Yet for all its promise, the adoption of healthcare technology by providers has been impeded by other factors. One such factor is the generally acknowledged resistance by care providers to information technology changes. To a degree, this resistance is due to two main challenges: the loss of productivity when changes are implemented and the often high capital costs for some enterprise information technology solutions that smaller or mid-sized practices are unable to shoulder or stomach. SaaS solutions have met the latter challenge by lowering the costs that have been one barrier to entry by not requiring separate and costly individual installations of solutions for each care provider or practice. Some reports suggest that such SaaS solutions are already reducing this provider resistance to technology adoption. The former challenge is being addressed more gradually by improved workflow and user experience design. These growing disciplines are delivering better solutions whose improved design minimizes the inevitable loss of productivity experienced while care providers, like adopters, are learning to use a new workflow or tool.

Atop these shifts in healthcare empowered by information technology, mobile health applications promise to be great catalysts for increased adoption and impact. With people being increasingly comfortable using smartphones for data applications and not just voice, it makes the adoption of information technology in general and mobile technology in particular easier in the healthcare industry. Mobile technology is particularly applicable to healthcare due to the significant cost, time, and inconvenience that are incurred in just transporting patients to doctors for those consultations that do not need to be in-person. Research by TripleTree presents a good analysis of the market and opportunities in mHealth. Technology and wireless phone companies also see the posibilities for healthcare and are now beginning to move to deliver solutions. For those whom might resist adopting health information technology, mHealth promises to bring health information technology to them.

As I’ve written before – the good intentions of HIPAA and the cost of compliance are undoubtedly an overhead to innovation of newer systems to better manage health information.  Massachusetts has done a fine job in increasing this burden, requiring as part of CMR 17.03 that “Every person that owns or licenses personal information about a resident of the Commonwealth shall develop, implement, and maintain a comprehensive information security program that is written in one or more readily accessible parts and contains administrative, technical, and physical safeguards [sic].”  Now, in addition to creating auditable systems that can abscond identity and protect personal information, innovators will now have to contend with the development of a document that will outline their strategy for securing information and guarding its transport.

So, will consumers ultimately benefit from increased regulation of data security and harsher penalties for policies that don’t go far enough to prevent a breach?  Benjamin Franklin is noted as saying “They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety.”  Applied to innovation and data security, consumers have to decide whether the promise of technology carries with it enough value to compensate for what may initially be a less than perfect standard for security of information.  The teeth of any legislation that aims to ensure consumer trust in the storage and transport of personal information should be tooled towards ensuring transparency.  The creep of regulation driven requirements for encryption and de-identification, with penalties imposed only upon the incident of data breach only delays time to market with no additional trust from the consumer.  However, clear and published documentation of steps taken to secure information creates valuable transparency in the marketplace and allows consumers to select those providers that offer the most transparent and most comprehensive strategies for data security.

Whether or not regulation is a valuable tool is a more political issue.  The real challenge for businesses and consumers in the future will be how to evaluate the cost of data security against the opportunity cost created by the accompanying delay in time to market.  If consumers decide that the delayed arrival of new technologies are worth the increase in data security, the role of regulation will be determined by how service providers respond to this demand by the market.

Based upon the various amalgamations of the data, the conclusion I have reached is that the health reform bill focuses largely on “access” through things such as:

• covering the currently uninsured by requiring (and where necessary, subsidizing) all Americans to purchase insurance,
• removing the ability of insurers to deny coverage based upon pre-existing conditions,
• removing the limits that insurers can place on members through ‘lifetime maximums’ that limit the total amount of money the insurance company spends on any member’s care
• extending the age limit for children to remain on their parents’ policy

I applaud these actions, and recognize that they are an important element of reforming the way we deliver healthcare by ensuring that people have access to care. That said, increasing access alone will not only fail to moderate the cost trend – it is likely to exacerbate it. So what’s missing?

