Digital Health: What’s Next?

My most recent “Last Words” article published in Health Information Management & Communications Canada magazine:

A good friend and former work colleague often remarks that once you have worked as a market analyst, you will always think like a market analyst. This observation rings particularly true around New Year’s when I feel the irresistible urge to offer my prognostications on what’s next for digital health.

This year, rather than offer specific predictions, I offer an overview of three major drivers that I believe will influence digital health priorities and direction in the near future.

Meaningful Use

In what might turn out to be one of the most significant announcements of 2016, Andy Slavitt, Acting Administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), declared:

“The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.”

According to healthIT.gov (a web site operated by the U.S., Office of the National Coordinator for Health Information Technology), Meaningful Use is defined as “using certified electronic health record (EHR) technology to:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and family
• Improve care coordination, and population and public health
• Maintain privacy and security of patient health information”

Speaking at the J.P. Morgan Annual Health Care Conference on January 11, 2016, Mr. Slavitt identified what he referred to as the four “themes guiding our implementation” of a Meaningful Use replacement:

• Reward healthcare providers for the outcomes they achieve using digital health technologies rather than simply for use of these technologies.
• Customized goals that allow solutions to be tailored to practice needs. Slavitt stated that “technology must be user-centered and support physicians, not distract them.”
• Levelling the playing field for start-ups and new entrants. This objective will be achieved by requiring open APIs in order to “move away from the lock that early EHR decisions placed on physician organizations” and thereby “allow apps, analytic tools, and connected technologies to get data in and out of an EHR securely.”
• Mr. Slavitt proclaimed “we are deadly serious about interoperability” and put technology companies that attempt to “practice ‘data blocking’ in opposition to new regulations” on notice when he stated that such practices “won’t be tolerated.”

Each of these themes reflects issues and challenges that have hampered the effective use of digital health technologies by both healthcare providers and the general public.

While the Meaningful Use program does not apply to Canadian healthcare organizations, it did have and its eventual replacement will have a significant influence on the digital health landscape in Canada.

Digital Health Investment

In their year end review for 2015, Rock Health, a venture fund dedicated to digital health, stated that venture funding for digital health companies in 2015 raised $4.5B.  This level of funding was an increase over the record breaking level of digital health investments in 2014 and, according to Rock Health, represents a compound annual growth (CAGR) from 2011-2015 of 32%.

Rock Health noted in their year end review that while “overall venture funding showed a slight dip in 2015, digital health continues to hold a healthy 7% of total venture funding.”  They also remarked that investors continue to show their interest in digital health companies and observed that there is a “growing tail of investors who participated in at least one deal.”

This steady level of funding and growing investor interest leads Rock to declare that “digital health is no longer a novelty.”

Rock Health identified three particular digital health categories that exhibited noticeable growth in funding in 2015: personal health tools and tracking, care coordination, and life sciences technologies.  They commented that “as the industry faces growing pressure to cut costs, digital health will play a key role in enabling engagement with the end-user and improving communication and coordination.”

Digital Everywhere

Computing technology, once the nearly exclusive realm of geeks and hobbyists, is now an integral part of everyday life for most people.

According to comScore, a global media measurement and analytics company, an average of 29.4 million Canadians per month accessed some form of on-line service during the fourth quarter of 2014.  Based on Statistics Canada figures, this on-line community represents just over 80% of the Canadian population.

Not only are a majority of Canadians engaging in some form of online activity, comScore notes that they are increasingly doing so across multiple devices including desktops, laptops, tablets, and smartphones. The number of Canadian mobile subscribers grew 5% from December 2013 to December 2014, with just over 80% of these subscribers owning a smartphone capable of accessing a variety of online services.

The pervasiveness of digital technology is changing how digital health solutions are perceived by end users.  Neither patients nor health providers need to be enticed to use digital technology; they do so in most other aspect of their lives. They need only be offered digital health solutions that are both useful and usable.

Summary

By clearly communicating its priorities and future direction, CMS is providing investors with insights that will shape their investment decisions.  This investment, if focused more on addressing user needs and less on certifying compliance with meaningful use guidelines, will likely produce digital solutions that end users will embrace and use.

