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:
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.
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.
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.
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.
Matt Guldin · 2 years ago
Liz Gavriel · 4 years ago
John Moore · 2 months ago
John Moore · 2 months ago
Alex Lennox-Miller · 3 weeks ago
Walgreens ‘Front Door to Care’ Strategy is Building Horizontally
Last Tuesday, Microsoft and Walgreens announced a strategic partnership aimed at “transforming healthcare delivery,” including a commitment to a “multiyear research and development investment.” The partnership intends to create new care delivery models, retail innovations, next-generation health networks, integrated digital-physical experiences, and care management solutions.” Additionally, Walgreens will pilot 12 store-in-store “digital health corners” featuring “select health care-related hardware and devices” in 2019.
Through the partnership, Walgreens hopes to improve access to virtual care and other healthcare services, make better use of data with analytics in community settings, and to create personalized healthcare “experiences.” The goal is to improve patient health outcomes, lower overall healthcare costs, and better integrate IT between participants in the healthcare ecosystem. They plan to accomplish this via:
This consumer-focused platform sounds like it will be part of a larger ecosystem aimed at connecting consumers, providers, pharma manufacturers and payers supported by Microsoft’s cloud, AI and IoT technologies. Additionally, Walgreens will transition the majority of the company’s IT infrastructure to Microsoft Azure.
This and other partnerships (see Figure 1) are part of a larger strategy for Walgreens to be the new ‘front door to care’–bringing healthcare to where patients and customers want to receive it. Walgreens can make it easier for patients to access care since 75% of the United States population is within 10 minutes of a Walgreens.
The question now is whether Walgreens can scale its various partnerships quickly enough to contribute to satisfy investors or to attract payers and employers looking to drive cost savings.
Each partnership is different in terms of complexity and will scale at its own pace (see Figure 1). Some will begin to show more immediate results and some will require multiple years to be successful. Here are some of the key observations and unanswered question about the most recent announcement.
At the J.P. Morgan Health conference, management stated it has all of the healthcare services that Walgreens needs at this point through the various partnerships it formed over the past 18 months. The question is how quickly Walgreens can execute on them. Walgreens management stated the partnership with Humana has gone well, but it is still very early days, and the company can’t make projections about the scope of the rollout beyond the initial 2 locations in the Kansas City area. However, the positive results of the LabCorp partnership mean that it will expand to 600 stores over the next few years.
While customers may already see benefits from these partnerships, whether investors will have the patience to allow these partnerships to mature is an open question. Management has been under pressure to explain how these various partnerships will contribute to the companies’ financial performance.
Walgreens announced a new digital consumer platform, Find Care Now, last July to help consumers connect to an array of services offered by its provider partners, Walgreens-owned health services, and third-party providers including telehealth services (MDLive and DermatologistOnCall) and on-demand doctor house calls (Heal), where available.
Find Care Now will be hosted on Microsoft Azure with plans to enhance it with chronic disease management and more patient engagement apps. Whether the apps developed with Verily will be included is unclear. Walgreens plans to develop a separate B2B platform with Microsoft with services for payers and device manufacturers.
The overwhelming majority of Walgreens’ 370+ retail health clinics use Epic’s EHR. Announced in Nov. 2015, the rollout was fully completed in March 2017. Walgreens announced 14 new partnerships with healthcare systems, such as Advocate Health Care in Chicago and Swedish Medical Center in Seattle, in which the health system operates clinics inside Walgreens retail stores. These health systems hire the providers, oversee patient care, and bring in their own EHRs. The question is how, and more important if, Verily and Microsoft might work together with Epic to find synergies from the solutions each is creating with Walgreens.
Walgreens has a different strategy to its ‘front door to care’ model compared to Aetna-CVS and Walmart which relies upon a multiple ‘horizontal partnerships.’ The question now is whether Walgreens can scale its various partnerships, especially with Humana, quickly enough to contribute to satisfy investors looking for better financial performance or to attract payers and employers looking to drive cost savings.
2019 Predictions: M&A, Big Tech, and the Fate of ACOs
The Meaningful Use gravy train finally came to an end in 2018. As the strongest EHR vendors struggle to define new revenue streams, weaker ones faded from view through acquisitions or leveraged buy-out. Meanwhile, funding for ‘digital health’ start-ups continued to increase, though it likely hit the high water mark in 2018. And lest we forget, Amazon, Apple and Google continue their forays into the healthcare sector as the market is simply too big to ignore.
