2016 Retrospective

My 2016 New Year’s resolution was to blog regularly here on LinkedIn. I was aiming for something between weekly and fortnightly postings. This is my 31st post of the year, so on average I hit that target. As this visualization shows, the pace slowed down as the year went on.

My plan was to summarize the consensus predictions from various health IT blogs and periodicals, then track each prediction throughout the year. Generally, I kept to the plan with only a few diversions.

The most popular topic (based on views) was the HIMSS16 conference. I wrote one article prior to the conference that discussed trends in the educational topic offerings and a second article after the conference based on an analysis of tweets tagged with #HIMSS16. 



I was hoping the pre-conference article would be a good prediction of the hot topics at HIMSS16, and the post-conference article would demonstrate what the hot topics actually were. What I found instead with the pre-conference article is that HIMSS changed its educational session categories significantly between 2015 and 2016. And the post-conference analysis of tweets showed that vendors were imploring conference attendees to visit their booths. The exercise was fun but less informative than I expected.

The number two article was a digression into the world of presentation skills. I put together an analysis of what makes John Oliver’s presentation techniques so effective.

Most of this year’s blog posts enjoyed one or two weeks of readership immediately after publication; this was one of the few that experienced a second peak of readership, perhaps because someone discovered it and shared it months later.  

Articles about predictions held the number 3 spot on the chart, but this category was number 1 in terms of the number of articles posted because I updated the predictions throughout the year. I found it interesting that the articles concerning predictions in general were much more popular than articles about individual predictions. 

Blockchain was a surprise topic for me in 2016. In January, when I was researching predictions for the year, there was one line in a single blog post about Blockchain. (Congratulations to Chilmark for being ahead of the curve!) By mid-year, Blockchain was indisputably trending in health IT.

Rounding out the top five most popular categories – and comprising half of the published articles – was interoperability, a perennial popular topic. In 2016 the industry came to a consensus that issues related to technology and standards for interoperability are largely solved, and the biggest reason why interoperability fails is because there’s no business motivation to share data – or often, there are business reasons not to share data. The culmination of this conversation was to penalize information blockers as part of the 21st Century Cures Act, which was passed in the final weeks of 2016. 2017’s interoperability conversation may be about making information sharing “on by default” instead of “off by default” as a way of taking it to the next level.

Will I continue blogging in 2017? Yes, but with less frequency. I’ll forego the posts about individual predictions and focus on more general predictions and conferences like HIMSS. Check in next year!

2016 Year in Review Report Card: Was the Crystal Ball Correct?

In January, I read a number of articles and blog posts about predictions for the New Year and assembled a consensus list of the top 10 predictions for 2016. With 90 percent of the year behind us, here’s a review of how each of the predictions performed and its associated grade.

1. The role of IT (and also the role of CIO) will shift starting in 2016. Maintaining and improving core infrastructure and legacy systems will remain important, but IT will also need to step up its development efforts using customer-focused, agile techniques to meet the requirements of the rapidly evolving business environment.

Any IT department will have an operational role as well as an implementation role, but it’s not clear that departments or CIOs handled this dual responsibility differently in 2016 compared to past years.

Prediction accuracy: C-

2. Major changes in provider and payer organizations -- including mergers, acquisitions, divestitures, and partnerships -- will favor organizations that are poised to capitalize on new models of reimbursement. Government may block or regulate some of these activities to ensure a competitive environment.

Changes to the playing field, such as the Affordable Care Act, Meaningful Use, and value based reimbursement plans (such as ACOs), began to have an effect on payers and providers. Smaller players are finding that they need to align with larger organizations that have better technical capabilities, and large players are looking for opportunities to partner to increase efficiency. Government has indeed blocked some mergers, most notably the mega-mergers in the payer industry: Aetna/Humana and Anthem/Cigna.

Prediction accuracy: A

3. Where market forces and self-policing by industry fail to keep costs and quality in line, government will step in to enact reforms. Drug costs, lab developed tests, mobile apps and medical necessity are among the candidates for regulation.