What are your thoughts on digital health trends and drivers?  Please share your thoughts with me at michael.martineau@avenant.ca or on my blog at ehealthmusings.ca

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Feedback May Impact ONC Timetable

The U.S. Office of the National Coordinator for Health IT (ONC) recently issued a call for comments on its proposed stage 2 and stage meaningful use requirements.  This call for comments has generated considerable feedback, most of which has been posted publicly and has been reported in various publications.   According to recent healthsystemCIO.com article, an ONC workgroup “will review the timing of its staging structure”.

Of particular interest to me was workgroup member Judy Murphy’s observation that “There appears to be a groundswell movement which has people sending (blog) postings back and forth.”.  Apparently, public debate using social media tools such as a blog can have an impact.

Mike

Quality Measures – Stage 2 and Stage 3 Meaningful Use

Having announced the Stage 1 Meaningful Use rules this past summer, the U.S. Office of the National Coordinator for Health Information (known to most people as the ONC) did not wait long to start work on stage 2 and stage 3 Meaningful Use rules.    Earlier today, David Lansky, Chair of the Quality Measures Workgroup, posted a request for comments on proposed new clinical quality measures.  These measures were developed by five tiger teams, each focused on different measure domain:

• Patient and Family Engagement,
• Clinical Appropriateness/Efficiency,
• Care Coordination,
• Patient Safety, and
• Population and Public Health.

The resulting measures were reviewed and consolidated by the Quality Measures Workgroup which is now calling for public comment. In addition to general comments, the Quality Measures Workgroup also seeks specific examples of measure for each measure concept.

Comments will be accepted until December 23, 2010 [which, by the way, also happens to be my oldest son’s birthday 🙂 ]

Mike

 

Greg Reed at ITAC Vendor Forum

Today I attended an ITAC Health vendor information session at which Greg Reed, the CEO of eHealth Ontario, provided an update on the agency’s plans and priorities.  While I had hoped that Mr. Reed would make a more definitive statement regarding the agency’s role and offer a clear articulation of the agency’s updated strategic plan, I did walk away with a better sense of the underlying philosophies influencing how the agency operates and the challenges that it faces in positioning itself in the complex Ontario health system.

Mr. Reed continues to demonstrate an unwavering commitment to “getting it right” and steadfastly refuses to assert his own views about the “right” direction for either the agency or eHealth in Ontario.  Instead, Mr. Reed insists that he needs to take the time necessary to consult with all stakeholders.

Mr. Reed spoke for just under an hour and then took questions.  He divided his presentations into four parts to cover the following topics:

• Update on various efforts to remediate eHealth Ontario
  
• Observations on what he has seen / heard during his visits across the province
  
• Update on strategic planning activities
  
• Musings on eHealth Ontario’s role
  

Mr. Reed structured his remarks on efforts to remediate problems at eHealth Ontario in terms of the four general areas of concern raised in the Auditor General’s report.  He noted that the agency’s analysis identified 84 root causes for the problems identified by the Auditor General. In terns of the four areas of concern, Mr. Reed offered the following update on efforts to address these concerns:

• Oversight / governance – The agency is “almost there” in addressing these concerns according to Mr. Reed.
  
• Procurement – The agency has overhauled the procurement process so that it is more open and transparent albeit more complicated.  According to Mr.  Reed, the agency is “just about done” addressing this area of concern.
  
• Project planning – The agency needs “outside help” and has engaged someone (wasn’t clear whether it was new hire or a consulting engagement) to lead remediation efforts in this area.  Mr.  Reed stated that he could not identify the person but that an announcement was forthcoming in the near future.
  
• Strategic planning – Mr. Reed had “hoped to have a plan by now” but that he was still talking to stakeholders to get feedback.  As part of this process Mr. Reed indicated that he wanted to engage the audience is a dialog during the question and answer portion of his presentation.
  

Mr. Reed offered additional insights regarding remediation efforts including:

• The eHelath Ontario leadership team has been “reinforced” with “8 or 9 new vice-presidents
  
• Significant staffing changes.  150 out of a total staff complement of “800 to 850” employees have left the agency and roughly 200 new employees have been hired.  Some of the new hires replace consultants.   According to Mr. Reed, there are now 118 consultants working at the agency.  This number represents about 12% of the eHealth Ontario workforce, a level that Mr. Reed feels is “about right”.
  
