The Future Is Still Not Here

By Kim Bellard, November 13, 2014

US News & World Report had some fun looking back at what experts in 2004 predicted for health care in 2014.  Not surprisingly, they found that we're not quite there yet, but might be by 2025.  The future, it would appear, is always ten years away. 

Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:

2004 prediction: In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.

Whoops.

To be sure, there have been several important changes in our health care system over the past ten years.  Some of the more important ones would have to include:

• PPACA has assisted several million more people to obtain coverage.
• HITECH has spurred EHR adoption.
• Share of coverage through employers has dropped significantly.
• Provider consolidation continues relentlessly.  

In terms of realizing those predictions about controlling costs, improving customer service, reducing medical mistakes, or addressing malpractice concerns: well, not so much.

The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014.  Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes.  Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.

If this is progress, I'm not sure we can take much more of it.

By way of contrast, think about the technology world in 2004:

• Apple was selling the heck out of iPods, with the iTunes Music only a year old.  The iPhone, iPad, and App Store were only gleams in Steve Job's mind.
• Google had just gone public.  Google Maps had yet to debut (2005) and its Android mobile platform was years away (2007).  
• Most mobile phones did not have cameras, the Motorola RAZR was the cool phone, and the Blackberry still set the standard for what passed as smartphone, with the Palm Treo giving it a run for its money.
• Facebook was still limited to university users, and Twitter was two years away from its first tweet.   
• YouTube did not exist (2005), and Netflix hadn't started streaming (2007).

Why isn't health care seeing those kinds of radical changes in the landscape? 

Certainly there have been plenty of important clinical innovations in the last ten years.  Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have, 

Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people.  By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).

I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.

The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future.  Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed. 

Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits?

Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush.  I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data.  By 2024 we should be using real-time data to prevent hospitalizations and other acute episodes, but who will pay for, and act on, the monitoring and interventions?

Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth.  That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.

If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.

As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it.  I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.&

Let's not wait ten years.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Top Ten Medical Innovations for 2015

By Clive Riddle, October 31st, 2014

The Cleveland Clinic annually announces their take on the Top Ten Medical Innovations that are likely to have major impact on improving patient care in the coming year. They have just released their ninth annual version of this list, selected by a panel of 110 Cleveland Clinic physicians and scientists. With no further adieu, here – verbatim – is their narrative on their compilation of the Top 10 Medical Innovations for 2015:

1. Mobile Stroke Unit
   Time lost is brain lost. High-tech ambulances bring the emergency department straight to the patient with stroke symptoms. Using telemedicine, in-hospital stroke neurologists interpret symptoms via broadband video link, while an onboard paramedic, critical care nurse and CT technologist perform neurological evaluation and administer t-PA after stroke detection, providing faster, effective treatment for the affected patient.
2. Dengue Fever Vaccine
   One mosquito bite is all it takes. More than 50 to 100 million people in more than 100 countries contract the dengue virus each year. The world's first vaccine has been developed and tested, and is expected to be submitted to regulatory groups in 2015, with commercialization expected later that year.
3. Cost-effective, Fast, Painless Blood-Testing
   Have the days of needles and vials come to an end? The new art of blood collection uses a drop of blood drawn from the fingertip in a virtually painless procedure. Test results are available within hours of the original draw and are estimated to cost as little as 10% of the traditional Medicare reimbursement.
4. PCSK9 Inhibitors for Cholesterol Reduction
   Effective statin medications have been used to reduce cholesterol in heart disease patients for over two decades, but some people are intolerant and cannot benefit from them. Several PCSK9 inhibitors, or injectable cholesterol lowering drugs, are in development for those who don't benefit from statins. The FDA is expected to approve the first PCSK9 in 2015 for its ability to significantly lower LDL cholesterol to levels never seen before.
5. Antibody-Drug Conjugates
   Chemotherapy, the only form of treatment available for treating some cancers, destroys cancer cells and harms healthy cells at the same time. A promising new approach for advanced cancer selectively delivers cytotoxic agents to tumor cells while avoiding normal, healthy tissue.
6. Checkpoint Inhibitors
   Cancer kills approximately 8 million people annually and is difficult to treat, let alone cure. Immune checkpoint inhibitors have allowed physicians to make significantly more progress against advanced cancer than they've achieved in decades. Combined with traditional chemotherapy and radiation treatment, the novel drugs boost the immune system and offer significant, long-term cancer remissions for patients with metastatic melanoma, and there is increasing evidence that they can work on other types of malignancies.
7. Leadless Cardiac Pacemaker
   Since 1958, the technology involved in cardiac pacemakers hasn't changed much. A silver-dollar-sized pulse generator and a thin wire, or lead, inserted through the vein kept the heart beating at a steady pace. Leads, though, can break and crack, and become infection sites in 2 percent of cases. Vitamin-sized wireless cardiac pacemakers can be implanted directly in the heart without surgery and eliminate malfunction complications and restriction on daily physical activities.
8. New Drugs for Idiopathic Pulmonary Fibrosis
   Nearly 80,000 American adults with idiopathic pulmonary fibrosis may breathe easier in 2015 with the recent FDA-approval of two new experimental drugs. Pirfenidone and nintedanib slow the disease progress of the lethal lung disease, which causes scarring of the air sacs. Prior to these developments, there was no known treatment for IPF, in which life expectancy after diagnosis is just three to five years.
9. Single-Dose Intra-Operative Radiation Therapy for Breast Cancer
   Finding and treating breast cancer in its earliest stages can oftentimes lead to a cure. For most women with early-stage breast cancer, a lumpectomy is performed, followed by weeks of radiation therapy to reduce the likelihood of recurrence. Intra-operative radiation therapy, or IORT, focuses the radiation on the tumor during surgery as a single-dose, and has proven effective as whole breast radiation.
10. New Drug for Heart Failure
    Angiotensin-receptor neprilysin inhibitor, or ARNI, has been granted "fast-track status" by the FDA because of its impressive survival advantage over the ACE inhibitor enalapril, the current "gold standard" for treating patients with heart failure. The unique drug compound represents a paradigm shift in heart failure therapy.

Wondering what Cleveland Clinic proclaimed a year ago would be the top innovations for this year? Here was their top ten list from last year:

1. Retinal Prosthesis System – Early Stage Bionic Eye
2. Genome-Guided Solid Tumor Diagnostics
3. Responsive Neurostimulator For Intractable Epilepsy
4. Direct-Acting Antiviral Oral Hepatitis C Drugs
5. Perioperative Decision Support System
6. Fecal Microbiota Transplantation
7. Relaxin For Acute Heart Failure
8. Computer-Assisted Personalized Sedation System
9. TMAO: A Novel Biomarker For Heart Attack, Stroke Risk
10. B-Cell Receptor Pathway To Treat Blood Cancers

Google Wants to Helpout Your Health

by Kim Bellard, October 21, 2014

I suppose it was inevitable that I'd end up writing something about Google's interest in health, since recent posts have focused on efforts from Facebook and Amazon, as well as the general gold rush for health IT.  Fortunately Google has obliged me by introducing a neat health-related wrinkle on their Helpouts service.

Google's new service pops up an offer to do a video chat with one of their Helpouts physicians when you are doing health-related searches, in case you want more expert opinions and advice.  It certainly beats getting an ad for a pill or a health aid (although I don't imagine Google will stop presenting those as well).

Let's back up.  For those of you not previously familiar with it (and count me among those), Helpouts is a Google service, launched last November, that allows consumers to connect with applicable experts via live video chats. 

The new feature connects the service to search results.  You may not have Google Helpouts top-of-mind when looking for health information, but it's a pretty safe bet that you might use Google search in doing your research.  Pew says 72% of Internet users searched for health information within the past year, with 77% of them starting with a search engine. 

"Google Docs" takes on a whole new meaning now, doesn't it?

The telemedicine aspect of Helpouts is not strikingly new.  What distinguishes Google's effort, of course, that it is pro-active.  It doesn't wait for you to decide things are serious enough to seek out a doctor, but, rather, uses your search activity to trigger the offer of a consult.  I think this will be an important part of our health system's future -- not merely reacting but being proactive.  All these remote monitoring devices are pretty pointless if we don't use them to try to intervene early, instead of waiting for an acute event or an office visit to trigger care.