So what’s in store for 2019?
We brought together our analysts’ brain trust and came up with the following baker’s dozen of 2019 predictions. Over the near decade of making these annual predictions, our batting average has consistently been well above .500, so don’t ever say we didn’t give you an advanced warning on the following:
Revenue cycle management M&A activity will continue to pick up with the most notable acquisition by Optum as it doubles down on its Optum 360 managed revenue cycle business and acquires Conifer Health Solutions from Tenet.
Despite the hype and media attention around alternative primary care clinics (e.g. Oak Street Health, Chen Med, One Medical), the actual number of physical locations serving patients will remain paltry at less than ten percent of the number of retail health clinic locations.
Walgreens will likely make the first move to acquire Humana in 2019, but Walmart will outbid Walgreens to win Humana over.
The number of FDA approvals for algorithms in 2018 was impressive and shows no signs of abating. Additionally, 2020 will see a further tripling of regulatory approvals for AI.
Consumers’ use of telehealth will continue to see rapid growth and rising competition leading to significant consolidation among the plethora of vendors. By year-end, a major non-healthcare-specific consumer brand will join the mix, and the market will be down to five direct-to-consumer (DTC) nationwide brands.
By the end of 2019, every major healthcare analytics vendor will provide a cloud-hosted offering with optional data science and report development services.
Cloud offerings have become far more robust, concurrent with HCOs’ struggles to recruit IT talent and control costs. Amazon’s AWS and Microsoft’s Azure will be clear winners while Google’s own cloud infrastructure services will remain a distant third in 2019.
Laws and regulations to-date have not compelled providers to freely share data with patients. ONC’s information blocking rule, which will be released before the end of 2018, will make it easier to transfer data to other organizations but will do little to open the data floodgates for patients, clinicians, and developers.
Despite loud protests, the vast majority of provider-led MSSP ACOs will take on downside-risk as CMS shows flexibility in waivers. However, hospital-led ACOs, who continue to struggle with standing up a profitable MSSP ACO, will exit the program in 2019.
Continued changes in post-acute care reimbursement, especially from CMS, combined with the migration to home-based services, puts further economic strain on these facilities. Nearly twenty percent of post-acute care facilities will shutter or merge in 2019.
The warning signs are there over the last couple of months that the stock market has become skittish. This will extend well into 2019 (if not lead to a mild recession). It will hardly be an ideal time to do an IPO, and those planned by Change Healthcare, Health Catalyst and others will wait another year.
Elon Musk will have a nervous breakdown leading him to reinvent the healthcare system from his bed during his two-week recovery at Cedars-Sinai.
Revisiting Our 2018 Predictions
As is our custom here, we like to look back on our predictions for the closing year and see just how well we did. Some years we do amazingly well, others we over-reach and miss on quite a few. For 2018, we got seven of our 13 predictions spot-on, two were mixed results and four predictions failed to materialize. If we were a batter in the MLB we would have gotten the MVP award with a .538 batting average. But we are not and have to accept that some years our prediction average may hover just above the midpoint as it did this year.
Stay tuned, 2019 predictions will be released in about one week and it is our hope that they will inspire both rumination and conversation.
(Note: the bigger and plain text are the original predictions we made in 2017, while the italic text is our review of 2018).
Major mergers and acquisitions that mark the end of 2017 (CVS-Aetna, Dignity Health-CHI and rumored Ascension-Providence) will spill over into 2018. Both Humana and Cigna will be in play, and one of them will be acquired or merged in 2018.
MISS – neither happened. However, Cigna did pick-up PBM service Express Scripts and rumors continue to swirl about a possible Humana-Walmart deal or more recently, even a Walgreens-Humana deal.
Hot on the health heels of CVS’ acquisition of Aetna, growth in retail health reignites, albeit off a low overall footprint. By end of 2018, retail health clinic locations will exceed 3,000 and account for ~5% of all primary care encounters; up from 1,800 and ~2%, respectively, in 2015.
MISS – Modest growth in 2018 for retail health clinics with an estimate of around ~2,100 by year’s end. Telehealth, which is seeing rapid growth and on-site clinics may be partially to blame.
In a bid to one-up Samsung’s partnership with American Well, and in a bid to establish itself as the first tech giant to disrupt healthcare delivery, Apple will acquire a DTC telehealth vendor in 2018.