• Joint planning with Ontario government regarding network and data centre operations. The Ontario government is reusing portions of the eHealth Ontario network for other gov’t department traffic and there are discussions regarding use of an existing Ontario government data centre.
  
• Working to change the organization’s culture from “command and control” to “more open and transparent” where good ideas can come from anywhere, not just through the chain of command.
  

Mr. Reed explained that he had spent considerable time “in the field” talking to an “alphabet soup” of organizations. He noted that it quickly became apparent to him that the Ontario health sector was a complex environment which he categorized as “very heterogeneous” in many ways, from process to technology. This complexity will, according to Mr. Reed, make developing an interoperable electronic health record a “daunting task”.

When engaging various stakeholders, Mr. Reed explained that his approach has been “listen, learn, hypothesize ideas, and solicit feedback on these ideas”. It is this collaborative and iterative approach to developing a new strategic plan that is taking more time than expected but which is considered an important ingredient to arriving at the right strategy for Ontario.

There was a palpable change in the room when Mr. Reed shifted his presentation to an update on the strategic planning process. Many people reached for their notepads and could be seen scribbling furiously as Mr. Reed spoke. Mr. Reed opened his remarks regarding strategic planning by stating eHealth Ontario’s overarching goal: Whenever someone in Ontario touches the health system in the presence of a provider want that provider to have much information about the patient as possible, preferably in electronic form. Mr. Reed noted that keeping this information accurate and consistent while also assuring that it is securely protected is a major challenge given the high transaction rates that will have to be supported.

Mr. Reed talked at length about two strategic priorities:

1. Deliver on key commitments. Mr. Reed stated that it was imperative that the agency deliver on commitments that it makes in order to build credibility. He offered a quick status report on several key initiatives including the Diabetes Registry (a misnomer, according to Mr. Reed, as it really is an application), Drug Information System (procurement expected to start late this year, early next year), and foundation technologies such as registries (client, provider, location, etc which need to be “cleaned up” and turned into a resource that the provider community can use).
   

   Mr. Reed mused about the difference between local initiatives and cross-sectoral projects such as Chronic Disease Management systems that “feel like government work”. These cross-sectoral applications have no economic incentive for a single provider but offer significant benefits to the health system as a whole. Such projects, according to Mr. Reed, are likely best handled at a provincial rather than local or regional level. Since many eHealth projects have more local benefits, Mr. Reed believes that many solutions will come from the provider community working with vendors.
   

2. Drive meaningful use and adoption. According to Mr. Reed, the province is “awash in electronic health records” that range in sophistication and that have been designed to meet local needs. Most of these systems are not “controlled or owned by government”. The problem in driving an interoperable electronic health record is that these systems are not connected in any way and that we have, as a result, a plethora of “information silos”.
   

Mr. Reed introduced the concept of “natural referral areas” in which providers have an incentive to work together. According to Mr. Reed, there are 4 to 5 such areas in Ontario, most of which are larger than many provinces. Rather than a “big bang” approach that results in a single electronic health record system, Mr. Reed suggested that it makes more sense to develop an interoperable electronic health record within each referral area and link them at a later date. This multilateral approach respects local needs and priorities and potentially offers a way to get personal health records into patients’ hands sooner. By adhering to common standards and working towards a common goal, regional initiatives will eventually converge to create a provincial interoperable electronic health record while providing benefits at a faster pace than a unilateral, “big bang” approach.

To my disappointment, Mr. Reed did not offer a succinct and clear statement regarding eHealth Ontario’s role. Indeed, when asked during the question and answer session how the agency plans to work with the LHINs, Mr. Reed responded “I don’t know”. He did muse on the agency’s role, offering some thoughts, including:

• Need to collaboratively develop an overall architectural framework, with the agency making the “hard decisions when necessary”.
  
• Need to “draw people into the tent” rather than make pronouncements about how things should work.
  
• The agency will act as a “strategic investor” funding local and regional projects around the province.
  