Drug companies executed some high-profile price increases in 2016. For example, EpiPen’s price increased more than 400 percent since 2009, which triggered pointed questions from Congress. Apart from trying to publicly embarrass Pharma executives, there has been little or no successful legislative action aimed at controlling prices.

Similarly, the FDA announced it will delay finalization of guidance that will change the way lab-developed tests are regulated, which may kill the initiative entirely.

Prediction accuracy: D

4. Security threats will continue to be a top priority for IT departments. New techniques and best practices will become more widespread to help reduce some threats.

Cybersecurity remained at the forefront of everyone’s attention in 2016. Health record breaches continued to the point where supply of hacked records is outstripping demand and device manufacturers like St. Jude and J&J felt the sting of security flaws. In response, private consortia as well as ONC-led efforts are being developed to help advise the industry on how to best avoid and combat cybersecurity problems.

Prediction accuracy: A- (We have to deduct some points for missing one of the biggest security stories of 2016: Blockchain.)

Blockchain is one dimension of cybersecurity that was not predicted prior to 2016. In fact, only one sentence in one article mentioned it as a possible weapon against cyberattacks. By August, ONC had sponsored an ideation challenge, and several new projects and startup companies emerged in the healthcare sector. 2016 was definitely a breakout year for blockchain in healthcare.

5. Interoperability is perennially on the list of areas needing improvement. In 2016 vendors and IT departments must make significant advances or face government intervention. Meaningful Use Stages 1 and 2 helped migrate a majority of medical records from paper to electronic format and established an interoperability baseline. To build on this momentum, data needs to flow freely among systems.

The main focus for interoperability in 2016 was on deliberate information blocking. The consensus seems to be that technology and standards are adequate, and interoperability can be achieved where there is the will. We’re still a long way from semantic interoperability, though.

Predication accuracy: B+

6. Simple patient care activities that have historically taken place in the primary care provider's office will occur in other settings, notably retail locations (such as pharmacies) and remotely via telemedicine. 

Telemedicine is growing in popularity; however, it remains hampered by inconsistent regulations and uneven reimbursement practices. While primary care outside of the provider’s office will lower costs and increase convenience for patients, 2016 was not its breakthrough year. Perhaps 2017 will be.

Prediction accuracy: B-

7. Mobile apps, wearables and the Internet of Things (IoT) will enhance and automate remote management of patients with chronic conditions. The same technologies will also help healthy patients maintain good health and watch for early warning signs of medical problems that they can electronically transmit to their care providers (patient generated data). Exactly how clinicians will use consumer device data and whether the government will regulate it are still open questions.

Like telehealth, mobile/wearable tech is in a growth mode. While there hasn’t been a huge success story, there have been plenty of announcements of innovative pilot programs, such as the Sutter Health/Validic project.

Prediction accuracy: C

8. Population Health will move from a buzzword to actual practice. Precision Medicine -- which takes into account each patient's unique social and genomic determinants of health -- will emerge as the new cutting edge for healthcare providers to proactively render care.

Precision Medicine received a boost from the President’s Precision Medicine Initiative and the Vice President’s Cancer Moonshot. These programs led to a series of grants and partnerships between vendors and research institutions. Precision Medicine is just making its way into everyday practice, and oncology is the thin edge of the wedge.

Prediction accuracy: B+

9. Employers and other purchasers of healthcare insurance will begin to scrutinize costs, demanding more predictability and transparency. 

Health insurance premium increases continue to outpace inflation, with an expected 5 percent rise in 2017. Employers have few tools to control price increases, and it doesn’t look like predictability or transparency will be at their disposal anytime soon.

Predication accuracy: D

10. The healthcare system will require a different set of tools as its focus shifts from treating patients with disease to maintaining healthy populations. Analytics, care coordination systems and secure communication tools will gain prominence, and the primacy of the EHR/EMR will decline.

