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| Busier as ever |
More than 45,000 visitors to the worlds largest healthcare
IT conference held in Orlando, Fla,
browsed through 1200 booths looking for IT
solutions for their facilities and listened to the many educational sessions. There
is still a dichotomy between what was shown and the real world as the IHE
showcase demonstrated 12 use cases where information seamlessly flowed between
different vendors, while it is not always so smooth in practice based on
stories from the trenches.
Here were my observations from this conference:
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| Distinguished panel at Keynote |
1.
Interoperability,
are we there yet? The meeting was dominated by the recent information-blocking
rule, which was unwrapped by the US department of Health and Human Services
(HHS) literally the day before the convention started. As Seema Verma, the US
CMS administrator pointed out in her key note presentation, the government has
given out US $36 billion on incentives to implement electronic health records
with not much interoperability to show for it, so now it is time for the
industry to step up.
Former US CTO Aneesh Chopra added to this saying that the CCD’s (Continuity of
Care Documents) that are exchanged right now might not be the best solution to
exchange patient information, but we need to look for other means such as open APIs,
which can be used to tap into any EMR for information. These open APIs will
become a requirement by 2020 according to the HHS. Penalties to health
information exchanges and health information networks could be up to $1 million
for lacking interoperability. Maybe this will help, however the rule is
expected to get pushback from some of the stakeholders. For example, the AHA
was quick to point out that it disagreed with certain parts of the
requirements: “We cannot support including electronic event notification as a condition of participation for Medicare and Medicaid,” stated AHA Senior Vice President for Public Policy Analysis and Development Ashley Thompson.
2.
Open API,
is that sufficient? An open API is merely a “connector” that allows
information to be exchanged, however, as was noted in the same keynote speech, if
the only thing that can be exchanged is the patient name, sex and race, or if
the clinical information is not well encoded and/or not standardized, the API
is not of much use.
That is why implementation guides
based on use cases specifying the many details of the information to be
exchanged are critically important. The good news is that these implementation
guides are a key component of the new FHIR standard, which can be
electronically interpreted and are defined according to a well-defined
template. The DaVinci activity which has already defined 12 of these guides and
which are part of the FHIR balloted standard will facilitate the exchange. The
focus of these guides is on provider/payer interactions and includes for
example medication reconciliation for post discharge, coverage requirements
information and document templates and rules. The booth demonstrating these use
cases was one of the busiest in the IHE showcase area.
3.
What
about social determinants? Health care determinants follow the 20/20/60
rule, i.e. 20 percent of ailments are determined genetically which can
increasingly be predicted by looking at your DNA sequence, 20 percent are influenced
by a healthcare practitioner such as your doctor, but 60 percent, i.e. the
majority, is determined by the patient through his or her own actions and
social determinants. For example, if you are genetically at risk for a heart
condition, and your doctor has already placed a stent in one or more of your
coronary arteries to help blood flow to your heart muscle, but you don’t change
your life style, you won’t be able to get any better. Now, let’s say you are
homeless and depend on food that is not good for your condition, you could be
in trouble. It would be good if your physician knows those social factors,
which could also include where you have traveled to recently. However, there
are no “codes” available to report this in a standard manner. The majority of
the health care determinants (60 percent) are not encoded, therefore, there is
much work to be done in this area.
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Impressive number of providers
participating in Commonwell |
4.
How is
information exchanged between providers? The ARRA (American Recovery and
Reinvestment Act) from the previous administration had put money aside to
establish public Health Information Exchanges (HIE’s). Unfortunately, many of
these HIEs took the grant money and folded after that ran out, notably the HIE’s
in North Texas and Tennessee and many others, shutdown after failing to find a sustainable
business model.
Several vendors took the initiative to establish a platform for information
exchange as they figured out that the effort to string connections one-by-one
between healthcare providers would be much more expensive than creating their
own exchange, which is how the Commonwell non-profit started. As of the
conference, they had 12,000 connections to providers, which is probably 10 percent to 15 percent of all providers, which is a good start towards gaining a critical mass. Cerner seems to be the largest EMR vendor in this alliance. Epic was notably absent and has been the main driver of a somewhat competing alliance, called Carequality with different functionality but establishing similar objectives, i.e. exchanging information between EMR’s from different vendors at the providers.
The good news is that there is now a bridge established between these two
platforms, which again makes the critical mass even larger. This situation is somewhat
unique for the US as other countries have government initiatives for information
exchange but for those countries without an initiative, the same model might
work. This will hopefully solve the problem that was mentioned by one of the
providers who said that it has been relatively easy to exchange information
between his EMR (which happened to be Epic) and others as long as it was an EMR
from the same vendor, but very hard if not impossible to get anything out of an
EMR from another vendor into his EMR. This is a great effort, which together
with the anti-blocking rules from CMS, might finally allow healthcare
information to be exchanged.
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One of the many portals
demonstrated |
5.