I have a couple of suggestions, or at least questions, on the new Helpouts feature:

• It's not clear to me how specific the type of physician available is to the search request.  If you are searching on angina, for example, it'd be nice if you got a cardiologist to talk with rather than a dermatologist.
• It's not clear to me if the experts are always physicians, or if they triage the experts based on the severity of the information being searched for.  

On the second point, I've written before about personal health assistants -- including Better from The Mayo Clinic -- as well as potentially using AI to provide such a service.  I think it'd be even cooler if Helpouts gave you a personal health assistant, starting with an AI agent and progressing to a specific human team if necessary, with physicians available for the most complex needs.  Maybe that's Helpouts 2.0.

Of course, Google's health interests don't end with the current Helpouts approach.  They are already pushing Google Fit as a way for Android developers to connect their health apps, and it'd be a great next step if Google could tie Helpouts to those apps, using the data mined from them to trigger an offer of a consult -- or an intervention, depending on the urgency of the need.

It'd be even better if you could opt-in your own physician(s) and health system to the Helpouts service instead of relying on Google's set of physicians.  

As long as I'm already trying to come up with more things Google could do in health, I might as well add that I'd love to see them get into the transparency business.  They try to help consumers find the best prices for other goods, and certainly health care can use all the help it can get in this regard.

Google is thinking bigger than these more modest expansions, like their "moonshot" to genetically map a healthy human body, or their new health and well-being company Calico, which has already announced the building of a major research facility.  I like that they are taking the long view, focusing on prevention and cures rather than simply more treatments, but there's still plenty of ways they can help the health care system in the short term as well.

Hmm, Google loves robots: maybe robotic surgery -- or doctors -- is next.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Clinicians Embracing mHealth – but not so much if patients are involved

By Clive Riddle, September 12, 2014 

Although lagging behind many other service sectors, healthcare clinicians do continue to their march towards the inevitable professional embrace of mobile apps, social media and other web applications – typically as long as that embrace falls short of interacting with their patients. 

Wolters Kluwer Health just released survey results on nurse practitioner use of mobile health, social media and the web. The survey was conducted on their behalf by Lippincott Solutions. 

The survey found that 65% of nurses currently use a mobile device at work for professional purposes at least 30 minutes per day, and 95% of healthcare organizations allow them to consult websites and other online resources for clinical information at work. 

The survey findings also indicated:

• 83% of nurses perceive that their organization's policy allows patient care staff access to web sites, including social media, to access general health information regarding patient conditions
• 48% of respondents that access health information say their organization encourages nurses to access online resources; while 41% allow for occasional use; and 5% only as a last resort
• 89% of healthcare organizations allow nurses to use online search engines at work
• 60% of respondents say they use social media to follow healthcare issues at work
• 86% say they follow healthcare issues on social media outside of work
• 20% of nurses use mobile health apps for two hours or more per day
• Among those who use mobile devices at work, Nurse Managers, at 77%, are more likely to use them than Staff Nurses, at 58% 

But their report notes that “73% of healthcare respondents say that organizational policies strictly prohibit direct patient care staff to have social interaction with patients on social media and social sites, compared to 51% say that organizational policies prohibit direct patient care staff to have access to their organizations’ own social media pages.” 

A Walters Kluwer survey of physicians last year found that 21% of doctors didn’t use smartphones in their practice, 46% used them less than 25% of the day, and 33% used them more than 25% of the day. Regarding use of tablets, 39% of doctors didn’t use tablets in their practice, 37% used them less than 25% of the day, and 24% used them more than 25% of the day. Of those who did use mobile devices at work,  24% use mhealth apps; while 33% used their smartphones to communicate with patients, and  17% used their tablets for patient communication. 

While many integrated systems like Kaiser have structured electronic interaction with patients into their system, basic impediments for many continue to be a lack of reimbursement, as well as legal concerns about doing so. 

Yet it is exactly that interaction that their customers are asking for.  For example, Harris Poll results just released for a survey commissioned by Wellocracy found that 66% of those who have used a wearable mhealth tracker or app in the past 12 months ndicated that they would be interested in receiving personalized feedback on their health data from a trusted health expert, such as a doctor, nutritionist, fitness trainer or licensed lifestyle coach, and of those respondents: 75% would be willing to pay for personalized feedback and coaching from a doctor, and 73% from a nutritionist, nurse or dietician.

May I Speak to the Doctor's Computer?

By Kim Bellard, June 25, 2014

There's a new provocative study in Computers in Human Behavior that suggests we may be more likely to tell the truth about personal matters, such as health problems or medical history, when talking to a virtual human instead of to an actual human.  I'm not sure if these findings threaten to set back the patient-physician relationship 10,000 years, or promise to advance it fifty years.

The article -- It's Only a Computer, by Lucas, Gratch, King, and Morency -- tested participants' willingness to disclose information to a "virtual human" on a computer screen.  When the participants believed the virtual human was fully automated instead of being controlled by a human, they reported lower fear of self-disclosure, were less likely to shade the truth in order to create a good impression ("impression management"), and were rated as being more willing to disclose information.  The key to the behavior was their belief that no human was involved, whether or not a human was actually acting behind the scenes.

The virtual human idea is not pie-in-the-sky, good only for research studies.  Versions of it are already being tested, such as by Sense.ly, whose digital health avatar was profiled by MIT Technology Review a year ago.  It captures patient information via an avatar, which can respond to patient statements or data and can even answer questions.  

Clearly, we're entering a new world.

The kind of artificial intelligence that might power these avatars/virtual humans can also be used to assist physicians instead of competing with them.  IBM, of course, has been touting Watson in health care for several years now.  As Wired recently reported, there are a number of AI efforts out there to assist physicians. 

Wired also notes that companies are trying to keep their products viewed as offering recommendations instead of making decisions, which would push them over into FDA approval and regulation.  We probably will get there, but that step will be a big gulp.

Some experts believe people will improve their health behaviors -- e.g., get more exercise or lose more weight -- if they know they are being monitored.  Others fear people will end up forgetting about their trackers and will slide back to their previous behaviors. 

The plethora of tracking devices poses issues not only with the sheer volume of data generated, but also with integrating the disparate data from multiple operating systems into a unified record. 

The idea that health information is only collected at a medical office or lab, and that patients should wait to act on it until a human can talk to them, is simply no longer viable.  The data are increasingly going to be available 24/7, and when it means something important there have to be mechanisms to act upon it in real-time.   Maybe that is through alerts to physicians, who then initiate contact with patients, or maybe the wearable ecosystem can trigger its own alerts and advise the user what is going on using avatars and other automated mechanisms.

A recent op-ed by Dominic Basulto in The Washington Post stated that "Google and Apple want to be your doctor, and that's a good thing."  Mr. Basulto concluded:

Companies like Apple and Google can help to break down the notion that health has to be something offered by a monolithic company with a confusing set of rules and terms. It might just be the case that mobile health care facilitated by wearable tech will turn out to be better than traditional doctors.

I think it is a stretch to say that mobile health will be "better" than traditional doctors, but I think these and other technological options can certainly radically change when, why and where people need to see physicians or other health care professionals.  And that's good.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Seated Behind a Health Plan Dashboard

By Clive Riddle, March 21, 2014

Spring has sprung, and if your fancy lightly turns to thoughts of health plans, and in fact you are driven towards such thoughts, a dashboard can be useful. You may be in luck, as Sherlock Company provides a summary from their health plan dashboard as part of their complementary publication, Plan Management Navigator.

Here’s what Sherlock Company reports in their just released March 2014 issue of the Navigator, about the trailing three months ended December 31, 2013, for health plans participating in their dashboard program. Health plans in their Dashboard universe are comprised of Blue Cross Blue Shield and Independent/ Provider-Sponsored Plans.