1. Payment reform – much has already been said about the perverse incentives created by the fee-for-service reimbursement model. True health reform must include payment reform that puts the incentive on delivering better outcomes, not simply delivering more care.
2. Limits on litigation – another incentive that doctors have to prescribe care that doesn’t directly correlate to better outcomes is the fear of litigation. True health reform needs to address our litigious nature as a society, and protect doctors from frivolous lawsuits.
3. Patient behavior reform – despite plenty of evidence to the contrary, the predominant mindset among patients is that more care is better care, and that more expensive care is better care. In order to moderate the healthcare cost trend, there will need to be less consumption of healthcare and a shift from late stage medical care to more preventative medicine. Increased access to care will certainly help, but more will need to be done than to simply provide people with the ability to see a doctor – they will need incentives that actually change behavior.
4. Eliminating waste due to fraud and overuse – an obvious way to reduce healthcare spending is by eliminating the 30% that is estimated to go to waste or fraud. Advantages of health IT are that it can limit duplication of healthcare (waste), increase efficiency of the care currently being applied (efficiency) and apply controls to prevent or detect outliers (fraud protection).
5. Reforming the system itself – largely overlooked is the idea of reforming entirely the system of how insurers, patients and providers work together. True Healthcare reform would enable more disruptive innovation in the market – such as allowing members to select whatever combination of wellness and health insurance they like (even across state lines) rather than limiting to 2 or 3 choices by their employer, or allowing members to carry their plan with them for as long as they like, even if they change employers. There are limitless possibilities for new and unique business models that will provide better value at lower cost.

The reform bill that was signed into law this week is a start, but to really change the healthcare landscape in America, we will need to address many (if not all) of the items above as well.

What do you think?

It’s evident that the average person doesn’t feel like they pay for the difference between a medical procedure that costs $15,000 at one hospital versus the same procedure that costs $7,500 at another hospital.  In fact, when faced with price information, many healthcare consumers actually trend towards the higher cost option.  The predominant mindset is that higher cost means higher quality.   That, combined with the idea that “the insurance company is paying for it, not [the patient]”, then why take the risk that the lower cost option might be lower quality?

How did we get here?

One contributor to this mindset clearly is that the employer-sponsored health plans have bred all the cost-consciousness out of the healthcare consumer.  The reason for this is because the cost of healthcare is virtually invisible to employee subscribers.  If you ask anyone who has employer-sponsored health coverage what they pay for health insurance, a minority may be able to quote how much of the money comes out of their paycheck each month (e.g. their out of pocket contribution for healthcare premiums), but virtually no one knows how much their company is paying for insurance on their behalf.  The thing no employees seem to think about is the fact that employers would be happier to take the money that they currently contribute to subsidize employees’ healthcare premiums and instead put it into the employees’ paychecks.   Since most companies subsidize at least half of the cost of health insurance (with some paying two thirds or even 75%), the opportunity cost for health insurance is at least twice (if not 3x or more) higher than what people recognize as their “cost” for health insurance.

Imagine if you were paying for mobile phone service each month but had no idea what it cost?  Would it be realistic not to expect monthly phone subscription prices to rise?  One of the main tenets of a competitive economy is that competition drives prices down, but this is only possible when people actually compare the prices of like products and choose the cheaper alternative.  This is impossible if the consumer doesn’t know the price.  This is one of the fundamental issues behind the rising cost of healthcare – ignorance on behalf of consumers for the actual cost of healthcare – and yet it’s one issue regarding which I’ve heard very little discussion as the health reform debate wages in Washington.

What if…?

What if we had a world where health insurance was no longer predominantly employer sponsored?  What if instead, employers put the money that they currently use to subsidize health insurance into the employee’s paycheck every month, and the insurance company billed the employee for the full amount of their health insurance coverage?  The government could still give healthcare insurance consumers the tax break that we get today so there would be no increase from what a subscriber pays now to what they would  pay under this new model – but consumer awareness (and sensitivity) to the full cost of healthcare would skyrocket.

