HL7 New Zealand

News and Views from HIMSS 2017

Produced by Martin Entwistle, Board Member HL7 New Zealand

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This paper provides a personal view of highlights from the Health Information Management Systems Society Conference (HIMSS) 2017, which took place in Orlando Florida February 19-23, 2017.

Despite the uncertainties over future directions for healthcare in the US, resulting from the new administration, there was significant buzz in several areas of strategic importance with significant potential impact on health systems development in the near to medium term.

The following are the themes that appear to be of particular importance, and with relevance to the New Zealand health sector. The list is not comprehensive, other themes that have importance to those working in more narrow or specialized fields are not included:

• Consumerization of patient care and customer experience
• AI and cognitive computing
• Advancing value-based care
• Population health, connected health and patient engagement
• Improving interoperability between the connected health world and EHR systems 
• Cloud computing and security for the digital healthcare enterprise

Consumerization of Patient Care and Customer Experience

Over the last 5 years there has been an accelerating awareness of a significant social change in the way people seek to engage with and consume traditional healthcare services. The organization Health 2.0 has been leading discussion on this through its conferences and workshops, initially with an emphasis on the disruptive potential of new market entrants with a consumer products and services and more recently increasing interest from mainstream healthcare providers, insurers and vendors. At this Conference the importance of addressing consumerism in healthcare was explicit, with the many and wide-ranging implications being presented and discussed.

Consumerization is about the changing role of consumers (patients) from being a reactive recipient of care to playing a more proactive role in being in control of how they manage their own health, seeking services that focus on wellness rather than just sick-care, being better informed about the choices available and demanding services that better fit their day-to-day lives rather than for the convenience of the health system itself.

This was a common theme throughout the conference. Providers are accepting that this is no longer a future-state concept, but a major dimension of future healthcare delivery that needs to be taken seriously and addressed as a priority. A number of presenters observed that failure to address this deep-seated need by patients represents a major threat if not tackled, with patients moving to alternate providers or accessing services outside mainstream healthcare that do address their needs.

The implications for health systems development are significant, as the systems and services required to meet these needs are very different from those currently available, and the detailed requirements are still not well defined. Relevant solutions include; customer relationship management systems to profile and engage with individuals even when not sick, devices and apps to support behavior change and wellness, big data analytics to help anticipate needs and intervene preemptively, remote managed care including telemedicine and video visits. Of critical importance is not just the functionality these new systems provide, but the experience they generate. Reference models for success are closer to Amazon, Facebook and Salesforce than they are to the health systems currently in place.

AI and Cognitive Computing

Artificial Intelligence (AI) is not new to healthcare. In the 1980s and ‘90s AI was the focus of significant research and development efforts. At that time, AI solutions were built around fuzzy logic, and neural networks used to develop predictive learning systems. There were some interesting results but they did not have sufficient accuracy to become widely adopted. As a result, AI has been on the sidelines for some years.

But no longer! AI is once again a hot topic. Solutions are again focused on predictive analytics, but with methods developed through big-data mining systems that have been evolving over the last 5 – 7 years, and resulting in solutions very different than before. They include the application of machine learning, reasoning, natural language processing, data mining, human-computer interaction to deliver advanced analytics.

There are many companies big and small active in the area offering both broad and narrow solutions. Among the big companies, and while still on the cutting edge, IBM, Google and Microsoft are taking a major role in leading the way forward. However, IBM-Watson was definitely the most prominent of these at HIMSS 2017.

AI systems are undoubtedly complex and historically their use for the development of solutions has been in the hands of experts in the area. Once of the new developments presented at the Conference is the availability of AI analytics tools as cloud-based services. This has the potential to widely expand their use as it puts the tools in the hands of a wider range of developers to build these into their solutions.

Encouragingly, much of the energy is going into practical uses of these solutions to ensure these have wide-scale value in the real world and directly impact patient care and the outcomes achieved. One of the challenges experienced historically was that the underlying fuzzy methods were not easily understandable, so the outputs were viewed with some skepticism, particularly by doctors. With this new wave of solutions ease of use and believability are significant areas of focus. Indeed, a whole new area of technology is being created, “cognitive computing”. 