MISS – Apple continues to work on the periphery of care with a focus on driving adoption of its Health Records service in the near-term with a long-term goal of patient-directed and curated longitudinal health records.
Despite investments in population health management (PHM) solutions, payers still struggle with legacy back-end systems that hinder timely delivery of actionable claims data to provider organizations. The best intentions for value-based care will flounder and 60% of ACOs will struggle to break even. ACO formation will continue to grow, albeit more slowly, to mid-single digits in 2018 to just under 1,100 nationwide (up from 923 as of March 2017).
HIT – MSSP performance data showed only 34% earned shared savings in 2017 (up from 31% in 2016) and by year’s end it is estimated there will be ~1,025 ACOs in operation.
While some of the major EHR vendors have announced support for write access sometime this year and will definitely deliver this support to their most sophisticated customers, broad-based use of write APIs will happen after 2018. HCOs will be wary about willy-nilly changes to the patient record until they see how the pioneers fare.
HIT – FHIR-based read APIs are available from all of the major EHR vendors. Write APIs are still hard to find. To be fair, HCOs as a group are not loudly demanding write APIs.
True cloud-based deployments from name brand vendors such as AWS and Azure are in the minority today. But their price-performance advantages are undeniable to HIT vendors. Cerner will begin to incent its HealtheIntent customers to cloud host on AWS. Even Epic will dip its toes in the public cloud sometime in 2018, probably with some combination of Healthy Planet, Caboodle, and/or Kit.
HIT – adoption of cloud computing platforms is accelerating quickly across the healthcare landscape for virtually all applications. Cloud-hosted analytics is seeing particularly robust growth.
Providers will continue to lag behind payers and self-insured employers in adopting condition management solutions. There are two key reasons why: In particular, CMS’s reluctance to reimburse virtual Diabetes Prevention Programs, and in general, the less than 5% uptake for the CMS chronic care management billing code. In doing so, providers risk further isolation from value-based efforts to improve outcomes while controlling costs.
HIT – Awareness of the CCM billing code (CPT code 99490) remains moderate among providers and adoption is still estimated at a paltry less than 15%.
Mobile accessibility is critical for dynamic care management, especially across the ambulatory sector. More than 75% of provider-focused care management vendors will have an integrated, proprietary mobile application for patients and caregivers by end of 2018. These mobile-enabled solutions will also facilitate collection of patient-reported outcome measures, with 50% of solutions offering this capability in 2018.
MIXED – While the majority of provider-focused care management vendors do have an integrated mobile application (proprietary or partnership), collecting PROMs is still a functionality that remains limited through an integrated mobile solution.
A wide range of engagement, PHM, EHR, and care management solutions will make progress on documenting social determinants of health, but no more than 15% of solutions in 2018 will be able to automatically alter care plan interventions based on SDoH in 2018.
HIT – despite all the hoopla in the market about the need to address SDoH in care delivery, little has been done to date to directly affect dynamic care plans.
The hard, iron core of this issue is uncertainty about its real impact. No one knows what percentage of patients or encounters are impacted when available data is rendered unavailable – intentionally or unintentionally. Data blocking definitely happens but most HCOs will rightly wonder about the federal government’s willingness to go after the blockers. The Office of the National Coordinator might actually make some rules, but there will be zero enforcement in 2018.
MIXED – Last December we said, “The hard iron core of this issue is uncertainty about its real impact.” Still true. Supposedly, rulemaking on information blocking is complete but held up in the OMB. The current administration does not believe in regulation. So “data blocking” may be defined but there was and will be no enforcement or fines this year.
Providers will pull back on aggressive plans to broadly adopt and deploy PHM solution suites, leading to lackluster growth in the PHM market of 5% to 7% in 2018. Instead, the focus will be on more narrow, specific, business-driven use cases, such as standing up an ACO. In response, provider-centric vendors will pivot to the payer market, which has a ready appetite for PHM solutions, especially those with robust clinical data management capabilities.
HIT – PHM remains a challenging market from both payment (at-risk value-based care still represents less than 5% of payments nationwide) and value (lack of clear metrics for return on investment) perspectives. All PHM vendors are now pursuing opportunities in the payer market, including EHR vendors.
This is a case where the threat of alert fatigue is preferable to the reality of report fatigue. Gaps are important, and most clinicians want to address them, but not at the cost of voluminous dashboards or reports. A single care gap that is obvious to the clinician opening a chart is worth a thousand reports or dashboards. By the end of 2018, reports and dashboards will no longer be delivered to front-line clinicians except upon request.
