tuesday, Feb. 12, 12:00pm – 1:00pm, Convention Center W315A

Speakers:

  • Nancy Beavin, Interoperability Leader, Humana Inc

Why Attend: Basic primer and update on how payers are trying to delivering insights into EHRs at the point-of-care. This session will address some of the most pertinent challenges to this topic including bidirectional information exchange and provide an overview of how Humana has tried to tackle this issue to date.  

Unifying Provider and Payer Data to Propel Value-Based Care

Thursday, Feb. 14, 8:30am – 9:30am, Convention Center W208C

Speakers:

  • Claudia Williams, CEO, Manifest Medex
  • David Kates, CTO, Manifest Medex
  • Erica Galvez. Chief of Staff and VP of Programs and Partnerships, Manifest Medex

Why Attend: This will provide a good update on how Manifest Medex is working through the challenges of trying to create a unified patient record across a large geographic region (CA) with multiple payers and numerous providers organizations. It will also provide some insights into how this HIE is being used to support various value-based payment initiatives across California.

Other Session Topics:

If You Build It, Build It Well: User-Centered Design and Agile Development Provides User-Delight

Wednesday, Feb. 13, 4:00pm – 5:00pm, Convention Center W307A

Speaker:

  • Subha Airan-Javia, Associate Professor of Medicine, UPenn; Chief Medical Officer, TrekIT Health, University of Pennsylvania Health System

Why Attend: The chronic usability problems of healthcare applications must be addressed. This session is about one organization that is trying to incorporated mainstream ideas for healthcare users.

Leveraging Technology to Improve Prior Authorization

Wednesday, Feb. 13, 2:30pm – 3:30pm, Convention Center W204A

Speakers:

  • Heather McComas, Director, American Medical Association
  • Tyler Scheid, Senior Policy Analyst, American Medical Association

Why Attend: This session will provide highlights on the growing problem and specific challenges that physicians face with prior authorizations. Beyond just identifying specific challenges, this session will also provide an overview of the technology solutions to achieve higher rates of automated prior authorization.

What other sessions and events are you looking forward to? Tell us in the comments below and maybe we can see you there!

HIMSS18 – A Cacophony, Not Yet a Symphony

My post before HIMSS talked about how jazzed (not jaded) I was to be attending my 20th HIMSS conference. Now that HIMSS18 is in the bag – what did I learn?

ML and AI

On Monday I presented the results of our AI survey at the Machine Learning & AI for Healthcare preconference event at the Wynn. Although there were a few hundred seats, the event sold out weeks in advance. A number of folks I knew who planned to buy a ticket at the door were shut out. So that’s a lesson – when it comes to attending hot topics, don’t procrastinate!

Keynote speaker Lynda Chin from the University of Texas compared using of AI to having a paralegal on your team – it’s someone intelligent that could pull resources together to help you make better decisions. She summed it up simply: “Machines serving humans, not humans serving machines.”

Many other speakers came from large health systems and spoke to important use cases:

  • Kaiser Permanente: Colorectal cancer detection 1-2 years earlier with AI.
  • UPMC: Game-changing pediatric readmissions prediction.
  • Duke Institute for Health Innovation: Implementation of AI with thousands of input features.
  • Stanford Health Care: Working with “small” vs “big” data.
  • Brigham & Women’s: Costs of short-time cancellations vs no-shows.

It’s become a given that these leaders and their vendors use AI and use it well. My favorite from the above examples was Srinivasan Suresh, CMIO at Children’s Hospital of Pittsburgh of UPMC. His slide highlighted that, although he had no impressive AI or ML credentials, he was still able to use these kinds of tools successfully to predict pediatric readmissions due to seizures, asthma, and pneumonia, which led to more effective interventions.

HIMSS and health IT may be more of a cacophony than a symphony, but I’m glad to be in the orchestra.

Keynotes

AI and the cloud were key themes this year and have become mainstream topics. For our views on Eric Schmidt’s keynote about data, analytics, and AI, see our earlier HIMSS18 recap blog.

Glad I had teammates that made it into Seema Verma’s CMS keynote the next day – her announcement about patient data access, open APIs, and Blue Button 2.0 was welcome. You may recall the previous year, given the change of administration, there was little that CMS or ONC could say about anything. Although we’re seeing some progress, it doesn’t seem substantial enough to move the needle on value-based care.