Suddenly, health insurance consumers would be much more likely to become discerning consumers of health insurance (and healthcare services).  Combine this with the concept that in this model, health insurance subscribers become the decision makers regarding which insurance they buy (instead of being limited to the options that their employer offered).  This new price awareness plus decision making power would lead to a new competitive environment among the health plans, where plans would innovate and compete to provide higher value options for consumers.  Decoupling plans from employers would also entice health plans to focus on ways to enable their subscribers be healthier.  The plans would be able to see a much larger return on each dollar of investment made in a subscribers health today, since there would be a much larger possibility that the subscriber would still be in that plan many years from now.

It’s unrealistic to expect that we can address the cost trend without addressing the lack of cost sensitivity on behalf of the ultimate consumer of healthcare services – the patient.

At HealthCampBoston, the convergence of thought around various challenges facing health care was evident. And this was not the development of a myopic view but a vision of a path through challenges.

To illustrate, I’ll dive into one challenge discussed in one of the sessions throughout the day-long unconference. The challenge was the major one of reporting clinical patient data by providers.  Most people agreed that this is necessary and may soon be required by providers seeking to qualify for economic stimulus funding for healthcare. Yet some providers are disinclined to do so as reporting exposes too much too quickly. Professionals in any field would hesitate at exposing business “tricks” on which they have become reliant. Provider offices faced with a difficult coding systems for billing sometimes place diagnostically inaccurate but monetarily accurate codes into health records for billing purposes, and so some fo these providers are understandably hesitant to have these seemingly harmless shortcuts cut short.

These shortcuts which can generate inaccurate data are not different than the many outside healthcare (just check out banking), but the impact of these shortcuts can be severe to individual patients when it concerns health records, as was evidenced by ePatientDave’s experience. At HealthCampBoston, a realization emerged that different solutions would have to be developed and used in concert to determine what would work best for providers and patients. John Moore suggested a virtual weigh station where patients would validate information before it was added to their PHR as a way to keep bad data out may be needed. Who better to manage one’s data than oneself. Another suggestion was that provider facilities would clean up the data before publishing it. You broke it, you own it. Another idea was to exclude billing data and only publish clinical data to PHRs, but this alone would not solve the problem. A physician noted that sometimes, non-billing related information such as temporary conditions (like pregnancy) were left on a patient’s record indefinitely. The convergence of thought came not from groupthink but from the realization that solutions often did not have to be mutually exclusive and that no single one is an obvious a silver bullet to this problem of effectively publishing and reporting clinical data that could be shared by providers and measured by payers, to align with paying for reporting and performance, which also brings other challenges.

The fact that there are incentives, both publicly and privately funded, aimed at providers which pay for reporting now and that they are being followed by a nascent wave of pay for performance incentives is heartening. The fact that there are now robust PHRs from Microsoft, Google, and others and that data can be electronically signed by the providers publishing this data also makes it more likely that increasingly clean clinical data will be provided for patients. I suggested that given choices, patients will reward providers who can a) publish data to PHRs at the request of patients and b) publish clean and complete data. This might be the best incentive and stimulus of all.

Started in 1990, the Human Genome Project was an early effort dedicated to mapping and sequencing the human genome. The time and money spent to complete a whole sequence of DNA were many years and billions of dollars.

The technology has advanced significantly since then.  For the first time in history, individuals can gain access to their personal genome information through different companies. Now, DNA sequencing can be turned around in months. Depending on how complete of an analysis you want, you can take a look at your genome by paying a fee.

Here are a few options mentioned by Kevin Davies, Editor in Chief of Bio-IT World, at the HBSAB event: “The $1000 Genome: How Routine DNA Sequencing Will Reshape Medicine”:

• 23andMe – $399; analysis is based on genotyping; output: 110 clinical and research reports
• deCodeMe – Complete scan for $985, analysis of 38 conditions. Cardio scan for $195 which covers heart attack and atria fibrillation. Cancer scan for $225 which covers 7 cancers.
• Navagentics – Health Compass for $2,499 which covers 23 health areas. Annual Insight for $499 that includes analysis on 10 common health conditions.
• Knome – $150,000, high-touch service that sequence the whole DNA

If you are willing to “donate” your genome, you can participate in the  Personal Genome Project which will analyze human DNA for free. The data will be published and help with on-going medical studies.