Health Plan reported “an increase in health revenues of 8.7%. Revenues for Medicaid grew most rapidly, increasing by 17.2%. Medicare Advantage revenue growth followed at 4.7%, while Indemnity product revenues increased 2.7%. ASO/ASC and Managed Care revenues fell by 6.2% and 4.3%, respectively. Overall, membership increased 1.1% for all health lines. Enrollment in Managed Care fell 1.1%, while increasing 1.6% for Indemnity. ASO/ASC membership declined 0.4%.”

“Membership grew in both Medicaid and Medicare by 4.6% and 4.2%, respectively. Both Managed Care and  Medicaid experienced the largest price increases, both at 3.5%. Indemnity followed with a price increase of 1.1%. Medicare Advantage products had a price decrease of 2.3%, while ASO/ASC posted a decline of 5.3%.”

“Health benefit ratios for health lines deteriorated by 2.0 percentage points to 90.0%. Managed Care and Indemnity had the largest increases of 5.4 percentage points and 4.5 percentage points, respectively. The number of scripts per person increased by 0.4 to 9.5 on an annualized basis. E/R visits per thousand members fell 13.4 to an annual rate of 241.8 per thousand, while hospital days also increased by 21.2 days to 335.1 days per thousand. The administrative expense to premium ratio increased 0.6 percentage points to 11.8%, while the administrative costs per member per month increased 2.3% to $34.76. Claims volumes increased 0.87 to 17.7 per member per year, while inquiries per member grew 0.34 to 1.9 per member per year. Staffing ratios fell 0.32 FTEs per 10,000 members to 21.1.”

You can click here if you’d like to subscribe to Sherlock Company’s complementary Plan Management Navigator, which includes additional articles full of great health plan data, benchmarks, and insights like those provided in the Dashboard Summary.

mHealth on my Mind

by Clive Riddle, February 28, 2014

With the HIMSS14 gargantuan annual conference being held this week in Orlando, the spotlight has been shining bright on mHealth and other health information technology as of late.  In conjunction with the conference HIMSS Analytics released results from their 3rd Annual HIMSS Analytics Mobile Survey.

Here’s some highlights shared in their report:

• 59% of respondent stakeholders have a mobile technology plan; another 29% are developing a plan.
• Of those with a policy in place, here’s what the policies addressed: (1) 82% listed Means of securing devices (i.e. storing information on device); (2) 78% listed Use of personal devices for clinical/work use; (3) 71% listed Management of lost/stolen devices; (4) 71% listed Ability to access data from remote locations 71.43%; (5) 63% listed Types of apps approved for use ; (6) 45% listed Brand/version of device 44.90%
• Respondents scored HIPAA highest as the federal legislation with the most nHealth impact; Meaningful Use was second
• 95% use at least one security tool to secure data on mobile devices;  Of those with security tools, 94% used Passwords; 71% used encryption measures; and 69% used remote wipe capability
• 83% indicate their physicians use mobile technology to facilitate at least some patient care.
• 71% indicated their nurses used mobile technology to facilitate at least some patient care
• Clinicians are most likely to use technology to support patient care by either: Looking up patient information (69%); or Looking up non personal health information (65%). Rounding out the top five responses were  Use for education/training purposes (49%);  Clinical notifications (42%) and Secure communications regarding patients (39%)
• The top five tools used to engage patients/consumers in their healthcare were (1) App-Enabled Patient Portals (56%);  (2) Telehealth Services (52%);  (3) Provide Remote Monitoring Devices (36%);  (4) Prescribing Apps (23%); and (5) Discharge Kit with Mobile Technology (13%)

On another front, moving to specific, Citrix released ranking of the Top 10 Mobile Health Apps By Number of Network-Connected Subscribers, which was posted in Healthsprocket as follows:

1. Runtastic
2. My Fitness Pal
3. RunKeeper
4. Weight Watchers
5. Nike+
6. Map My Run
7. Pregnancy
8. Period Diary
9. Lose It!
10. Baby Bump

I'll Take My Care To Go

By Kim Bellard, February 17, 2014

I have to admit that when fast food restaurants first got into drive-throughs, I didn’t really see the point.  Well, I missed that one: they now do 60-70% of their business via the drive-through, changing the architecture, menu, and consumer expectations of the fast food industry along the way.  Aside from pharmacies, I haven’t seen drive-throughs impact health care yet, but one doesn’t have to be much of a seer to recognize that that the need to actually visit providers’ offices for health care is quickly being whittled away.

Let’s start with kiosks, which are increasingly providing quick alternatives for some services that used to require consumers to visit their doctor.  For example, in the news recently was a deal higi did with Rite Aid, which will put higi’s kiosks in some 4,000 Rite-Aid stores.  higi already has kiosks in Publix and Whole Foods.  Their approach features kiosks that allow consumers to measure and track their vitals, while gamifying that mundane process.  They combine all the measures into a single “higiscore” that consumers can easily track, and also offer some community features.

higi is not alone in the kiosk business.  There’s SoloHealth, which claims 40m annual user engagements, driven in large part due to its deals with Walmart/Sam’s Club and Safeway, as well as some deals with health insurers, such as Wellpoint and HCSC.        

Not unlike higi, SoloHealth offers quick self-service screening options, but the deals with insurers have them offering information on health plan options as well, a move that is not without critics due to the perceived privacy concerns. 

HealthSpot goes the other screening kiosks one better by also offering video visits with board-certified physicians.  They’ve been doing deals with provider organizations.  HealthSpot also recently teamed up with telepharmacy – there’s another wrinkle! – vendor MedAvail Technologies to create an all-in-one Redbox-type system. 

Of course, non-office visit alternatives are broader than kiosks, especially “virtual visits” offered via phone or computer.  Parks Associates recently found over 25% of American households have used some kind of virtual care, and predict that will grow to 65% by 2018. 

Examples of virtual visit vendors include TeleDoc, American Well, and MDLive.  TeleDoc has been offering a telephone-based physician consult service for years, and now also offers a video consult service. 

American Well started with email physician consults, added video consults, and recently went beyond its traditional payor partners to offer a direct-to-consumer option at $49/visit.  American Well notes that its services are available via web, kiosk, and mobile – and, in fact, says that 60% of its video visits are from mobile devices.  MDLive is the most recent newcomer of the bunch, but has a wide range of tele-services and some serious backers, including Sutter Health and John Sculley.  

Kiosks themselves may end up being a niche offering along the continuum of points-of-care, as the video consults are already available on computers and mobile devices and as more and more biometric measures can be done via remote monitoring and apps – why drive to a kiosk when you get do the same things at home or on your phone?  After all, health related apps are booming, and include screening and diagnostic tools.  The stethoscope app, for example, has been around for several years and has proved popular with both consumers and – surprisingly -- physicians. 

So we’ve got sophisticated bio-metric screenings at your convenience in a wide number of retail settings and, increasingly, via mobile devices, plus we’ve got physicians available literally in the palm of your hand.  That’s not all.  IBM’s Watson is teaming up with “social health management” vendor Welltok to help answer consumers’ health and wellness questions without the assistance of a physician – or any live person. 

All these new options for receiving care and medical advice remind me again about how much behind the curve traditional health insurance and health providers are. 

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Humana’s Vipin Gopal on Advancing the Frontiers in Predictive Modeling

By Clive Riddle, December 10, 2013

Vipin Gopal, PhD, Vice President of Clinical Analytics for Humana gave the opening plenary presentation last week during the Seventh National Predictive Modeling Summit in Washington, DC, providing an excellent overview of the current and future state of predictive modeling in healthcare.