Natural Language Processing (NLP)

A big part of my week was meeting with NLP vendors. Chilmark Research is close to releasing our major report on this topic, and it was great to get insights from more than a dozen vendors. Some of the smaller ones are highly focused on specific use cases (Health Fidelity and Talix on risk stratification; Clinithink on matching patients to clinical trials). 3M and its partnership with Alphabet’s Verily are a powerful combination on determining the “dominoes” of costs and care. Also of note: M*Modal’s virtual provider assistant and use of ambient devices, as well as Nuance’s partnership with Epic to add more conversational AI functionality. We are seeing voice assistant success paving the way to virtual scribes – those that can “whisper” in the physician’s ear will be most valuable to ensure that decision support is not bypassed by passive systems.

Interoperability

As John Moore posted in his earlier HIMSS18 recap, it’s sad (well, infuriating) that we still have to address interoperability. I attended two events held by the Strategic Health Information Exchange Collaborative (SHIEC), which has been successful in providing a rallying point for 60 HIEs and 40 vendors to share knowledge and provide comments to ONC regarding TEFCA and data exchange. But it only represents a fraction of the hundreds of private and public HIEs in the country, so there is still a long road ahead. A payer committee was a welcome sign that convergence was part of their agenda.

Sensors

At the opposite end of the interoperability spectrum, I attended a session by Houston Methodist on body sensors, where the distances are measured in inches and the signals are often so weak that temperature or motion (such as a kicking baby) are enough to throw them off. Sensor network fusion is the frontier – the more information you can capture from more places with more context, the better. For example, one of Methodist’s use cases was rapidly predicting a patient fall.

I also met with Somatix, a small vendor with a big idea we’ve been hearing about for years – using data from wearables to track more routine activities of daily living (some of which, like smoking, are harmful). The vendor is attempting to take this to the next level with more accurate gesture detection and predictive analytics so appropriate (and even real-time) interventions can be made using specific apps. As Brian Eastwood recently posted, we’re still waiting for wearables to provide insight. I didn’t sport a wearable at HIMSS18 (I broke two and lost another in 2017), but I’m on the lookout for a good, waterproof one.

Image Interpretation

Another key area of focus for us is the use of AI to interpret digital medical images. An impressive talk by University of Virginia and the National Institute of Health included use of speech recognition (using Carestream and Epic) to embed hyperlinks of AI-recognized areas of interest into reports for the EHR. The two-year effort showed productivity improvements of 3x over unassisted analysis and reporting.

A presentation by Entlitic claimed AI-enabled “superhuman” techniques able to detect lung cancer two years sooner than existing approaches. Their solution made it easy to compare an existing case to similar cases where timelines of data showed disease progressions. The company has 65 radiologists that label their training data, claiming only 1 in 4 that apply for the job pass their test. We’ll dive into detail about these kinds of advances in our Digital Medical Imaging Report scheduled for Q4’18.

Image Exchange

I spent time with Ambra, a major provider of image exchange solutions (others include Nuance and lifeIMAGE). Aside from the challenge of the size of medical images, it always surprises me how difficult it is to move them around and make them available despite good standards (DICOM). It was only recently that Epic, for example, addressed image exchange, and it’s not part of many HIEs. I’m glad to see we’re moving beyond the vendor neural archiving discussion and toward a focus on the cloud and useful exchange of images in clinician workflow.

Receptions

I also attended half a dozen receptions during the week. The biggest was sponsored by a large consulting firm. It was an evening of fun, but it reminded me of what was right and wrong about our industry and a conference in Las Vegas – who’s really paying that bill? My last reception was with BetterDoctor, which specializes in the quality of provider directory data. It always seemed ironic to me that the most regulated profession in the world has such a problem with accurate information (retirement, credentialing, locations, and so on).

My Ears Hurt

To rework my “I’m Jazzed” comment from the top with a music metaphor, HIMSS is more like a blaring of thousands of different instruments with each of the “sections” competing to be louder than the other – and the sounds of Vegas don’t help. There are many great musicians and an increasing number of duets (e.g., partnerships, ACOs), but we’re still playing off too many different pages. Adding to the problem is the conductor (the government) changing every few years.

It may be more of a cacophony than a symphony, but I’m glad to be in the orchestra. I hope you are, too.