The EHR has evolved perfectly to suit the fee-for-service environment in which it was created. It captures episodic data, generates billing information, and serves as the institution’s legal medical record. However, in an ACO or other risk-sharing environment, the EHR is unable to thrive. While it still has a role as a legal medical record, it cannot perform the required analytics and care coordination tasks.

The shared risk environment has not yet evolved a product category to perfectly solve its unique problems; however, we’re definitely seeing a shift away from the EHR as the sole workspace for providers. Tools with more population-level features and access to data beyond the institution’s EHR are becoming dominant.

Prediction accuracy: A

Conclusion

Based on this year’s experience, it seems that using a consensus of prediction articles and blog posts provides a reasonable – but imperfect – method of foreseeing how a year will shape up. The basic, high-level trends were easy enough to spot, but some other predictions failed to materialize. And unfortunately, the consensus technique did not envision some of the biggest stories of the year, like blockchain and the ACA’s struggles.  

Overall accuracy: B-

“Public health is not healthcare” is one of the first things I learned when I started attending public health conferences as a healthcare IT vendor. A number of concepts, standards and workflows overlap and appear to be the same in both sectors. But in reality, they’re very different worlds.

Healthcare is about treating one patient at a time using medicine. Public health, especially epidemiology, is about treating whole populations using statistics and policy tools. The different goals, funding, oversight and outcomes of public health and healthcare stem from this fundamental difference.

The ONC’s 10-year interoperability roadmap recognizes this distinction by explaining that individual episodes of care within the healthcare system can be rolled up to the public health level and used to create new interventions that elevate the overall level of community health. The roadmap’s goal is to reduce the time it takes to iterate between lessons learned within the healthcare system and implementing new public health policies.

One difference between public health and healthcare is the source of funding. Healthcare is funded (mostly) privately, while public health typically relies on government funding. Time after time we see how government funding – typically requiring legislature – is too slow to effectively react in some public health scenarios, such as natural disasters or a disease outbreak.

A perfect example is the recent Zika crisis. The first Zika case in the U.S. was identified in July 2015. The President requested funding on February 22, 2016. Congress finally passed a bill that included Zika funding in September 2016. During the protracted funding process, some otherwise unallocated funds were identified to help combat the outbreak, but overall the reaction time of the public health system was too slow and ineffective.

Last week, in response to systemic problems such as these, the Department of Health and Human Services (HHS) released a white paper entitled Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure. The whitepaper encourages stakeholders in the public and private sectors to work in a different way by envisioning healthcare and public health as two ends of a spectrum rather than separate silos that communicate rarely and begrudgingly.

The white paper contains five recommendations:

1. A health leader in each community should assume the role of Chief Health Strategist, who will work with relevant parties to address areas of concern and plan ahead for public health crises.
2. Cross-sector partnerships can help streamline funding, services, governance and collective action.
3. Public Health Accreditation Board (PHAB) criteria for department accreditation should be enhanced to encourage best practices, so that 100% of the US population is covered by a nationally accredited health department. Today, about 80% of the population is covered by such a department.
4. Data, metrics and analytics should be used to provide focus on important issues.
5. Funding for public health should be expanded and more flexible, so that sources of funding can be combined and easily reallocated.

After learning that public health is not healthcare, the second thing I learned about public health is that “all public health is local,” meaning that different cities and even different neighborhoods have different priorities when it comes to public health. The Public Health 3.0 plan embraces this maxim by improving flexibility, empowering public health workers at a more local level, and increasing the focus on social determinants of health.

It remains to be seen how and at what pace public health organizations will adopt the white paper’s recommendations, but the good news is that it identifies best practices already in place across the nation and proposes their universal implementation.

Blockchain: the Next Healthcare Revolution?

Blockchain has been growing in popularity over the past two years (see figure 1), but it has only recently begun to gain traction in healthcare. In January 2016, the use of blockchain in healthcare was just a blip at the edge of the radar. Flash forward 10 months, and it's now a hot topic. 

Figure 1: Web searches for blockchain

Here's an update on recent developments for blockchain in healthcare.