Vipin summarizes the state of predictive modeling from his and Humana’s perspective as follows:

• They have seen rapid evolution as a discipline over the past decade
• There is newer and better software, data sources, hardware
• There are a lot more applications
• They have a deeper understanding of their members
• There are now more efficient and effective delivery mechanisms for model output
• Predictive Modelers will make a broader and deeper impact for in the coming years

Vipin offers as advice, these guiding principles for organizations deploying predictive modeling functions:

1. Establish a set of "quick wins" to drive early results and build momentum
2. Show results to bolster the business case behind making further investments
3. Focus on the issues that have the most direct impact on the business
4. Ensure that effort is placed on key strategic issues and pressing challenges
5. Address challenges with underlying data
6. Clean and streamlined data is an enabler for the creation of more effective and comprehensive analytical models

Vipin advocates that leading-edge analytics should encompass these themes:

• Focus: Are we solving the right problems?
• Nimble: Rapid analytics to respond to business needs
• Cutting-edge Methods: State-of-the-art problem solving
• Tools: Leverage advancements in the analytics marketplace
• Optimize: Maximize output of analytic resources
• Integrate: Systems approach to data, analytics and action
• Real-time: Closing the feedback loop with the most recent data

What are the key components of predictive modeling in healthcare, according to Vipin? Three things that should all work towards improved outcomes, high engagement and reduced costs: (1) Integration of Data,

Action, and Analytics; (2) Infrastructure incorporating Consistent, comprehensive datasets, Cutting edge analytic tools, and Deployment to action; and (3) Talent (predictive modeling staff and outsourced vendors.)

Vipin notes that past modeling work primarily relied on claims data, while current work aggregates multiple data sources to create an integrated view of the member for consistent and rapid analytics.

So where are we headed with data sources? Vipin reviewed these Next-Gen sources:

• Text Based (EMR; Nurses’ Notes; Call Center Transcripts)
• Devices (Remote monitoring, Smart Phones)
• Online Data (Social Media Data, Web Footprint)

And where are we headed overall? Vipin sees a broad range of applications, including Clinical, Marketing, 

Financial, and Fraud Detection. He sees us mining deeper data sources, driven by a need to know our consumers better, while deploying more efficient delivery mechanisms that incorporate real-time alerts and mobile devices.  The “Holy Grail” in all of this? Vipin says it is predicting and influencing consumer behavior; and we need to do this in an environment in which there is a proliferation of models and we hopefully will simultaneously see efforts to have them work in unison!

Checking out 16,275 Patient Health Apps

By Clive Riddle, November 1, 2013

The IMS Institute for Healthcare Informatics, part of IMS Health, this week released  their report: Patient Apps for Improved Healthcare: From Novelty to Mainstream, which examined all 16,275 apps directly related to consumer patient health and treatment (out of a total 43,689 health care apps,  of which 7,407 are for health care professionals) available from the Apple ITunes store.

Murray Aitken, executive director of the IMS Institute for Healthcare Informatics had this to say after releasing the report: “The movement toward digital therapeutics is clear. Mobile health apps have the potential to drive a disruptive shift in patient engagement and healthcare delivery. Harnessing the power of apps has become a focal point of innovation, yet barriers remain to their broad and systematic use by providers and patients. Development of clear evidence on the benefits of driving positive behavioral changes and improving health outcomes will be key to breaking through the barriers.”

The IMS analysis involved categorizing apps based on providing one or more of these functionalities:

• Inform:  Provide information in a variety of formats (text, photo, video)
• Instruct:  Provide instructions to the user
• Record: Capture user entered data
• Display: Graphically display user entered data/output user entered data
• Guide:  Provide guidance based on user entered information, and may further offer a diagnosis,  or recommend a consultation with a physician/a course of treatment
• Remind/Alert: Provide reminders to the user
• Communicate: Provide communication with HCP/patients and/or provide links to social networks

Here’s some key points from their 65 page report:

• More than 90% of healthcare apps reviewed by the IMS Institute scored less than 40 out of a possible 100 for functionality, based on 25 screening factors.
• While 10,840 of the 16,275 apps reviewed can provide and display information, less than half of those can also provide instructions and approximately 20% can also capture user-entered data.
• More than 50% of available healthcare apps have been downloaded fewer than 500 times.
• Five apps account for 15% of all downloads in the healthcare category
• Patients over the age of 65 are among the top users of healthcare resources, yet  only 18% of the elderly U.S. population use smartphones, compared with 55% of consumers age 45-54

The report identifies these four issues that must be address, ”in order for apps to move from novelty to mainstream”:

1. There must be recognition of the role apps can play in healthcare by payers and providers, as well as regulators and policymakers.
2. Security and privacy guidelines and assurances established among providers, patients and app developers.
3. A systematic evaluation of apps to inform their appropriate use.
4. The effective integration of apps with other aspects of patient care.

Survey on Consumer Engagement and Health Tracking

By Clive Riddle, October 25, 2013

Partners Healthcare’s Center for Connected Health, commissioned Harris Interactive to survey 2,000+ consumers on health engagement and tech driven tools to monitor health and wellness, in conjunction with the launch of the Center’s new Wellocracy program.  They found that almost half of respondents (48%) say they have trouble staying motivated to live a healthy life, and less than a fourth (22%) are very confident that they can keep track of their own health.

Joseph C. Kvedar, MD, the founder and director of the Center for Connected Health tells us, "there are dozens of activity and health trackers on the market today, and literally thousands of health apps available for consumers. Yet, instead of getting people moving towards a healthy lifestyle, most feel paralyzed by all these choices and the technology can be dizzying. "We know that if we give people -- young and old -- insights into their health and help them understand how lifestyle choices impact quality of life, they feel more accountable, engaged and live a healthier, more active life. Integrating 'self-health' tools like activity and nutrition trackers and sleep monitors into our daily lives, we can learn from our own behaviors and make positive changes to take charge of our health. We're taking these devices and apps, personalizing the experience and helping people figure out the right health technologies, the right strategy and the right inspiration to get on the right track to health and wellness."

Here’s finding the Center has shared from the survey results:

• 68% of consumers agree that encouragement from friends and family is important for them to achieve health goals
• 65% of consumers believe that using a health tracking device, website or app would be beneficial,
• 32% felt these tools would help them stay motivated to meet health and fitness goals
• 31% believe the tools would provide accountability
• 27% felt the tools would help them stay in control of their health

• 86% believe that feeling informed about their own health is empowering
• 59% of women and 56% of men aged 35-44 reported that it is hard to stay motivated to live a healthy life
• 52% and 51%, respectively of women and men aged 35-44 wished they could make better use of technology to keep track of their health
• 55% of women and 49% of men aged 18-44 believe that easy tracking  is essential to achieving health-related goals
• 48% of women and 42% of men aged 18-34 reported that encouragement from family and friends is essential
• 42% of women and only 20% of men aged 45-54 reported that support and tools from their healthcare provider is essential
• 19% of women and 17% of men aged 35-44 are very confident in their ability to keep track of their own health
• 25% of women and 21% of men aged 55 and over are very confident in their ability to keep track of their own health

• 56% of all consumers  have never used any type of health tracking device, app or website
• Adults aged 18-34, were most likely to use diet (23%) or fitness apps (26%) on their phones
• 7% of adults aged 55 and over reported ever using a diet app and only 3% have used a fitness app on their phone
• 35-44 year olds were the age group reporting the highest use of digital activity pedometers (19%)
• 5% of adults aged 18 and over reported ever using a sleep tracker

While these results are encouraging for engagement initiatives, we need to remember that they survey indicates more than half of consumers have never used any such tool – even a website.

Games (Some) People Play

By Kim Bellard, May 13, 2013

I have to admit that I am a child of the television age, with movies as a close second.  I never really got into video games, like PacMan, Tetris, Mario Brothers, Call of Duty, Grand Theft Auto or even Madden NFL, and am only now belatedly becoming addicted to Angry Birds.  As I suspect is true of many of us old health care pros, I am also late to the potential revolution that video games offer for health care.  I’m glad others in the field have been paying more attention.

The video game industry is not for teenagers, and its size is shocking – it dwarfs the music industry, and, depending on which source one uses, either has surpassed or soon will surpass the movie industry.  It’s helping to drive the chip, PC, and mobile phone industries; none can afford to fail to deliver the speed and video quality that modern gamers demand.  We’re talking about a soon-to-be $70 billion industry here; still only a fraction of the health care industry, but much bigger, for example, than spending on health IT. 