Personally, I have not yet decided to get my DNA genotyped or sequenced yet. I am not sure my primary care physician is ready for the amount of data and the type of data that I would get. I am not sure I am ready to know about my health risks. However, I understand the benefit of preventative health measures and I have been told that learning more about myself – what health risks I have – may lead to life changing decisions – devoting more effort to discovering the cure for MS, for example.

I am excited about what’s possible. I hope to continue learning about this space and look forward to this being even more accessible and mature.

Privacy has always been an issue with health information, and with the continued movement of medical information systems online – the challenges that will be posed will be overwhelming.  At a recent conference of HIMSS – the Healthcare Information and Management Systems Society – I spoke with someone working on solving the problem of protecting individual elements of PHI – allowing one doctor to see certain parts of my medical record, and forbidding access to that information by another practitioner.  His question was: how do you do this in a way that is easy?

I didn’t have an answer for him, largely because the problem isn’t a simple one to solve.  It’s expensive to implement PKI for medical records.  Implementing PKI for individual slices of the record?  Now that may simply be unattainable.

Privacy and security are expensive non-functional requirements in the healthcare IT space.  HIPAA undoubtedly keeps many a CTO awake at night.  The challenges of ensuring that medical records are secure and portable at the same time pose system challenges at each step: de-identification of relationally stored data, encryption of all transactions between systems, understanding authority and ownership of medical data, and on and on.  Yet with all of these non-functionals in play – the healthcare IT world is what it is and struggles to emerge from an outdated evolutionary model to something that is 2.0.

Consumer-oriented tools like personal health repositories are prime cases.  Where the 2.0 revolution for the rest of the web looked to convince people that privacy had determinate value, healthcare walks into the 2.0 world with very ingrained ideas of what levels of privacy are not only demanded, but required.  Facebook never had to contend with rules and regulations that required de-identification of such trivial data as who are you related to? Healthcare faces an uphill battle in that these rules are fairly well established already.  Innovation that requires the entrepreneur to confront these issues may well be stifled by the shear overhead of considering the privacy implications of each feature to be implemented.  History has shown us that people are willing to sacrifice privacy if the information they provide to a service results in greater value delivered.  Personal finance darling mint.com has thrived by convincing people that the information they provide around their personal finances will result in Mint being able to deliver services that they would otherwise be unable to deliver.  Mint simply had to overcome suspicions and fears by the consumer.  Healthcare ventures need to overcome barriers articulating these consumer uncertainties as law.

Mint simply had to overcome suspicions and fears by the consumer.  Healthcare ventures need to overcome barriers articulating these consumer uncertainties as law.

This drag on innovation and time to market is accurately reflected in the lag that is so readily evident in healthcare driving a consumer-centric model in technology as compared to other industries.  Whenever you introduce non-functional requirements to a project – requirements not immediately measured by the user – you add overhead that delays time to market.  This is precisely why Massachusetts Governor Deval Patrick considered granting a waiver to stimulus-funded construction projects for compliance with ADA accessibility standards.  He recognized that the cost and delay of adding additional requirements on the project may jeopardize timely completion, and ultimately – funding.  The outcry at the very idea may very well have been justified, but the motivators are still the same – projects demonstrate the most progress when they are completed to the point that they are largely usable – not entirely usable.

Some may argue that the road to hell is paved with good intentions, and that ignoring ADA compliance would simply trade one vice for another.  But perhaps with all that is at stake with the funding proposed as part of federal fiscal plans over the next two years, we should take a hard look at HIPAA and think about whether it can be treated as a suggestion rather than a rule in the vision that usable healthcare IT in the marketplace will solve the hard problems, leaving the mundane stuff for later when it doesn’t jeopardize progress.