HIMSS18 – A Bipolar Experience

HIMSS18 Review 3 of 4

A decade of attending the annual HIMSS conference and I leave both excited and depressed. Excited and enthused by meeting so many people who are dedicating their lives to affect positive change by improving healthcare delivery through IT. Depressed as yet again I find a lack of real leadership and vision among many who repeat the years’ worn phrases of interoperability, patient-centered care, reducing physician burden, and the like.

“Oh please, can’t we just get on with it,” I scream to myself.

In keeping with the bipolar theme that is HIMSS, following are my takeaways, in an up-down fashion.

Up: Anthem goes public on its deal with Epic r/e HealthyPlanet. This partnership is an exciting step in enabling provider-payer convergence wherein Anthem will embed IP (risk, prior authorization, claims adjudication, etc.) into HealthyPlanet and take HealthyPlanet to market with wrap-around services.

Down: Head-in-the-sand vendors who are entrenched in FFS model. These vendors told me point blank that the market will revert back to FFS, that value based care is DOA. Gotta wonder what they’re smoking.

Up: Telehealth going mainstream. Saw loads of examples/demos of telehealth with direct or near-direct integration to the EHR. Been hearing about the coming of telehealth since I started this company in 2007. I believe we are finally there.

Down: Almost zero discussions on managing the costs of care/cost containment. There was some discussion on reducing clinical variability – but beyond that, HIMSS was devoid of any deep conversations on this critical variable in the value equation.

Up: Clear demonstrable, scalable use cases for AI. I was particularly impressed with the work 3M has done with Verily, leveraging Deep Mind technology for specific measures. Though just released, 3M has already landed 17 provider clients and 2 payers.

Down: The preponderance of AI vendors with little sense of scaling their solution. Many of the AI vendors I talked to have ongoing projects with “Big Brand” healthcare systems. That’s great – but disturbingly, few have taken the next step to address how they plan to scale their solution within an organization for widespread adoption and use.

Up: New solutions leveraging FHIR to insert actionable insights directly into clinical workflows. This is near nirvana for me, as it gets beyond the Herculean task of interoperability writ-large and tackles those points where significant friction and opportunity exists.

Down: One policy pundit after another talks yet again about the need for interoperability. Frankly, this is no longer a technical issue. Interoperability is a policy issue and really does not belong at an event such as HIMSS – where we should be talking about the future, not rehashing the past ad nauseum.

Clearly, a lot of work lays ahead for us in the health IT arena, which provides us all meaningful work going forward. And frankly, we are in but the top of the third inning – there is so much to do, it really is an amazing time to be in the healthcare IT market.

Thankfully, we are at last moving beyond the prescriptive use of IT via meaningful use, transitioning to meaningful insights from the data we are collecting and placing into clinical workflows. There is a near unfathomable opportunity to begin leveraging clinical, genomic, and other data sets that will lead us to dramatic improvements in care delivery – improvements that are likely beyond our comprehension at this time.

Despite some of my downer moments at HIMSS18, I could not be more excited for what the future holds for us as an industry – and, personally, in how even I and my care team will leverage new insights to more effectively and efficiently manage my own condition.

HIMSS18: Care Management and Engagement

HIMSS18 Review 2 of 4

By Matt Guldin and Brian Eastwood

Having returned and (mostly) recovered from HIMSS18 in Las Vegas, the Chilmark Research team wanted to share our thoughts on what we saw in presentations and heard in conversations. This post includes our analysis and insights on Care Management and Engagement; additional posts will consider Analytics/AI and Interoperability as well as Population Health Management and Convergence.

Overall, we were pleased to see progress on telehealth, as well as a broader understanding that healthcare organizations (HCOs) will get patient engagement right only when they assemble a comprehensive collaborative health record (CHR). On the other hand, we were disappointed in slow progress toward addressing two prominent public health issues — the opioid crisis and behavioral health — as we didn’t see many large-scale use cases for engagement in general or episodic payments in particular.

There certainly was an increased awareness and discussion of integrating behavioral health into primary care and care coordination at HIMSS18. However, this shift is still in its very early stages.

Care Management Themes

Lack of focus on the opioid crisis: Last week, the CDC released a Vital Signs report that showed a 30% increase in emergency department visits due to suspected opioid overdoses from July 2016 to September 2017. Despite this continued public health crisis, there was a general lack of targeted solutions or marketing focused on this topic at HIMSS18.