The video game industry itself faces its own challenges; for example, the era of game consoles may be ending, as more gaming is done on mobile devices and with other options for player control.  That’s not to say the era of video games is passing, but rather that it continues to change rapidly.  Hand-held games were revolutionary when first introduced, as were game consoles, PC-based games, the Wii controller, Kinect, to name a few.  Video game companies who do not innovate can find themselves quickly left behind.  This “evolve-or-die” mindset is one that I wish was more prevalent in health care, whose attitude is more often “we know best” and/or “not too fast!”

Always looking ahead, the Robert Wood Johnson Foundation started its Games for Health project back in 2004.  They have given grants of over $9 million, and have an active conference and information sharing presence in the health/gaming intersection.  They’re not just spurring development of games and games technology, but also funding research on the games’ effectiveness through their Health Games Research program. 

The research is showing some results.  There are many reports about the health benefits of video games, such as a recent study that found video games can slow or even reverse mental decay, and a broader list of positive impacts that include motion skills, stress reduction, pain relief, vision and decision-making skills.  Apparently, both seniors and kids can benefit. 

An example of how game principles can be applied in health care is Mango Health, which turns the problem of medication management into a game, complete with rewards that can be turned into gift cards or charitable donations.  It is not the first or only such example, but is illustrative of the potential games offer.

The Entertainment Software Association, perhaps sensitive about criticism that violent videogames can have adverse impacts, prominently touts video games’ role in health care (along with family life, art, the economy, education, social issues, and the workplace – boy, these guys really are defensive, aren’t they?).  Two of the key areas it cites are in rehabilitation and in training.  For example, USC’s Institute for Creative Technologies researchers developed Jewel Mine to provide customized rehabilitation to people with a variety of neurological and physical injuries.  Other efforts use out-of-the-box gaming systems, like Wii or Xbox, to make rehab more enjoyable.  And there is an organization, Games4Rehab, that tries to tie users, developers, clinicians, and researchers together in this area.

One of the innovators in training that ESA cites is the University of Maryland Medical Center’s Advanced Simulation, Training, Research, and Innovation Center (MASTRI).  MASTRI has been working for over six years now on high tech simulation and training for health care.  Even ONC is using video games for training, as is Darpa (in their case, mobile medical training for first responders). 

One recent study found that surgeons who used the Wii – not on any specific medical games but just using standard Wii games -- outperformed their peers in laparoscopic simulators, due to improved spatial attention and hand-eye coordination.  My favorite study, though, was the one that found gamers did better at simulated surgery than medical residents.  Maybe the wrong people are doing those kinds of surgeries.

Surprisingly, payors haven’t all been late to this particular game.  Humana, in particular, was a pioneer, focusing on video games as far back as 2007.  Aetna  and United have joined the movement, and last year the Wall Street Journal summarized various insurer efforts.  One senses they’re not quite sure what they should be doing, but don’t want to get left behind.

People have coined the term “gamification” to include game-like features into non-game pursuits.  Author Jane McGonigal wrote a fascinating book called Reality Is Broken, the subtitle of which is “Why Games Make Us Better and How They Can Change the World.”  She doesn’t confine herself to video games, nor does she talk much about their applications for health care, but the mind-set she describes -- which include overcoming obstacles, rewards, collaboration, interaction, voluntary participation, and feedback -- is very much something people in health care should be incorporating more. 

The health care system does often seem like a maze, but it’s not one that most people have any fun navigating, nor one where many people emerge thinking they are winners.  This is an industry where, for example, use of outdated communications technologies like pagers waste an estimated $8.3 billion annually.  This is an industry that demanded, and is getting, hundreds of billions of dollars from the federal government to bring their medical records into the 20th century (and I mean that), largely still in siloed, mainframe EHRs that can’t talk well with each other and whose requirements for “Meaningful Use” are being delayed again.  It is not, in short, an industry that would seem an early adaptor of the lessons video games can teach.

Video games are no panacea for health care.  Not everything is a game, not everything should be approached like a game, and not everyone likes games.  Still, there are a couple of important lessons we should draw from them:

• To each his own: for a not insignificant and growing portion of the population, games are a familiar and preferred medium.  If we want to educate, motivate, and influence behavior for that segment, game-like approaches are the way to go.  The likelihood of reaching serious gamers through, say, a telephonic disease management program would seem to be very low.  The point is not to use video games for everything for everyone, but to use the right media for the right populations.  We now have lots of options to reach people, including not just games but also social media, text, email, mobile.  The challenge to providers, health systems, and health plans is to figure out how to best use each tool for which portion(s) of the population.   
• Take advantage of the technology and design:  Video games are in an arms race for better experience, and, as with arms races, there can be spillover benefits to other sectors.  High quality simulated images (even 3-D), on-demand, motion-sensing, multimedia, multi-person, and, above all, relentlessly interactive – all describe modern game capabilities and should be describing applications for health care, even if not used for games themselves.  Maybe health care organizations should hire fewer mainframe programmers and more game designers to work on their B2C efforts. 

Excuse me, but I better go play some games…for my health, of course!

Boston: Coincidences, Complexity, Continuity, Care

By Cyndy Nayer, April 25, 2013

America's Freedoms Are Our Vulnerabilities

There is no doubt that the terrorism of the Boston Marathon 2013 was heart-stopping, heart-rending, and a cruel reminder that America's freedoms are also our vulnerabilities.  It's also a bit ironic that, because of a family emergency, both of my daughters had flown down to our house and were with us when the bombs went off.  Why is this important enough for me to mention here?  Because if my older daughter hadn't come down to help, she would have been exactly at the finish line where the bomb went off. Coincidence?

I don't believe in coincidences.

The week, and the socialmediasphere, have been resplendent with coincidences, the most poignant of which was the story of the couple who both were in the health care provider space, both came to cheer the runners of the marathon, both had a portion of their left legs blown off in the explosion.  They were separated by the blast, and they remain separated in different hospitals, but they are recovering and they are talking by phone to each other (see below for how you can help).

Who were the terrorists, what was their motivation, what will happen to the survivor, I have to leave to the sleuths and judicial systems to discover and decide.  My work is to uncover the learnings that we can all ingest to fortify our health promotion and business recovery.  Here are some thoughts.

1.  Boston has terrific hospitals, prepared for trauma management.  I've managed many fitness events, and, of course, a key component was the clinical staff onsite.  They volunteered their time for running injuries, dehydration, and the sort.  Some of them on April 15 had seen combat duty in Afghanistan and Iraq, and they were able to flip into mash-unit mode quickly.  All of the injured who made it to the hospitals have survived, albeit many have much rehabilitation to work through.

2.  Boston has moxie and motivation.  Bostonions have been described recently as gritty, defiant, and strong, and this makes great sense since this is the birthplace of the American Revolution--the shot heard round the world--and of the freedoms that would coalesce into the US Constitution.  When the explosions came, the runners ran INTO the crowds to help those who were hurt, ran to the hospitals to give blood (another 2.5 miles after their 26.2 mile run), and reached out to one another.  They may fight like family, but when the pressure is on, Boston is one big supportive family. For more on the grittiness of Bostonians, and a chuckle, click here to see Colbert's Report for April 16, one day after the bombs.  

3.  Boston finishes what it starts. Samuel Adams (not the beer, but the revolutionary) said, “Nil desperandum, Never Despair. That is a motto for you and me. All are not dead; and where there is a spark of patriotic fire, we will rekindle it.” There were people around the nation, and now, around the world (London) running races for Boston over the past 10 days, and there will be more.  There are calls for boosting the economy and taking Boylston Street back--it opened today--and for helping those who were locked out of their homes and businesses for these days.  This is the Boston that warned of the Red Coats, rode the Freedom Trail, waited 86 years for the Red Sox pennant.  When folks were hurt, people did what they could:  one woman baked oatmeal chocolate chip cookies for the police/troopers/FBI/ATF, etc. to eat when the 2nd suspect was arrested.  Grit and defiance demand food, too, after all.