Information is the lifeblood of healthcare, used by and influencing the decisions of everyone from patients to providers to payers.  But health information is far removed from whatever humble roots it may have had.  Government regulation and the demand for information as part of the never ending flow of funding for research has created information that lives in a largely disaggregated state, each element having a largely singular purpose and connected to the whole by and large by human beings looking for patterns and relationships that influence decisions.  Standards exist in various forms, and more and more are being imagined to find a panacea for the liberal exchange and use of this information.

Oddly, the world wide web has already tackled this problem, albeit more generically.  Some forward thinking people, including web founder Timothy Berners-Lee imagined a global network of information that would need to be modeled as a series of defined abstractions as to what data described.  The Resource Description Framework or RDF is a standard that suits exactly this purpose – aiming to make the description of a resource fully portable but not universal.  Additionally, these same forward thinking people envisioned a need to model relationships between resources – such as how a person might be related to a corporation. The same aim applied – to make these descriptions portable, but not universal.  For instance, in some case, a person may be a litigant against a corporation, which in another they may be described as being employed by the corporation.  For this we have the Web Ontology Language or OWL. Together, these two standards are the primary concerns of the semantic web.

In healthcare, we have several key motivators for information interchange and exchange of standards.  Business intelligence, the general idea of applying reason and analytics to understand the various measures of the business domain so that decisions can be influenced, is a big one.  For years, data warehousing and data federation have been the tools used to tackle problems of assembling domain information in ways that would allow meaningful analysis.  But these tools both exist because they are complimentary, not because they are necessarily competitive.  Secondly, data integration is an increasing concern amongst public and private entities alike.  While HIPAA mandates portability as part of it’s very name, the idea of a truly portable health record has been but a dream.  Competing standards are evolving, whether it be CCD or CCR, or even the amoeba-like HL7.  But as they are currently constituted – they are merely candidates for competitive evaluation rather than integration, and at the very most, subject to the same Extract-Transform-Load paradigm from data warehousing methodology or data federation of complimentary existing systems.

It is all of this effort and redundancy that make healthcare and portable health information a robust candidate for consolidation as part of the semantic web, the backbone of web 3.0.  In a world that is full of disorganization and competing standards, the use of RDF as interchangeable and mergeable pieces as from pieces of the business domain into an expanding, scalable ontology for that domain will spare the need for convergence on how to describe the domain and instead focus on enabling interactivity.  If the CCD or CCR were defined as RDF, anyone could easily combine these two interfaces which describe the domain of the medical record into an ontology that best describes the problem at hand.  Then, analytics can occur by understanding the domain and the relationships in that domain, rather than requiring a deep understanding of the data itself.

This is just coming across the wire, but some quick thoughts:

1. Coupled with an HIE solution, this could make eClinicalWorks the de facto EHR standard.  With all the debate around where to store data and how to decide upon standards, a proprietary solution now has a sales channel and a price point to dominate the marketplace.  Let’s not underestimate the need for HIE though – without the tools for participating physicians to collaborate and access patient data from other physicians (with all the kosher privacy and security barriers in place, of course), this just creates many, many smaller silos that then need to be connected later.
2. Wal-Mart could become the largest healthcare network in the country.  They are effectively creating the infrastructure to incorporate a great number of doctors into a virtual practice.  Combined with health kiosk models and retail-based health clinics like that of CVS/CareMark, Wal-Mart has the opportunity to explode into the healthcare market and compete for insurance dollars beyond the pharmacy – perhaps even create their own insurance offering.
3. Will the government react adversely? While this announcement is an exciting collaboration between big players in the private sector, the current administration has to feel that this has the opportunity to be monopolistic and counterproductive to their own agenda.  It will be certainly interesting to see if there is an angle longer-term for the Wal-Mart/Dell/ECW team in being the key player in standardization of HIE and EHR protocol.