MISS – Reports and dashboards are alive and well across the industry and remain the primary way to inform front-line clinicians about care gaps.
Arterys, Quantitative Insights, Butterfly Network, Zebra Medical Vision, EnsoData, and iCAD all received FDA approval for their AI-based solutions in 2017. This is just the start of AI’s future impact in radiology. Pioneer approvals in 2017 — such as Quantitative Insights’ QuantX Advanced breast CADx software and Arterys’s medical imaging platform — will be joined by many more in 2018 as vendors look to leverage the powerful abilities of AI/ML to reduce labor costs and improve outcomes dependent on digital image analysis.
HIT – With about a month left in 2018 the count of FDA approved algorithms year to date is approaching 30 and could potentially hit three dozen by year end. This is a significant ramp up in the regulatory pipeline, but more is needed in the way of clear guidance on how they plan to review continuously learning systems and best practices for leveraging real-world evidence in algorithm training and validation.
What do you think of 2018 for health IT?
Consumer-Driven Forces Disrupting Primary Care
The traditional model of consuming healthcare services is changing. Frustrated consumers – accustomed to the technological advances that have improved air travel, retail, and a host of other industries – increasingly eschew the doctor’s office for newer, more convenient care delivery models. They’re even willing to pay more for these services.
This ongoing shift forces all healthcare organizations, from solo practices to sprawling academic medical centers, to reconsider how they treat low-acuity conditions now and plan to address chronic care management in the future. This month’s Domain Monitor will examine how retail health, telehealth, and direct primary care continue to threaten the traditional model of primary care, identify the challenges that these types of “convenient care” pose, and explain how prudent healthcare IT vendors can address these challenges.
What’s In Store for 2009: Top Ten Trends & Forecast
Maintaining a tradition among IT analyst firms, following is Chilmark Research’s forecast of Top Trends for 2009. While there is a significant amount of “crystal ball gazing” in any forecast, 2009 is particularly challenging due to an economy that has yet to stabilize and a new administration and re-invigorated Congress that seeks to “reform healthcare.” Against this backdrop, our predictions reflect and extend what we have seen in 2008, our continuing research, and conversations with numerous stakeholders in the healthcare sector. As always, we welcome your feedback, via comments on what you foresee in 2009 as well.
Healthcare Not Immune to Economic Woes: Declines in investment returns and philanthropic giving coupled rising bad debt, fewer consumer/patient visits (delay care) and increase in charity care will wreck havoc on an industry sector that is accustomed to being immune to economic downturns. As it pertains to healthcare IT (HIT) spending in 2009 will be way down as healthcare providers look to control costs. Providers will go into maintenance mode simply maintaining the systems they now have in place. IT projects at least 50% of the way towards completion will see continued funding, if they can see light at the end of the tunnel and ROI will be quickly realized. All other projects will be curtailed, delayed or killed. Some bright spots in all this doom and gloom; apps that focus on eligibility checking, revenue cycle management and more progressive cloud-based offerings (e.g., HIE with hosted EMR) will see reasonable growth in the 8-12% range.
Health 2.0 Companies Shrivel on the Vine: As consumers take on more responsibility for healthcare costs and seek low cost alternatives, use of the Internet as a virtual doctor/adviser will increase. Despite this increase, most Health 2.0 companies fortunes will evaporate for three simple reasons:
Those Health 2.0 companies that address all three concurrently and successfully are the ones to watch – ignore the rest.
Retail Health Clinics Gain Traction, Corporate Clinics Stall: Budget-constrained consumers seeking lower cost alternatives, and payers encouraging such practices, will increasingly turn to retail clinics for much of their healthcare needs in 2009. This will lead to continued growth in use and build-out of retail clinics across the country. Despite their potential savings, corporate clinics are a long-term investment. Corporate clinic providers such as the two Walgreens acquired in 2008, (i-Trax and Whole Health) will see growth stall as employers layoff employees and pursue shorter-term cost cutting strategies.
Virtual Visits – A Mixed Bag: Related to Health 2.0 is the proliferation of Internet-based third party healthcare service offerings, (e.g. American Well) which bring together technology, streaming video and an ability to access a doctor over the Web 24/7. Problem is, healthcare is based on trust and as inherently social creatures, humans base trust on direct, in-person interactions. Thus, third party virtual visits will struggle. This will not be the case for eVisits with a consumer’s existing physician/care team where a relationship already exists. eVisit reimbursements are now becoming commonplace and consumers will increasingly use such services due to convenience and lower costs.