Cognitive computing systems depend on various aspects of artificial intelligence (AI) to acquire knowledge from the massive amount of data fed into to them. Outputs focus on getting the right information to the right user at the right time and in an impactful format so that rapid decision making without further information processing can be achieved. Uses include matching the patient to specific tailored interventions. For example using genetic data inputs to identify optimal clinical interventions for that patient. Natural Language processing can mine intelligence from unstructured clinical notes and link that information from other clinical inputs to identify patients with specific but hard to identify risks, eg depression.

Some companies are ‘betting the bank” on the future importance of cognitive computing. Ginni Rometty, IBM chief executive, in a key-note presentation said that cognitive computing technologies could usher in a golden era for personalized and precision medicine. “We’re in a moment when we can actually transform pieces of healthcare. It’s within our power”. “This era that will play out in front of us can change the world for the better.”

Advancing Value-based Care

In the US, value-based care is seen as critical to addressing rising health care costs, clinical inefficiency and duplication of services. In value-based models, doctors and hospitals are paid for helping keep people healthy and for improving the health of those who have chronic conditions in an evidence-based, cost-effective way. This contrasts with the traditional fee-for-service approach, where payments are made on the basis of services provided irrespective of the outcomes achieved.

Under “Obamacare” the US government strongly signaled a major shift to value based care by enacting MACRA (Medicare Access & CHIP Reauthorization Act), that would cut physicians base salaries and put more emphasis on incenting quality outcomes. MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment System, or MIPS.

Presentations at the Conference outlined that in the recent past, four models have evolved for the delivery of value-based care:

Accountable care organization (ACO) – Accountable care organizations are alliances of doctors, hospitals and other health care providers that deliver and coordinate care for their patients and are paid based on their success at improving overall quality, cost and patient satisfaction with their health care experience. In an ACO, providers are responsible for improving the quality of patient care and health outcomes, at equal or lower costs, through better coordination and preventive care.

Patient-centered medical home (PCMH) – In a PCMH, a primary care doctor leads a clinical team that oversees the care of each patient in a practice, and is focused on providing enhanced care coordination across the health care system. Financial incentives are based on performance on specific quality measures. When practices do well on quality and efficiency measures, they share in the savings they create. While still fee-for-service, this entry-level value-based model encourages quality and efficiency.

Bundled payments – In a bundled payment model, a single payment is made to doctors or health care facilities (or jointly to both) for all services associated with an episode-of-care, such as a hip or knee replacement. “Bundled payment rates” are determined based on the costs expected for a particular treatment, as well as costs for any preventable complications that may arise. 

President Trump’s promise to repeal and replace the Affordable Care Act (ACA) which underpins “Obamacare” is what is leading to much uncertainty over the future of value-based care. Nonetheless, there was a general consensus at the Conference that the shift to value-based care and that quality payment programs very similar to those developed under MACRA, will continue.

However, the transition from fee-for-service to pay-for-value payment models is one of the greatest challenges the U.S. healthcare system faces. Management of value-based services is data intensive and requires new business processes and workflows. Few provider organizations have the necessary end-to-end clinical, financial and administrative systems in place and there were a significant number of vendors offering such solutions as well as the advisory services for implementation and management.

Population Health, Connected Health and Patient Engagement

Population health management (PHM) is one of the fastest-growing segments in U.S. healthcare systems development. It was reported at the Conference that the majority of $8 billion in US digital health investments during 2016 went to support complex PHM initiatives. At the same time PHM solutions are a major area for development by existing vendors large and small. 

One of the interesting battles being played out, is whether advanced PHM solutions should be delivered as core capabilities of EHR systems or through specialized applications. In addition to EHR vendors Epic, Cerner, Allscripts and AthenaHealth providing solutions to their existing customers, the following vendors were identified among others as being well established in the provision of solutions and services; Optum, Philips Wellcentive, Caradigm, Lightbeam, Deloitte, Health Catalyst, Enli, Premier, i2i, Medicity, Lumeris, Best Doctor, Medecision, ZeOmega, Influence, Humana Transcend Insights, Conduent (Xerox), Cognizant Trizetto, Orion Health.

To give some idea of the challenges for systems development, six diverse functional components were presented as being necessary to deliver the full-scope of required PHM capabilities:

• Data collection aggregation, storage and patient registries
• Connectivity and identification of gaps in care
• Big data stratification and risk segmentation/cost metrics
• Patient engagement and external data acquisition
• Care team coordination and management
• Outcomes measurement, reporting and analytics

As advanced solutions increasingly need to make use of some of the more complex computing capabilities previously identified in this paper, in particular patient engagement, cognitive computing and AI, it is going to be hard for any vendor to provide solutions that meet all these needs and it will be especially hard for EHR vendors to keep up with the pace of development. This suggests that future solutions will be created through seamless integration of systems capabilities from multiple vendors.

