Monday, March 12, 2018

HIMSS 2018: Wake-up call for the sleeping giants.

As I browsed through the vendor exhibits among the more than 45,000 healthcare IT professionals gathered in Las Vegas last week for HIMSS 2018, I noticed that the big IT giants Amazon, Google, and Microsoft (Apple was noticeably absent from the exhibit floor), as well as other businesses who are in the CRM space (Salesforce) are finally taking notice of the opportunities in healthcare. It was also not a coincidence that Eric Smidt, past chairman of Alphabet, Google’s parent company, was the keynote speaker for the conference. I believe that this is very promising as healthcare in many ways is very much behind other industries and can learn from their experiences.

As anecdotal evidence of the need for better technology in healthcare, I listened to a presentation from a vascular surgeon who explained how he annotates relevant images on a PACS viewing station, then takes a picture with his iPhone of the screen and shares it using Chat with his residents and surgical team to prep for surgery. The reason for him to have to use his phone, is that we don’t yet have the “connectors” that tie these phones, tablets, and other smart devices with our big, semi-closed healthcare imaging and IT systems. The good news is that Apple just announced an interface allowing information exchange, which can be used, among other things, for patients to access their medical information from a hospital EMR. Also Google cloud announced an open API.
Here are my top observations from HIMSS2018:

Demonstration of new Apple
App accessing health records
·       Patients are taking control of their medical information: Apple announced a FHIR based interface on the iPhone that provides access to personal health records. The interface is built into the recent Apple phone as part of its health app. Information such as recorded allergies, medications, lab results, etc. is copied to the person’s phone. Note that this is different from solutions where this information is stored in the cloud (e.g. Google, etc.).
Regardless, it allows patients to access and keep their own information. It provides a mechanism for patients to share the information, as the hospitals are struggling to meet that demand (only one out of three hospitals can share information according to a recent AHA study, despite the fact that more than 90% of them use electronic health records).
In reverse, it is not that hard to upload this information back into an EMR of a physician or a specialist, together with information collected from blue-tooth enabled blood pressure, pacemaker, insulin pump, and other intelligent healthcare devices as well as wearables. At the IHE interoperability showcase demonstration areas, there were several demonstrations of how this upload can be achieved using standard interface protocols, often using FHIR.

·       FHIR is gaining more traction: The new HL7 protocol allowing easy access, especially by mobile devices, to so-called resources such as lab results, reports, and also patient information is getting more traction. However, there is a still a big disparity between what is shown as “works in progress” such as the demonstrations at the IHE interoperability showcase, and what is actually deployed. Almost every use-case that was demonstrated at the showcase had one or more FHIR elements, such as used for patient information access, uploading images or labs, accessing registries, etc. However, when I asked vendors on the exhibit floor where they deployed the FHIR interface, many of them told me that yes, they have their FHIR interface available but are still waiting for the first customer to actually use it.
There are a couple of exceptions, for example, at the Mayo Clinic they are using FHIR to access diagnostic reports, utilizing the EPIC FHIR interface, but there are still very few. One of the major obstacles with FHIR implementations is that it took them a long time (5 years to-date) to get to a standard that has at least some normative parts in it, which will be release 4 to be balloted soon, which means that any implementation you do right now is subject to changes as upgrades are non-backwards compatible. As an example, the Apple FHIR interface is based on release 2. So, I am officially upgrading my FHIR implementation status from “very limited” to “spotty,” but I believe that there is definitely a lot of potential.

Demonstration of VA to DOD gateway
based on FHIR technology
·       The VA is making major strides in healthcare interoperability: I feel compelled to call out the US department of Veterans Affairs as there is a push to shift some of their care to the private sector, while the fact of the matter is that research shows that the VA scores higher than the industry in many of the quality scores, despite the fact that yes, there is still a lot of disparity between the different VA facilities. The high quality of care is not in the least caused by the early implementation of electronic medical records and the ability to be paperless. But, their current medical record system is becoming out-of-date, hence the intention to replace it with a new EMR at the cost of about $10 billion over the course of the next 10 years. Nevertheless in many ways, their current system still outshines what can be achieved today by commercial vendors.
As a case in point, there is a connection between the VA EMR and the one from the DOD that allows for a smooth transition of veteran data between these two entities, which is based on FHIR. What is significant, is that of the many FHIR resources that FHIR has defined (more than 100 up to now, planning to be at about 150), the VA is able to exchange all of the information needed with only very few FHIR resources, notably Patient, Imaging Study, Questinonnaire, Observation, Clinical Impression, Diagnostic Report, Encounter, Condition, Composition, Allergy and Medications. This means that implementing a relatively limited subset can still be very effective. Hopefully their replacement EMR (Cerner?) will have the same kind of interoperability, which seems to be a point of contention right now in the contract negotiations for replacement.