Instead of vendors helping providers to help address this problem at the point of care or service, though, there is a “top-down” approach at the state level emphasizing tighter prescription regulations, inventory control, and tracking. There were some specific examples we did find though. One vendor, Venebio, has created a predictive analytics solution to identify and predict the specific overdose risk over the next 12 months for a particular patient; Venebio is selling to state Medicaid agencies, payers, and providers. Collective Medical, through their EDIE report, is helping to provide a list of current medications for ER patients which facilitates identifying drug-seeking patients.

Integrating behavioral health is in its early stages. There certainly was an increased awareness and discussion of integrating behavioral health into primary care and care coordination, including several educational sessions on the topic. However, this shift is still in its very early stages. To be determined: What types of models by the work best in varied primary care settings; how IT solutions such as telemedicine and digital health might help to address various challenges, including a lack of sufficient behavioral health providers and lengthy behavioral health service queues; and the role of self-support tools, which have high levels of engagement and effectiveness.

Scaling episodic payments remains a huge challenge. While a number of HCOs have already engaged in an episodic payment for a particular procedure or two in a service line (such as cardiology or orthopedics), scaling these efforts across several service lines for an HCO remains a challenge as solutions remain immature and most HCOs are in the early stages of forming post-acute networks. Some of the biggest challenges include the timely notification of when a patient enters into an episode, an inability to track patients across and outside the HCO, and an effective patient engagement strategy that is customizable to meets the needs of a patient in a particular episode.

Engagement Themes

Data matters. If there was a unifying theme to the preconference Patient Engagement & Experience Summit, it was the need to begin patient engagement efforts with a CHR – one combining clinical, claims, consumer, financial, and patient-generated health data to provide a comprehensive view of a patient’s diagnoses, social determinants of health (SDoH), and barriers to receiving care. Record in hand, healthcare organizations (HCOs) can shift away from generic patient outreach – think portal message, email, or even snail mail flier – toward outreach that better meets patients’ individualized needs.

Use cases remain simple. The operative word above is can, as HCOs aren’t yet meeting individualized needs. Many use cases at the preconference summit highlighted a single condition: Asthma, colon cancer, sepsis, substance abuse, outpatient physical therapy, etc. Two factors seem to cause this. The first reflects the adage that you can’t manage or improve what you cannot measure. Since HCOs are measuring readmission rates, HCAPHS scores, and joint replacement bundled payment performance as if their financial lives depended on it (and they do), patient engagement and experience efforts are frequently tied to these metrics.

Behavior change is hard. The second factor is the challenge of personalization. It’s fairly easy to use a CHR to identify what makes a patient unique (thanks to advances in AI and machine learning that colleagues Ken Kleinberg, Brian Edwards, and Brian Murphy covered in a separate HIMSS recap). It’s much harder to align those unique characteristics to specific actions that will improve clinical outcomes. As noted by Dr. Heather Cole-Lewis, Johnson & Johnson’s Director of Behavior Science, such alignment requires context, and today’s engagement solutions have not been designed to handle the complexity that comes with that context. For example, to accomplish a care plan goal of lowering blood pressure to 140/90, Cole-Lewis said, a patient may need to do one (or more) of at least seven things:

  • Start doing something.
  • Stop doing something.
  • Keep doing something.
  • Learn about doing something.
  • Do something once.
  • Do something for a year.
  • Do something forever.

Telehealth is maturing. If there was a bright spot for the engagement domain at HIMSS, it was the level of activity in the telehealth market. (Full disclosure: I wrote my first “telehealth is ready to take off” article in 2013.) Nathaniel Lacktman, chair of the law firm Foley & Lardner’s telehealth industry team, pointed out that the recently passed federal budget includes several extensions of telehealth reimbursement under Medicare, particularly for kidney dialysis, telestroke, and the patient-centered medical home. This should provide HCOs with the impetus to initiate or expand telehealth efforts that have otherwise stalled.

Plus, as John Moore pointed out in his HIMSS18 recap, telehealth vendors are pushing to cover the vast area between low-acuity DTC services and inpatient services through a variety of strategies. These include offering chronic condition management, supporting outpatient care settings, or unifying their inpatient and at-home UX. Stay tuned for Chilmark’s forthcoming report, Telehealth Beyond the Hospital, which will examine these strategies in much greater detail and identify which vendors are best positioned to execute in this market.

Give Us Your Data – Is it Really That Easy?

HIMSS18 Review 1 of 4

By Ken Kleinberg, Brian Murphy, and Brian Edwards

What’s inside the black box of algorithims?