• The leadership style is to be a “servant leader” that facilitates dialog and gets the right people in the room for this dialog
  

Overall, the presentation offered considerable insights into the philosophies and guiding principles but was a little short, I felt, on definitive statements of where to next and how we will get there. Perhaps Mr. Reed is right that more consultation is needed but I think that, at the very least, more definitive timelines as to when a new strategy will be in place and a succinct statement on the role of the agency are needed to set expectations and to drive discussions to a conclusion. What are your thoughts on what Mr. Reed shared today?

Mike

Impact of Standards on Vendor Consolidation

A new report from KLAS, a market research firm that measures vendor performance based on feedback from the user community, shows while the market for hospital EHR systems nearly doubled in 2009, only two vendors, Epic and Cerner, appeared to benefit from this market growth.   According to an article summarizing major findings from the KLAS report, hospitals “want a vendor that can be a consistent and reliable partner in their efforts to reach meaningful use”.   Jason Hess, author of the KLAS report, suggests that “Changes in the CIS (clinical information system the marketplace as a result of ARRA seem to have blindsided some vendors and left them struggling to stay afloat in the hospital market”.

While the US has chosen to let the market decide the vendors with whom they prefer to work,  the introduction of “meaningful use” regulations is nonetheless having an impact on the US market.  Vendors such as Eclipsys, GE, McKesson, and Quadramed lost more hospitals than they gained, according to KLAS and are “struggling to regain lost ground”.   While Siemens and MEDITECH did not lose ground in the same as some other vendors, their growth was much more limited than either EPIC or Cerner.

Mike

Meaningful Engagement

For better or worse, the phrase “meaningful use” is quickly becoming used to describe a metric by which many eHealth projects will be measured, either directly or indirectly.  Enshrined in the legislation governing the funding of electronic health record implementations in the United States, this term has caught the attention of eHealth leaders and decision makers across the world.  Close to home, for example, the theme for the eHealth track at this fall’s OHA HealthAchieve conference is “Meaningful Use: The Canadian Context”.

In an insightful paper entitled “Certification of Electronic Medical Records: Lessons Learned from Canada”, Dr. Matthew Morgan and Dr. Mark Dermer assert:

“Meaningful use is not only the primary goal for EMR adoption, it is also essential to health system sustainability and can serve as a powerful inductive force for the other key components of comprehensive nationwide health informatics infrastructure“.

They also note:

“The current US national dialogue on defining meaningful use criteria
and reconsidering initial targets is appropriate and productive.
Physicians and health informatics professionals are engaged in this
dialogue with payers, policy makers, product vendors, certification
agencies, politicians and patients.”

While they use the term explicitly, Dr. Morgan and Dr. Dermer describe a process for reaching consensus on “meaningful use” that includes “meaningful engagement” of all stakeholders.  Having watched the US “meaningful use” debate for the better part of the past year, I believe that it is this “meaningful engagement” that is driving the constructive and productive debate regarding “meaningful use” and that has allowed the US to move so quickly in developing its eHealth strategy.

While “meaningful use” may be capturing many people’s attention, perhaps we should think more about the “meaningful engagement” that seems to be a core philosophy in the US “meaningful use” debate.   I wonder if it is the process by which “meaningful use” was defined and the policies and standards needed to achieve it are determined that it is the more significant achievement.

Another way to think about “meaning engagement” is to consider a “middle-out” approach to eHealth strategies and architectures rather than either “top down” or “bottom up” approaches. Commenting on a blog post weighing the merits of top-down vs bottom-up approaches to developing the Australian eHealth strategy, Enrico Coiera suggests that a “middle-out approach” is a “co-production of industry, health service providers, and government“.   He further states that “Middle out is about setting the agenda co-operatively from the start – consultation is not necessary because everyone is already in the room. These aren’t just words or cliches, they are a mind set.”

What do you think?  Is “meaningful engagement” a metric that we should perhaps apply to the process by which eHealth related discussions and debates are measured?  Is a “middle-out” approach more effective at achieving “meaningful engagement”?