4.  Boston wears its patriotism and small-town love proudly.    Read this excerpt from one of the London marathoners, who also ran in Boston:

“I had a hard day out here,” said Neynens, who wore a 2013 Boston Marathon hat during his London run and finished in 2:48:09. “I was hurting, but obviously I was not hurting near as much as the injuries that I saw, people who lost their legs. I finished for all those people who were hurt and those people who couldn’t finish last Monday...

There was a banner we passed around Mile 25 that said, ‘Run if you can. Walk if you must. But finish for Boston.’ That meant a lot to everybody. It was great to see the support of everybody out there for the runners and for Boston."

 There were lessons for health, healthcare, and healthcare reform, too.

1.  Interoperability of electronic medical records could have been a problem.  In the marathon were runners and family-watchers from around the world.  What if there were a diabetic runner who, because of the bombings, was delayed in his/her sugar control?  There are so many other "what ifs" that the message is clear:  we need to quickly find a way to make these EMR-EHR-PHR talk to one another for the safety and security of the providers, patients, and communities.  We cannot afford to waste time finding a knowledgeable relative when life hangs in the balance.  [I wrote about this lack of interoperability in my post "EHR Is Speechless"].  There is no magic about data, the rules engines can be preserved as proprietary to each company, but the data must be accessible.

2.  Teamwork. Who will ever forget the masses of security forces closing in on the final suspect?  Or the video of the Chief of Police of Watertown MA saying his troops were never trained on counterterrorism, so they just did what was they thought was right?    Those of us riveted to the scenes will remember the ATF, FBI, fire departments, EMT, Boston police, State Troopers, and so many more.  But how many noticed that hot food was brought by the NY-NJ Port Authorities?  How many could ever forget the cheers and singing and clapping by the Watertown citizens when the ambulances and security cars crept slowly back into the city?  Now, imagine those kinds of teamwork in communities of care, with warm "handoffs" from primary care (Watertown police) to specialists (BPD, ATF, FBI, MA troopers) to recovery and long-term care (Red Cross, Boston Globe, and so many other watch-dogs and care providers).  Everyone had their job and new exactly what they had to do.

3.  Continuity and safety.  Recently I saved an article on the rates of hospital infections in the US compared globally, sent to me from my colleagues at MCOL.com.  Because of the trauma training, the warm handoffs, and the sense of accountability, continuity is a given in Boston.  It's the accountability that will guard the injured, the fallen and the recovery.  There's a new sense of "we share in this," and it's this sense that carry Boston through.  That's the real message of accountability:  we all own at least a portion of the problem, whether it's economic recovery or health promotion, and we all have a responsibility to step up to manage our community better.

Of course, in the land of the Red Sox, with the frame of David Ortiz' opening moments in Fenway Park, and the surprise visit from Neil Diamond to lead Sweet Caroline, the poignant moments caused tears and love and hugs.  For us who weren't in Fenway, or Boston, or Watertown, I treasure the picture that went viral on twitter and other social outlets:

 I don't think there are any coincidences.  I abhor terror, bloodshed, violence.  But these moments that I've called out remind me, and I hope all of us, of the goodness of people.  Who could possibly convey it better than Fred Rogers?  We needed to hear his words, "Look for the helpers," right then, right at that moment.  It opened our hearts and made us feel safe again, and we spotted more helpers and lavished praise, because we all needed to heal.

And then Boston Daughter (who had returned to Boston) sent me an email and a picture that she took, the one that starts this blog post, the site that amazed and tore and then opened her heart.  She told me she couldn't sleep, walked to the memorial Monday morning at 5am to pay her respects, and left her pink running shoes because she wanted to be part of the healing, too.

If you want to be one of the helpers, here are two ideas for you for donations.  There are many more, I simply had intersections with each of these here:

If you, like me and my Boston daughter, are an avid fitness participant, then you may want to make a purchase at @unitedwestride UnitedWeStride will donate all the proceeds from the purchase AND AN ADDITIONAL DOLLAR

@JetBlue  I audaciously sent a tweet on 4.22 to @JetBlue asking for serious discounts to Boston so we could boost the economy--I'm betting others did, too. On 4.23 I received an email with serious discounts.  Help those most affected by the Boston tragedy through The One Fund Boston, and JetBlue will match up to $100K. http://www.jetbluegives.org

 I hope peace comes to those who mourn and to those who heal.  I hope strength comes to our leaders and our protectors.  I hope our communities come together for health.

Involved But Not Committed

By Kim Bellard, February 28, 2013

There’s an old joke about the difference between bacon and eggs: the chicken is involved, but the pig is committed.  Perhaps the problem in health care is that when it comes to being engaged in our own health, most of us are chicken.  Maybe the wrong people have been cooking.

Patient engagement -- along with its many synonyms, such as shared decision-making or consumer-directed care – continues to be a favorite strategy for many health pundits.  I am biased towards it myself, although exactly what it means, or will mean in the future, is not entirely clear.

The prestigious journal Health Affairs recently devoted an entire issue to the topic.  In one study, Judith Hibbert and colleagues reported that patient activation scores help predict costs: lower activation levels were tied to higher costs, even after adjusting for risk.  A separate study, also by Hibbert, reviewed the literature and concluded that patients with higher activation levels had better health outcomes and care experiences, although the evidence was more inconclusive about the effect on costs. 

The trick, of course, is how to “activate” patients – is it all self-motivation, or can providers and other third parties (such as employers) encourage it?

One common method to influence patient engagement is an employer wellness program.  A recent National Business Group on Health survey reports that almost 90% of employers offer wellness-based incentives, spending an average of over $500 per employee on the programs.  Employers are getting tough too: 15% directly tie health plan eligibility to a health activity such as taking a risk assessment or biometric screening.  Almost two-thirds already tie employee contributions to completing such activities.  And 41% include, or plan to include, outcomes-based measures (e.g., lowering blood pressure) as part of the program.

Another strategy employers are using is increased employee cost-sharing, such as in consumer-directed health plans (CDHPs).  Critics accuse them of simply shifting costs to employees, but there are plenty of studies that indicate they may actually change employee behavior and help control costs.  For example, Cigna recently claimed that their CDHP members improved their health risk profile 12% while their health cost trend was 13% lower than traditional members.  Cigna CDHP members were also more likely to take health risk assessments, to use cost and quality tools, to choose generic drugs, and to seek preventive care. 

Consumers may be starting to take cost into account, but they don’t like it.  A study by Sommers, et. alia, reported on focus groups of insured patients.  The focus groups indicated that patients don’t like cost considerations to be part of health care decisions, and revealed that several stereotypes remain all-too-common, including that more expensive care is better care, and choosing more expensive care is some sort of victory over insurance companies (not realizing that, in the end, they and other insureds pay for that care).  Patients still don’t really know how to weigh risk versus cost. 

We treat health care costs much like we treat the deficit: costs come from other people, cuts should come from other people, other people should pay, and, oh-by-the-way, let’s think about it tomorrow.  That has to change. 

One thing that offers new hope for patient engagement is that the options for it have never been broader or more robust – mobile, electronic records, telemedicine, and social media, to name a few.

There are estimated 40,000 mobile health apps.  It seems you can get an app to do just about anything you can think of, plus many things you probably hadn’t.  The health apps vary widely not only in purpose but also in audience and quality.  A company called Happtique has just introduced a certification for health apps that will hopefully give consumers a better comfort about which apps to use, or for physicians to know which to recommend to patients.  They see the program not as a rating mechanism but as kind of like a Good Housekeeping seal of approval, assuring that at least a set of minimum standards have been met.  This could spur adoption.

It does appear that physicians are joining the mobile revolution, according to CompTIA.  Their recent survey indicated that one in five physicians is using a medical or health-related app daily, and 62% expect to be regular users with a year.  The trick will be how they incorporate them into their practice, for patient care and/or patient engagement.

EHR/PHRs provide yet another option to engage consumers.  To date, consumer adoption of PHRs have been disappointing, to say the least – even when they are available.  A recent study by Ritu Agarwal and colleagues, aptly titled “If We Offer it, Will They Accept?”, explores this issue and concludes that use depends on a number of factors – not just existing consumer preferences but also satisfaction with the patient-provider relationship, provider support for patient use of the PHR, and specific communication strategies to encourage use.  HITECH funding and “meaningful use” requirements may drive availability of patient EHRs, but persuading patients to use them will require some effort.