ONC/NIST Ideation Challenge Conference: Use of Blockchain for Healthcare and Research

ONC and NIST held a workshop on September 26-27, 2016 at NIST's Gaithersburg, MD headquarters as part of the blockchain ideation challenge they sponsored. The industry-wide meeting attracted more than 160 representatives from business, academia and government.

The event kicked off with an overview of blockchain and its cryptographic underpinnings, and then transitioned to a series of panel discussions and presentations from 8 of the 15 ideation challenge winners.

The key takeaway for me was that the industry is in "try everything" mode when it comes to blockchain. Blockchain is a compelling technology that promises to solve some of healthcare's longstanding problems related to privacy, security, data sharing and audit trails. However, the healthcare industry needs to identify use cases where blockchain will truly succeed. We're also still trying to figure out the best approach for integrating blockchain into healthcare's technology stack without disrupting existing users and applications.

One of the most compelling presentations was from the team at the MIT Media Lab, that presented its prototype for MedRec, a blockchain-based method of sharing data among patients and their various providers. While most of the presentations were theoretical in nature, MedRec is notable because the team has built a working prototype on Etherium in conjunction with Beth Israel Deaconess Medical Center.

Sovrin.org

Sovrin.org, a blockchain-based provider of self-sovereign identity services, recently launched September 29, 2016. This new service allows individuals to assert control over their identity. Much like a Facebook or Twitter ID, it will allow for federated login services. This means that in addition to "login with Facebook," you may soon begin seeing buttons on websites that say "log in with Sovrin."

The differentiating feature with Sovrin is that the individual, not a social media company, is in control of the user's identity. In fact no central authority, including Sovrin, is in control because of the distributed blockchain back end upon which the service is created.

Read more about Sovrin in their FAQ.

Distributed: Health

Nashville was home to the Distributed: Health conference on October 3, 2016 following a hackathon October 1-2. In contrast to the academic direction of the NIST blockchain event, this meeting focused on practical uses of the technology. More than 600 attendees from all healthcare market segments convened to learn about current research projects and proofs of concept. Despite the different focus, the “try everything” theme was the same. "2016 is the year of the pilot," declared Jeff Garzik of Bloq.

Blockchain's earliest use cases were in the Fintech sector, and there's no question it's here to stay in healthcare. The growing number of meetings about blockchain in healthcare this autumn is proof of that. 

Progress Report: Population Health and Precision Medicine

Among the consensus predictions for 2016 was a two-part forecast related to population health and precision medicine. First, population health would move from a buzzword to mainstream practice. Second, precision medicine will emerge as the new frontier for proactive patient care.

In July, I provided an update on the progress toward part two of this prediction, noting that precision medicine still seemed a long way off. However, a new HIMSS Analytics poll seems to paint a somewhat more optimistic picture. A poll of 137 hospitals reveals that 29% of providers are currently using some form of precision medicine. This surveydefined precision medicine as "treatment and prevention that takes into account individual variability in genes, environment and lifestyle."

Although 29% of providers are using precision medicine, that does not mean that 29% of all patient encounters involve a precision medicine component. The use of precision medicine techniques is unevenly distributed. Specialties like oncology, neurology, cardiology, and prenatal screening most commonly use precision medicine.

While less than one third of providers are using precision medicine, the HIMSS Analytics report states that two thirds of healthcare organizations are using population health initiatives. As predicted, population health has become mainstream, and precision medicine is beginning to enter the picture.

This doesn’t mean that precision medicine is replacing population health. On the contrary, precision medicine will play a supporting role to population health management.

Both care models can work together to manage risk. A key element of population health management is to stratify patients based on risk scores that are determined by a multitude of considerations. Elements of precision medicine like genetic test results, environmental factors, and lifestyle can contribute to the risk score calculations and provide a more sophisticated, accurate and predictive score.

Two rapidly advancing technologies: EHR functionality and big data will continue to improve clinicians’ abilities to incorporate precision medicine into their population health initiatives. In fact, big data is already linking EHR data to genetic variations as a way of predicting disease before the symptoms manifest. As it becomes easier and cheaper to integrate precision medicine into everyday practice, the industry will realize better outcomes and higher rates of return.