Mike

Open Process Drives Changes to Meaningful Use Criteria

According to a recent article in Health Data Management:

“The final meaningful use rule has many changes and clarifications in its 864 pages, testimony to the degree to which federal officials listened to stakeholders following publication of the proposed rule”.

According to another article that I read last week (I don’t have a reference handy), there were on the order of 2,000 submissions offering feedback and making suggestions for changes.  As I have discussed in previous blog posts, the Office of the National Coordinator (ONC) worked hard to engage stakeholders and to make the process by which the proposed rule was discussed as transparent as possible.  It appears that this approach was successful but I’d be interested in hearing what others think.  What aspects of the ONC approach worked best?  Are there lessons learned for other jurisdictions?

Mike

Need for Physician IT Leaders

I am listening live to a media conference at which the US Dept of Health and Human Services is announcing the final “meaningful use” standards.   Two of the leaders speaking at this conference are  the new director of the Centers for Medicare & Medicaid Services (CMS), Dr. Donald Berwick, and the National Coordinator for Health Information Technology, Dr. David Blumenthal.  Both men are medical doctors and both spoke to the benefits of electronic health records based on their own personal experience. Joining them was the US surgeon general, Dr. Regina Benjamin, who also spoke to her experience using electronic health records.

As I have argued in past blog posts, I think that we need physicians in very senior leadership positions in Canadian eHealth organizations such as Infoway and eHealth Ontario.  As Dr. Blumenthal demonstrated at the eHealth 2010 conference in Vancouver and again today at the HHS media conference, a physician who has made the transition from paper to electronic systems has tremendous credibility when they speak about the benefits and challenges associated with this transition.    I urge Canadian eHealth organizations to listen to a recording of today’s HHS media conference to hear for themselves how the compelling personal anecdotes of three high profile US healthcare leaders were used to highlight the benefits of electronic health records.

Mike

UPDATE:  You can catch a replay of the media conference here.

US EHR Strategy

I have been watching with great interest the development of the US EHR strategy, spurred, in large part, by stimulus funding through the HITECH.  I recently came across a succinct and insightful summary of this strategy written by John Glaser,  VP and CIO at Partners Healthcare in Boston and soon to be CEO at Siemens Health.  What I thought was particularly insightful and perhaps even profound was Mr. Glaser’s views on the uncertainity associated with the US strategy:

“It is not possible to launch this much activity of this scope with this many actors and have great certainty about the outcome. This uncertainty will be magnified by the evolving actions of the private sector—hospitals, health plans, suppliers and others that are engaging in a diverse array of often very imaginative implementation activities.

The implementation plans are good plans. Change of this magnitude will bring very real progress, but it will also bring a period of time that is likely to be bumpy.

The federal electronic health record strategy has been formed, and the country is at the start of its implementation. The strategy is ambitious, multifaceted and sophisticated. This journey faces many uncertainties and will not be easy. However, the strategy has a high likelihood of causing many health care organizations to make meaningful use of EHRs and improving the health care delivered in this country.”

Sometimes it is simply not possible to predict with any accuracy how change will play itself and being too prescriptive is a recipe for disaster.  I think that the US approach will generate sufficient activity that there will more successes than failures and a natural momentum will be created that will carry the eHealth agenda forward in that country.

Mike

Openess and Transparency

I have been following the US “meaningful use” debates quite closely and regularly listen in on committee and working group sessions related to this topic that are broadcast over the Internet.   Another venue for public participation in the debate is through a web-based discussion forum:

http://www.regulations.gov/search/Regs/home.html#searchResults?Ne=11+8+8053+8098+8074+8066+8084+1&Ntt=CMS-2009-0117&Ntk=All&Ntx=mode+matchall&N=8060

An example of the type of comments posted on this site is a letter from signed by Massachusetts  senators Paul G. Kirk Jr. and John F. Kerry.  They ask that “meaningful use” criteria require “the inclusion of a physician narrative beyond the template text”.  They argue that such narrative “enables medical providers to explain their thought processes, including issues such as why they recommended one treatment over another”.

I continue to be amazed at the degree to which the debate on “meaningful use” is made public.  My sense is that this level of openness and transparency is not only leading to a more robust definition of “meaningful use” but is also contributing to a more constructive and respectful debate.

Mike