Improving Interoperability Between the Connected Health World and EHR Systems 

Digital and personal connected health was the subject of its own 2 day forum at the Conference, accompanied by a booth in the exhibition hall providing a series of case studies and demonstrations by over 50 companies active in the area. 

Connected health embraces a number of technology domains broadly encompassed by the Internet of Things (IoT); medical and consumer devices for remote patient monitoring, mHealth apps for collection and display of data as well as direct interaction with users, advanced data mining, interpretation and presentation capabilities. New devices, wearable sensors and mobile apps now track fitness, behaviours and many important clinical measures, with the promise of even more complex and interesting metrics becoming available in the near future. It is a dynamic and expansive market, exploding with opportunity.

The resulting patient-generated health data (PGHD) is available to be flowed into EHRs to help improve engagement, adherence and clinical outcomes; individuals are connecting with providers through portals and apps to manage chronic conditions, and telemedicine is enabling a growing number of virtual visits. Functionality including gamification adopted from the consumer space is being leveraged to drive both sustained engagement and positive behavior change.

Connected Health already has the potential to improve care delivery across the healthcare continuum, with the promise of adding even greater value in the future. However, as more healthcare providers and plans embrace these technologies, they’re running into interoperability, regulatory, and cultural challenges. Case studies, best practices, and panel discussions, presented at the Conference outlined tools, technologies and strategies designed to address these challenges. A number of presenters called out that Connected Health represents a fundamental change in the way we provide healthcare services that require new systems, delivery models and workflows, and even more importantly a fundamental cultural shift to the total approach to service delivery prevention and remote engagement at large scale with the people for whom health systems are responsible.

A closely related theme is that EHR interoperability continues to be a barrier to progress, and is general and pervasive. Many of the EHR vendors presented work they are doing to overcome these barriers; openAPIs, adoption of interfacing standards (eg FHIR) and use of webapps, but progress is not as fast as many would like. This issue is a particular challenge to the seamless delivery of connected health capabilities into the clinical workflow which are is critical to adoption and use. In parallel, there is significant work underway to simplify EHR integration and facilitate sophisticated data exchange between organizations. FHIR was covered in many presentations and received significant interest for its potential to assist with this particular challenge.

Cloud Computing and Security for the Digital Healthcare Enterprise

Cloud computing and security in the digital healthcare enterprise, which for health systems development are closely linked, were also major themes at the Conference. 

A move to healthcare solutions that have been formally developed and deployed to leverage cloud computing capabilities has significant potential, but to date, healthcare world-wide has been slow to embrace these opportunities. There are a number of reasons; most healthcare providers have significant investment in on-prem deployments of their all-critical clinical systems including EHRs, migration appears potentially costly and to have significant risks even if the end results would have economic and business advantages, but probably the most significant barrier has been the perceived security risks.

The issue is around ensuring complete protection of electronic personal health information (ePHI), and the proven solutions available to healthcare IT teams that still rely on tried and tested, locally deployed security measures, eg network and endpoint security tools.

But the tides of change can no longer be held back and the healthcare industry is increasingly adopting the cloud, with health systems realizing the significant cost savings of contracting their data-center operations. This opens up important questions having to do with data being held in compliance with HIPAA-HITECH; whether ePHI is being encrypted and, if so, where the keys reside and how organizations can port their data from one cloud provider to another if needed.

The other hot topic in this space is medical device security and there were a number of educational sessions dedicated to this topic. Groups like the Medical Device Security Information Sharing Council (MDSISC) and NH-ISAC are focusing much-needed attention on medical device security, and there is growing momentum for security to be incorporated at the point of manufacture as opposed to being an afterthought.

Summary

In summary, this was one of the most interesting and invigorating HIMSS Conferences I’ve attended. While healthcare world-wide face very significant challenges, it seems that the health system development space finally has a range of truly exciting and in many ways disruptive solutions with very real potential to address these challenges. These systems are not only novel in concept, but can facilitate totally new business processes that if well implemented can provide the very different healthcare experience that is it now clear many individuals are seeking. Our ability to address this need  will materially impact the future care of healthcare, leading to a world very different that we know today.

HIMMSS Conference 2017 http://www.himssconference.org/