Precision medicine is the next initiative to follow population health, but it is not the end of the road. The Journal of the American Medical Association explains why precision medicine may not improve population health.

It’s difficult to say what will replace precision medicine at the frontier of improving healthcare. JAMA suggests it might be addressing social determinants of health such as reducing poverty, improving education, and focusing on access to resources. And that’s high hanging fruit not easily within reach.

Telemedicine: Coming Soon to a Provider Near You

This week the National Business Group on Health (NBGH) published the results of its most recent health plan design survey of large employers. The survey found that rising costs are a major challenge, with specialty pharmacy and high cost claimants the top two drivers. Large employers intend to continue offering health benefits to their employees, hoping to control costs with by managing pharmacy expenses and shifting routine care to lower cost settings, like telemedicine.

This approach aligns with prediction #9 for 2016: employers will begin to scrutinize insurance costs. It also leads into a discussion of prediction #6: routine care will shift to lower cost, non-traditional venues such as telemedicine.

As Meritalk reports, telemedicine is here, but unevenly implemented. One barrier to adoption is legislative issues – for example, lack of national compact licensure for healthcare professionals. Another barrier is resistance to change. While consumers may be ready to try telehealth, providers are dubious about remotely delivering quality, uniform care.

Another, less defined, adoption challenge is the fact that no widely accepted definition of telemedicine exists. In a recent blog post, Dr. John Halamka, M.D. discusses a number of technologies that qualify as “telemedicine,” ranging from poisonous plant identification through email to real-time video teleconferencing between doctors and patients. When telemedicine includes such a broad range of implementations, it’s difficult to pinpoint exactly when adoption occurs. Maybe telemedicine is already here, and we just haven’t recognized it yet?

Despite these challenges, momentum is coalescing behind telehealth, and the industry is poised to see rapid and widespread adoption from three driving factors.

1. Maturing technology

Network, audio/video, and remote device technology have been improving for decades, and today it’s feasible for patients to transmit real-time audio, video and data from portable, easy-to-use devices to a healthcare provider at a remote location. Previously, such an approach required a variety of technologies from different vendors on different platforms. Now an exciting development promises to bring several of these technologies together under a common platform, already enjoying widespread use in the consumer market.

 Apple recently filed a patent that may soon enable telemedicine through its iOS devices. Its FaceTime and HealthKit components provide most of the technology required for effective telemedicine in a tested, economical package that everyone already owns.

 Apple should not underestimate the effort required to add HIPAA compliance and clinically useful software, and can work with partners like Ochsner Health System to help springboard the company into this daunting vertical market.

2. Improved regulatory environment

In a brick-and-mortar encounter between a patient and a doctor, both parties are in the same room, and governed by the laws of the jurisdiction where the encounter happens. With a telemedicine encounter, the doctor and patient may be in different cities or even different states (so far the topic of practicing telemedicine across national boundaries has not been widely addressed).

This creates administrative problems in terms of licensure and reimbursement that will take a long time to resolve.

CMS is providing some help in terms of clarity around Medicaid reimbursement by stating that states are not required to do any extra work if they choose to cover telemedicine encounters in the same way (and amount) as they cover face-to-face visits. The agency is a leader in establishing reimbursement policies, so hopefully this presages similar guidance from other payers in the near future.

3. Immediate need to lower costs and improve efficiency

As the NBGH large employer survey makes clear, there is a powerful and immediate need to lower healthcare spending. The appropriate use of technology could save millions of dollars. For years the business world has realized the cost savings from foregoing face-to-face meetings when practical. As technology becomes more affordable, it makes sense to apply the same idea to healthcare.

One organization that has emerged as a telemedicine leader is the Department of Veterans Affairs (VA). A pilot program at the VA has matured. It now helps more than 100,000 patients each year and has lowered hospital admissions by 35 percent. These exceptional results like demonstrate why large employers are looking at telemedicine to reduce insurance coverage costs.