Monday, November 28, 2016

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
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-

Tuesday, November 1, 2016

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.