During Eric Schmidt’s opening keynote at HIMSS18, he asserted that, given the state of algorithms today, it’s possible to take any large data set and make strong predictions – and healthcare is no exception. There’s no need for clinical content knowledge, rules, or past experience. His statements were met with plenty of skepticism – less about the capabilities of Alphabet and its algorithms, and more about the realities of gaining access to the right healthcare data sets. This is not trivial.

So who should get data from who? What about patient consent? Who can be trusted? Historically, health systems have done their own analytics and research within the boundaries of their own systems. Vendor analytic solutions were implemented on site. Even this limited scenario presented complex challenges – in particular, just bringing data together to a point where it could be analyzed. Transferability of models was difficult, and costs were not shared. The use of analytics was therefore sparse, mostly limited to research and quality improvement.

Bulk data access will be critical for the industry to move beyond the current artisanal methods of building and maintaining data stores for analytics purposes.

Slowly but surely, the situation is changing. The cloud is becoming much more accepted, with many options possible (private, public, hybrid). Algorithms, enabled by rapidly advancing hardware/computing power, are capable of dealing with much larger and more complex data sets. Data operating system approaches can stream data in a liquid fashion from multiple locations/sources, reducing the need for centralized repositories.

A next step as data becomes more available is to fully utilize it. Advances in natural language processing (NLP) are able to extract/mine useful features from unstructured data such as text, faxes, and reports. Algorithms can increasingly use incomplete, messy, or ill-defined data and “fill in the blanks.” At a certain scale, data quality becomes less of a factor in conducting analytics.

Despite the black-box nature of AI systems, they can still be validated using objective methods, such as how and what they were trained upon, and how they perform in real-world clinical scenarios vs. human performance.

Whose Black Box?

There is also a lot of healthy discussion about how AI systems make decisions. The primary concerns are black-box algorithms and a lack of data transparency. This even reached a point where a major educational institution recently recommended that governments not rely on any AI or algorithmic systems for “high stakes” domains, such as healthcare technology, where the way a system makes a decision cannot be understood in terms of due process, auditing, testing, and accountability standards.

Despite the black-box nature of these AI systems, the fact is that they can still be validated using objective methods, such as how and what they were trained upon, and how they perform in real-world clinical scenarios vs. human performance. As long as they are not used in closed- loop systems, and as long as there is a human expert able to accept or dismiss their recommendations, they provide valuable input (before or after) for difficult cases (such as whether surgery or therapy is the best course of action). They may also serve as a last resort with the proper consent (as with a terminal cancer patient).

So that all is highly promising – but is healthcare ready to hand this data over?

Flat FHIR and Analytics

Percolating below the surface at HIMSS was disquiet about the “bulk data transfer” proposal. This proposed method would make large sets of data (think cohort-level data) more freely available for analytics purposes. It will allow a user or program in one organization to issue a broadcast query to the country at large and receive patient data from other organizations. For example, an ACO quality manager could issue a query to a community and get all of the relevant data for patients in the ACO.

This proposal, also known by the name “Flat FHIR,” is part of the TEFCA discussion (Trusted Exchange Framework and Common Agreement) insofar as such queries are a contemplated use case. But among people who are paying attention to this proposal, there are unanswered questions.

Open-ended queries arriving from anywhere in the healthcare system are not currently part of most HCO’s IT capacity plan:

  • Will organizations end up having to add more compute and network resources to satisfy such queries?
  • Does TEFCA’s requirement to provide non-discriminatory access mean that organizations will not be able to implement reasonable network traffic and quality-of-service controls?
  • If patients have different consent profiles in different organizations, how should a query recipient satisfy the request?
  • Will organizations have to establish revenue share agreements based on pro-rata data contributions?
  • Will the fact that TEFCA puts the onus on the query receiver to reconcile medications, allergies, and problem lists mean that the receiver must verify that its data is current with proximate organizations before satisfying the original query?

Such questions represent the tip of the iceberg. As a practical matter, before the bulk data transfer proposal can ever be a day-to- day reality, many technical, non-technical, and financial questions must be resolved.

Despite these questions, bulk data access will be critical for the industry to move beyond the current artisanal methods of  building and maintaining data stores for analytics purposes. After all, analytics has more to offer than the dashboards and reports that describe the recent past. HIMSS18 was less a venue to air out the challenges associated with making bulk data transfer a reality than it was an opportunity to preview some of the advanced and predictive analytics use cases it could enable.

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