Telemedicine seems be exploding, both in terms of easing of regulation and in terms of payor coverage, so it is not surprising that there are a plethora of companies making their mark in this space.  These include American Well, Cardiocom, HealthSpot, NowClinic, or Virtuwell, to name just a few.  These may not provide your personal physician, but they offer physician expertise at your convenience – 24/7, from your house or even mobile device, not restricted to a physician’s hours.  That’s got to help improve patient engagement.

The IOM just hosted a workshop on partnering with patients, and one of the conclusions was that physicians and health systems need help in developing those skills, plus they may need additional incentives to engage in the kind of dialogue patient engagement requires (why am I not surprised?).  When you think about it, though, relying on physicians, or even nurses, to drive patient engagement doesn’t seem realistic.  We can spend time and resources on training them, but we still face the barrier of the projected shortages in both professions (physician, nurse), especially with the baby boomers just starting to crash the Medicare barrier.  Primary care providers may just be too scarce, especially in rural and other already underserved areas.  Not everyone agrees with these dire forecasts, but the point remains, though: the health professional to patient ratio doesn’t scale well into an era of higher patient engagement.

And maybe it doesn’t need to.  Maybe it really is up to us as patients to take responsibility.  Fortunately, we still don’t have to go it alone.

Social media, for example, may not even rely on a provider-patient model.  Health care providers are still trying to figure out social media.  An infographic by Demi & Cooper advertising/DC Interactive Group suggests that only 26% of hospitals use social media (most commonly Facebook), while over 80% of individuals 18-24, and 45% of those 45-54, would share health information via social media.  Meanwhile, Patientslikeme has been breaking new ground for social media use in health care for many years now, using patient-to-patient expertise and experience.  We’re only begun to scratch the surface of what patient engagement looks like in a social media world.

Artificial intelligence could be the real game changer in patient engagement.  IBM has made a big bet on AI in health care via Watson, and a recent study from Indiana University reaffirms that use of AI has the potential to both improve outcomes and lower costs.  Widely available health content on the Internet started this ball rolling, but health care professionals start to look like just another option – a preferred option, to be sure, but no longer the only option – to getting health information, advice, perhaps even diagnoses.  And I’ll have to save discussion of robotic surgery for another blog…

We’re already got a mobile stethoscope app, remote monitoring options for conditions like diabetes or blood pressure, medication and other reminder apps, and increasing ability for AI to evaluate and diagnose.  Who needs health coaches or even physicians to drive patient engagement?  Maybe in the not-too-distant future the model for patient engagement will increasing look like patients simply using their mobile devices: i.e., when Siri marries Watson.

At the end of the day, the person who has to be committed to patient engagement has to be the patient.

Some Lessons from Sandy

By Kim Bellard, November 8, 2012

I have no doubt that many very smart people, and especially ones who were more directly impacted by Sandy than I was, will be doing extensive debriefings about Sandy’s impacts, and coming up with lots of far-reaching recommendations for next big disaster.  Still, I wanted to throw in a few thoughts about a couple lessons Sandy has for HIT.

One of the unexpected learnings from hurricane Katrina in 2005 was a boost in the perceived need for electronic health records, as many paper records were lost or destroyed by the storm, and as Louisiana residents widely dispersed across the country.  The paper and place systems for health information were found severely lacking, and Katrina was a clarion call to move health information into the 21^st century.

Seven years later, we have, in fact, seen much progress on that front.  HITECH was passed to stimulate the adoption and “meaningful use” of EHRs.  Over 300,000 physicians and4,000 hospitals received HITECH incentive payments through 3Q 2012 – some $7.7b.  Those numbers are expected to grow rapidly, and the increasingly tough meaningful use standards will drive better use of the data in the EHRs.

That’s all good news, and it would be easy to see how HIT should have helped mitigate some of the woes from Sandy.  Instead, what we’ve seen makes me wonder if we’ve learned anything at all. 

Sandy caused hundreds of hospitalized patients transferred, with some entire hospitals closed due to flooding.  That’s obviously not good for patients, but understandable under the circumstances.  I couldn’t help but wonder what was happening with their records.  Did all their information travel to the new hospitals, or was everyone forced to start from scratch? 

Best case scenario, the patient might have transferred to a sister hospital that used the same systems.  The worst case scenario, of course, was that the records were only on paper which was lost or destroyed.  The most frustrating scenario, though, would be that both the old and new hospital had electronic records, but that the respective hospitals couldn’t communicate.

Unfortunately, this latter scenario is all too likely.  David Whitlinger, the health of SHIN-NY, the statewide HIE for New York, cited disasters such as Sandy as why we need health information exchanges (HIEs).  He’s exactly right, of course – but even he couldn’t say how many of the impacted New York hospitals were participating in SHIN or were able to take advantage of its capabilities.  I suspect that if they had any big success stories from Sandy, they would be touting them.

I’m not picking on SHIN-NY.  HIEs are facing problems in many places.  In Michigan, for example, there are two statewide HIEs, which can’t communicate with each other.  According to the eHealth Initiative, HIEs biggest concerns included developing a sustainable business model, and competition from other HIEs.  Most of them still aren’t doing anything as sophisticated as transmitting entire patient records.  It would be comical if it wasn’t so depressing, and if my federal tax dollars weren’t subsidizing these efforts.

HIEs are supposed to ensure interoperability and transmission of patient and clinical data, but those battles are still being fought.  A recent report from KLAS Research indicates that providers express dissatisfaction with their HIE vendors, including their ability to move data between multiple EMRs.  Respondents mentioned, for example, that Epic scores well for connectivity, but not with non-Epic installations…which sort of makes the capability moot.

Then there is mHealth, a term that was only just beginning to be used when Katrina hit in 2005.  It’s now a big deal: the mHealth market is estimated to double in 2012, to over $1.3b, with literally thousands of mHealth apps on the market, from the trivial to the FDA-approved.  It is no wonder that mHealth has taken off; over half of the U.S. population now has a smartphone, with two-thirds of new purchases being smartphones.  According to the Pew Internet & American Life project latest findings, almost 20% of smartphone users have health apps.

Sandy showed us that we’re not quite ready for prime time on this front either.  Let’s start with the availability of mobile networks.  The New York Times reported on the spotty service and infuriated customers.  As one impacted resident said, “not having hot water is one thing, but not having a [cell]phone? Forget about it.”   The Times pointed out that one of the recommendations from Katrina was better emergency back-up mechanisms for the wireless carriers, such as longer-lasting emergency batteries, which have not been widely adopted.  The wireless carriers have resisted many of the regulators’ efforts, and were not routinely providing their outage statistics the way, say, the power companies were during Sandy.  The Wall Street Journal had a similar story. 

So much for having any of those fancy mHealth apps; just think about any chronically ill patients who might have been being remotely monitored by their physicians when Sandy hit.  The wireless carriers are not yet seeing their mission as providing life-critical support to their customers, and it is getting harder and harder to understand why.

Sandy emphatically illustrated that wireless service is one that emergency planners will have to take very seriously going forward.  It has obvious implications for contacting friends and family, getting status updates on the disaster and recovery efforts, and helping direct affected people to assistance.  I only hope they take mHealth equally into consideration.  Not just for the things it does every day, but how to further take advantage of its capabilities when providers and their places of care are unavailable or limited.  Just think of how telehealth, remote monitoring, prescription history, and other applications could be useful in the aftermath of a Sandy.

Sandy has also firmly re-enforced Katrina’s lesson about health records.  We heard that lesson, and have spent much time, effort, and money on it since Katrina, but we find ourselves not much better off in making health records more fluid.  The EHR/HIE industries and their various customers need to step up their efforts and fix this problem -- hopefully before the next Sandy. 