Are
patient portals finally taking off? It
is still a challenge to access health care information as there is not really a
universal portal that collects all of the information among different
providers. You might need to maintain access to the information being present
at your primary physician, your specialist(s), your hospital and even your lab
work provider. One of the ways to consolidate this information is to have a
single provider, such as the VA for veterans, and their portal “myhealtevet,” which
has been relatively successful. How this is going to work as the VA increases its outsourcing to private
commercial providers remains to be seen. If you are on Medicare or Medicaid,
CMS will provide a standard interface, which is used by several (free) patient
portal providers where you can log in to see all of your claims, prescriptions
and other relevant information. Again, if you do not happen to be a veteran or are
not covered by CMS, but are a patient between the two of these organizations,
there is not so much interoperability, however those two groups cover enough patients
to start having a critical mass as well.
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Standing room only at cloud
providers |
6.
Are cloud
providers making any progress? One of the speakers, who happened to be
working for New York Presbyterian, claimed that they are planning to have 80
percent of their applications and infrastructure in the cloud. There are more
advantages to the cloud than potentially reducing cost, such as easier access
by patients, and the potential to run AI algorithms for clinical support,
analytics and decision support. Machine learning is more effective when there
is a lot of data to be learned from, hence the advance of cloud archiving.
The big three cloud providers (Amazon, Google and Microsoft) are more than happy
to take your business, the Amazon booth was packed every time I passed it.
However, they still have a steep learning curve, even although they claim to
have open API’s and a healthcare platform with a lot of features, they have to
learn in a few years what healthcare vendors have accumulated in expertise over
many decades. The good news is that they have potentially very deep pockets so
if they are getting serious about this business, they could become major
players.
7.
Is
Uberization of healthcare happening? When people talk about Uberization
they typically
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| Get the Uber or Lyft app in your EMR! |
refer to the business model that provides easy access by
consumers through mobile media, accountability of the providers, and tapping
into a completely new source of providers such as private drivers who suddenly
become transportation providers, or, in the case of Airbnb, private home owners
who become innkeepers.
This is happening in healthcare as well as there is a big increase in
tele-health providers who provide phone access to patients who want advice
anytime, anywhere. Speaking with a physician who does this from his home, telehealth
is as easy as using Uber as a physician can sign up anytime and just log on to
take calls from patients for as long as he or she decides. As I listened to one
such physician’s experiences, he provided life-changing advice, especially to
patients who live in remote areas and otherwise would not be able to seek
medical advice because of their remoteness.
In addition to telehealth services, Uber and Lyft were also promoting their
transportation business to providers, to reduce potential no-shows by patients
who have trouble with transportation. A provider can contract with either one
of these to serve their transportation needs.
8.
What
about the wearables? Apple introduced access to medical records through its
health app
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Note the wearable EKG sensor
as well as monitor |
at the 2018 conference through a FHIR interface. Their provider list
has been growing steadily and is now close to 200, including the VA which by
itself accounts for 170 medical centers and more than 1000 clinics. This is a
significant number, but not even close to the number of providers in the
Commonwell platform, for example, whose members exceed 10,000. Therefore, there
is still a lot of progress to be made.
There was an increase in intelligent detectors that can communicate vital signs
and other clinical information using blue-tooth to a mobile device, for
example, to allow patients to be released earlier from a hospital back home
which is safer and more cost effective.
9.
Are we
Safe from hackers yet? There has been a major increase in cyber security
investment, which has become a necessity as healthcare has become a major
target for hackers and ransomware opportunists.
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| Huge Security pavilion |
Healthcare providers are making
big investments in personnel and tools to try to protect themselves. The
cybersecurity area of the conference was indeed huge as many new companies are
providing their services. The average security part of an IT budget is about 6
percent to 8 percent but there are some who spend as much as 12 percent. Imagine
an IT staff of a large organization, e.g. if you have 500 IT employees, there
could be as many as 50-60 staff dedicated to cyber security.
Based on recent incidents, we still have a lot of work to do in healthcare to
protect patient information, especially at the periphery, as medical devices in
many cases appear to provide easy access points to a hospital’s back-end. This
risk is one of the reasons that the FDA has been requiring a cyber security
plan to be filed with every new medical device clearance.
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| plenty of FAX apps |
10.
When are
we going to get rid of the fax machines? About six months ago, CMS publicly
announced that they want to get rid of all fax machines in healthcare by 2020.
This is only one
year away, however in practice it appears that by far the majority
of all healthcare communication in healthcare is done through the ubiquitous
fax machine. A good manner to transition might be to exchange documents using
the open API, and then do Natural Language Processing (NLP) to search for
medications, allergies, and other important information that can be processed
and potentially imported into the receiving EMR. In the meantime, there were
still many small companies that were advertising smart ways to distribute faxes
and I predict that this will still happen for several years to come.
In conclusion, this was yet another great conference. The
emphasis was on unblocking the information that is locked up in many healthcare
information systems and, until now, can only be exchanged if you happen to have
an EMR from the same vendor as its source, or if you are lucky enough to have a
provider that has access to Commonwell or Carequality, or a provider who uses
one of the relatively few public Health Information Exchanges (HIE’s).
Hopefully the industry and providers will start to cooperate on making this
happen, we’ll see next year when we are going to be back in Orlando FL again.
In the mean time, if you are baffled about some of the
terminology you might consider our FHIR, IHE or HL7 V2 training publications
and classes.
Since the recent Philips acquisition of the Carestream IT
business, I have received several phone calls and had discussions with both
elated and very concerned end-users. Interestingly enough, the positive
feedback was mostly from Philips PACS users and most concerns were expressed by
Carestream clients.