·       The big EMR companies are doomed (or are they?): This millennium has shown a major shift in healthcare IT as the past ten years the number of hospitals in the US having an electronic record has gone from 10% to more than 90%.
However, these monolithic, semi-closed systems which accumulate all the patient information in big databases that are hard to access with limited tools for dashboarding and quality metrics, and who often charge a hefty fee to provide yet another interface to get information in or out, might be on their way out unless they change their architecture and focus. For what it’s worth, even the White House is taking notice as Jared Kushner mentioned during the meeting that “Trump has a new plan for interoperability.”
Let’s look at an analogy on how other industries solve the information access problem, for example, a website for a hotel. If you would like to find directions to the hotel, you click on a link to Google Maps, if you want to know what the local sightseeing tours are, you click on “tripit”, for reviews you click on “Tripadvisor”, and so on.
Now let’s go back to our ideal EMR user screen, wouldn’t it be nice if you can get the patient information from a “source of truth,” which is a web-accessible source for patient information, the latest lab results from the lab, either internal and/or external, the past 6 months progress on a weight loss program from the patient’s Fitbit located in the cloud, diagnostic reports from the radiology reporting system, and so on. And by the way, arranging transportation for the patient is just another click on the Uber or Lyft App (note the announcement from Allscripts to embed a Lyft interface to their EMR).
The EMR would be a mash-up of multiple resources accessible through standard protocols (FHIR), in some cases guaranteed immutable, using blockchain technology, and the only functionality left would be a temporary cache and workflow engine that guides health care practitioners through their job in a very easy to use manner.
Currently user friendliness, especially, still leaves a lot to be desired, as a recent study showed that during an average patient visit, providers spent 18.6 minutes entering or reviewing EHR data on digital devices, and only 16.5 minutes of face-to-face time with patients. We’ll see what happens over the next 5 years and who will win and who will lose but it appears that FHIR might facilitate a disruptive development.

Standing room seats only for blockchain
·       Blockchain has some (limited) applications in healthcare. I purposely did not mention blockchain in the title of this write up so as not to overload my ISP as I found it to be the most hyped (according to the dictionary: “extravagant or intensive publicity or promotion”) subject of the conference. Presentations on this subject went beyond standing room only.
What is blockchain? It is an immutable, decentralized public ledger that could be used to securely share transactions without a central authority. Knowing that most of the patient’s health information is not intended to be public, and that some of the files (think a 1.5GB digital pathology slide) are just too big to simply move around and copy multiple times, it makes the application for blockchain very limited in scope. The immutable aspect is also hard to accomplish, even for objects or entities that you might think are immutable such as a patient/person.
Imagine that you would store the patient information in a blockchain (e.g. a url and “fingerprint” or “signature” of the data), can you really guarantee that there would be no changes? Some of the content might need to be updated such as a “disease status” in case someone dies, a different name in case a woman who marries, and it is not uncommon anymore for a patient to change sex.
Apart from the “content,” the structure might change as well, due to database changes such as allowing storage of multiple middle names, aliases, etc. Some of these solutions such as providing a unique, immutable person identification, will be resolved by other industries anyway as financial institutions have a lot of interest in making sure that they provide credit to “real persons” and identify if a financial transaction is requested by the actual person instead of a hacker or intruder.
There are however a few blockchain candidates for healthcare, one example was shown at the recent RSNA show dealing with certification and accreditation of physicians, which should be public and from a reliable source. Another example is dealing with consents, so that a healthcare provider can trust the fact that patient information can be shared with for example a parent or caretaker, and what part of the record can be shared and what not (e.g. limit access to mental illness records or the fact that a 16 year old daughter uses contraceptives). So, in conclusion, yes there are some limited applications for blockchain technology, many of them we can “borrow” from other industries, and some of them we can implement for medical purposes, but in practice it will be few.

Salesforce: Patients are
·       Healthcare is learning from CRM companies: According to one of the major CRM companies, Salesforce, Customer Relationship Management (CRM) is a technology for managing all your company’s relationships and interactions with customers and potential customers. Replace the word “customers” with “patients” and you have a perfect system that allows a healthcare institution to manage their patients in a better manner. That is why not only Salesforce but other companies (I saw a demo at Microsoft) are using the CRM core to provide patient management solutions.

·       Artificial Intelligence is making small progress: It would not be right not to mention AI in this report as it is in the top ten tweets about the conference. However, machine learning and Artificial Intelligence is still not as easy as one might think. Some researchers indicate that the IQ of intelligent machines to be equivalent of a 4 your old right now. But, as of now, machines are unbeatable for chess and jeopardy, so there are definitely some applications that can benefit from AI. Examples are predicting ER re-admission rates of certain patients and taking action accordingly, assisting a physician to make a better diagnosis, or, even better, ruling out any findings with an almost 100% accuracy, which would assist in routine screenings. In addition to the technology having to become more mature, there is also an issue with data access as I talked with one user who is in charge of entering manually textual data from old records in structured format, and the fact that much of the accessible data is not very structured. There is a lot of emphasis on AI, so much that some companies are re-branding their whole healthcare business around it (think IBM: Watson Health), which also seems an overkill to me. But AI will silently enter into many applications where it can impact workflow, enhance diagnosis and clinical outcomes.

Yes, I want theVespa
·       HIMSS is still an IT tradeshow: Imagine walking around the RSNA (radiology conference) and being asked if you want to enter in a $200 drawing, participate in a magician performance or, enter a drawing for a motorcycle. It would be unthinkable, but it is still common at the HIMSS. This indicates that it gears towards a different audience than clinicians. In contrast with the last time, however, I did not see any showgirls on the floor this year for photo-ops, so the only decision I had to make was if I would enter the motorcycle or scooter drawing. Having driven a Vespa myself when I was young, it was not a hard choice for me.

In conclusion, this was another great event, with some hype as usual, but I found especially the promise of “outsiders” getting involved in the business of healthcare to be very encouraging. A “fresh look” from these companies using some of the practices that make our life easier when we are not sick, could definitely make our life easier and improve patient care when we are sick. There is no reason that financial transactions can freely move between banks so that I can go to an ATM any place in the world and access my account, while my physician has trouble getting timely lab results, medications, allergies and other pertinent information. I can’t wait for the sleeping giants to not only wake up but get actively involved and make an impact.

Herman Oosterwijk is a healthcare imaging and IT trainer/consultant. In case you like to learn more about new standards, in particular FHIR, check out the upcoming web training and in-depth face-to-face training.