Dossia Ramps-up: Over two years in the making and a couple of stumbles along the way, Dossia was finally launched in late 2008 with roll-out to consortium member Wal-Mart employees (actually, WebMD roll-out with WebMD sitting on top of Dossia stack). Earlier this month Dossia announced its second PHR partner, Medikeeper. While Dossia’s ecosystem of partner apps is dwarfed by Google Health (GHealth) and Microsoft’s HealthVault, Dossia brings something to the table that the other two platform providers do not, some 8M+ potential users (employees). Expect at least three more of the consortium’s eight members to begin rolling out the solution, via PHR vendor, to their employees. We are placing our bets on Pitney-Bowes, AT&T and Intel to go live in 2009.
Chicken & Egg Scenario Plays-out for GHealth and HealthVault: As Google Health and Microsoft look to add more partners, in particular data providers such as pharmacies (GHealth) or payers (HealthVault) the big question remains: Will consumers begin actively storing their health data on these sites and subsequently engage any of the numerous apps that sit on top of these repositories? Right now it is a very mixed message. Today, traffic and subsequently use of either platform remains lackluster. Early reports are that GHealth is generating some decent consumer traffic (click-thrus) for partners. HealthVault, however, is generating very little traffic for its partners, but has created better visibility for these partners among larger corporate entities (e.g., payers, employers, providers, etc.).
Over the course of 2009 expect Google to become slightly more aggressive, first with biometrics, second with support for other standards and third attracting new partners, especially data owners. This last point is contingent on additional standards support. HealthVault will couple its aggressive actions to bring more data providers (payers & providers) and software partners into the ecosystem with direct to consumer marketing. HealthVault’s biggest challenge will remain – creating an engaging and easy to use interface for the consumer.
New HIE Models Leveraging Cloud Computing and SaaS Gain Traction: Chilmark Research recently completed a project for a client that gave us an opportunity to gain an in-depth understanding of the HIE/RHIO market. What is clear is that the vast majority of quasi-public RHIOs still have not figured out a funding model that is sustainable (e.g., CalRHIO is one hairy initiative that will be declared DOA in 2009). Health Information Exchanges (HIEs), that are increasingly receiving funding from payers or are set-up within a given IDN will continue to see reasonable, low-double digit growth. Those HIEs that prosper will be based on a cloud computing model and offer small physician practices, at little or no cost (sponsored by payer), via SaaS, such services as lightweight EMRs and eRx capabilities. We learned of several such projects, yet to be announced, that will roll-out in 2009.
Continua Compliant Devices Hit Market with Little Impact to Anemic Telehealth Growth: The industry consortium, Continua, recently announced that Continua compliant biometric devices will enter the market in 2009. Problem though is that Continua compliant devices only alleviate vendor lock-in for one can now mix and match Continua compliant devices from various vendors. Continua does not address the much broader and seemingly intractable problem of how to incorporate telehealth into the existing workflow of care providers and even more importantly, reimbursement models for telehealth remains immature. Until these issues are addressed, 2009 will not see a major boost in the sales of biometric devices.
Dreams of Big Fed Spending on HIT Do Not Materialize: Despite campaign promises and HIMSS Blueprints, healthcare reform and funding for HIT will not materialize in any meaningful amount in 2009. Half of the problem will come from continued economic woes in other sectors seeking rescue from federal coffers that will start drying up. The other half of the problem will result from healthcare reform, in all its many guises, that languishes as Congress over-reaches with its multitudinous approaches and little reconciliation in ’09. We expect 2010 to hold more promise.
mHealth Continues Expansion, Most Apps Lame: We see tremendous promise for mHealth and honestly believe it will be here that consumers truly engage in health and wellness at a very personal level. Despite the enormous potential, and a growing number of mHealth apps available for the consumer, we find that the vast majority of these apps are incredibly simplistic and do not fully leverage new smartphone capabilities. Over the course of 2009 we will see far more apps, particularly those originally developed for the iPhone, being re-purposed for Google’s Android OS, the BlackBerry OS and in Europe, for Nokia’s Symbian OS. Some truly novel, excellent apps are expected, but these will by far be in the minority.
That’s “IT” everyone and to a certain extent this list defines our research agenda for 2009. Stay tuned, it promises to be an extremely interesting year ahead.