I like the point that Brian Dolan of Mobihealthnews made in a recent post: technology is forcing us to rethink the classic concept of “point-of-care,” focusing more on where the patient is, not where the provider is, or even if the patient and provider are physically in the same place.  He was writing more from a mHealth perspective, but the paradigm shift applies broadly, as those evacuated Sandy patients could attest.

In the 21st century, health information can’t be tied down to paper or even to place, but has to be able to follow the patient wherever he/she receives care.

The Digital Health Self-Service Counter

By Clive Riddle, June 21, 2012

So you’ve navigated the self-service checkout counter, purchasing your toilet repair kit and halogen light bulbs at your big-box hardware store; and even braved the self-service experience with your greek yogurt, arugula and asiago cheese at your grocery store. Now are you ready to do the same with your healthcare?

Accenture says you are indeed, to a point, if you can just find the checkout counter.  They have just released results of the Accenture Connected Health Pulse Survey , based on an online survey of 1,110 U.S. patients to determine the preferred channels of electronic health information and services. They found that “the vast majority of patients (90 percent) want to self-manage their healthcare leveraging technology, such as accessing medical information, refilling prescriptions and booking appointments online, but nearly half (46 percent) are unaware if their health records are available electronically.”

What’s more, as Accenture’s Kaveh Safavi, MD, JD, tells us, “patients increasingly want access to their personal medical information, anytime, anywhere. But they’re not willing to give up the option of face time with their physicians.” (85% surveyed want to be able to communicate with their doctor in person.)  So just like the grocery and hardware stores that must still provide full-service counters next to their self-checkout lines, consumers want their in-person doctors and nurses and mhealth too. Although, as an aside, who are these 15% of consumers that don’t want to be able to communicate with their doctor in person?

Here’s more consumer findings from Accenture’s survey:

• 83 % want online access to their health records
• 48 % want their doctors to manage their medical records, while 44 % prefer to manage their own
• 33 % did not know whether services such as bill pay, electronic reminders and lab results were available to them online
• 72 % want to book, change or cancel physician appointments through via  website; 68% would like to do so via a mobile device (meaning most want both)
• 88 % want to receive email reminders for preventative or follow-up care;  63% would like to receive these reminders via their mobile phone (meaning most want both)
• 76 % want the option of email consultations with doctors, 74% would like telephone consultations, including via mobile phone (meaning most want both)
• 73 % would like to use a mobile device for requesting prescription refills; 72% want to be able to use a website to do so (meaning most want both)

For more about the role of in person vs. self-service healthcare, you can check out the mHimss blog by David Lee Scher, MD in which he offers 5 reasons why mobile health apps will never replace doctors. If you just want to read the cliff notes version, we’ve summarized his list in healthsprocket.

It’s the Data, Stupid

By Kim Bellard, February 21, 2012

Two announcements by payors last week caught my eye – both relating to payors and to health care data. 

Last week UnitedHealth announced that its Optum division would offer cloud services for health data, allowing health care providers and even other payors to move and access data via the cloud.  They are even extending the Apple analogy further by opening up their platform to outside developers, so that those developers can develop “apps” for the Optum platform.  They cite the example of an app that would make it easier for providers to structure payments in “bundles of care,” as are expected for ACOs. 

At the same time, three Blues plans – Horizon (NJ), Highmark (PA), and Independence (PA) – announced they had partnered with HIT company Lumeris to buy NaviNet.  NaviNet is a platform many health plans have used to facilitate real-time electronic connectivity with physicians and other health providers; NaviNet claims over 70% of US physicians use its platform.  The partnership with Lumeris is intended to improve NaviNet’s ability to communicate clinical information – in addition to eligibility, claim, and benefit information – and to facilitate ACO offerings.  Undoubtedly other Blue plans, not to mention other NaviNet customers such as Aetna, will be watching the acquisition closely.

The focus on data is by no means new to payors.  In the mid 1990’s UnitedHealth started building its data and analytics capabilities, eventually becoming Ingenix and now part of OptumInsight.  Aetna and Wellpoint also made acquisitions to beef up their data capabilities – Aetna acquiring ActiveHealth in 2005 and Wellpoint following suit in 2008 by acquiring Resolution Health.   Not to be outdone, Humana acquired Anvita Health, another health analytics company, this past December.

Equally interesting is that the payors aren’t just interested in analyzing the data; they want to help move it as well.   In 2010 UnitedHealth acquired Axolotl, one of the leading vendors that service the health information exchange (HIE) market, a market is that growing rapidly due to the influx of HITECH federal funds for HIEs and Regional Extension Centers (RECs).  Not to be outdone, a few months later Aetna acquired Medicity, another leader vendor for HIEs.  Although Axolotl and Medicity are the two largest HIE vendors, they are still estimated to account for less than 20% of the HIE market.  That would seem to leave the window open for other payors to acquire some of the remaining HIE vendors, but at least one leading firm – Chilmark Research – thinks participation in regional HIEs efforts may make more sense, given typical payor market shares and potential antipathy from providers and other payors.  

So what are the payors up to with these moves?  Some experts think they are diversifying to help offset PPACA’s limits on medical loss ratios (MLRs).  There probably is some truth to this, but we need to keep in mind that there is not as much actual insurance as most people think.  Well over half of health insurance today is self-insured, meaning the MLR rules do not apply to it and that the payors are doing the administration without the risk.  The main insured markets are individual coverage, small group (under 50 or 100 employees), and Medicare Advantage.   Historically not every payor has been in all of these markets – e.g., for decades Cigna focused primarily in large, self-funded employers – but with PPACA, the emergence of health insurance exchanges (the other HIEs), and the expected growth of Medicare Advantage, actual insurance is likely to become more important, and understanding their risk better becomes even more important to payors.  Plus, those self-funded clients are constantly demanding better and more targeted interventions to help control their costs, so the data analytics capabilities are increasingly important as part of a payor’s capabilities.  

Another hypothesis is that payors are scrambling to assert their role in an ACO world – whatever that may look like.  If providers end up as the ACOs, and they are essentially bearing the risk, the theory is that payors may find themselves antiquated.  That doesn’t seem likely to me, especially since so much of what payors do isn’t related to risk-bearing.  The exchanges and CMS are likely to still expect a (regulated) insurer to be responsible for the members, and multi-state or even multi-city employers would still need some entity to stitch the ACOs together (we saw this with HMOs in the 1980’s and 1990’s).   But by providing insight or connectivity to an ACO, payors may be able to provide value to them and to be an integral part of their solution.

Then there are the efforts by payors to buy their way into the provider world – e.g., Humana with Concentra, OptumHealth with Monarch  Healthcare, Highmark (again) with WPAHS – that will further blur the lines between payor and provider, as if the lines hadn’t already been blurred by organizations like Kaiser Permanente, Geisinger, or Intermountain Health.  Payors will have access to troves of new information through such direct involvement in the provision of patient care, but managing clinical efforts is not the same as managing network and insurance efforts (as some provider organizations have discovered in reverse!).

Data has always been one of the Achilles heels of health care.  All too often, patients’ data has been trapped in the silo in which it was delivered, with little or no ability to be shared, much less learned from or to have treatment guided by data from similar patients.  Administrative data – e.g., claims and eligibility – was able to break out of the silos to some degree, primarily because it was directly related to payment, but even with those types of data neither payors nor providers can claim to be entirely satisfied with the current state of affairs.  Health care data remains complex, minutely precise yet in many ways surprisingly useless, and generally just extremely messy -- mocking the ease and usability with which most other financial data manage to flow. 

Still, it doesn’t take much of a crystal ball to forecast that this sad state of affairs cannot last.  Data will flow.  It will be aggregated, analyzed, and applied, and it will be available -- used to guide both provider and patient treatment decisions at point of care/point of decisions.  It will acquire velocity, nearing the real-time status we’re used to seeing in most other industries.  More power will accrue to entities that can help data move and be useful, and more success will come to entities that use the data to be accountable for their efforts – whether providers, payor, or combinations thereof.  

I think it unlikely that payors will end up controlling health care data – not with the likes of Microsoft, IBM, GE Health, athenahealth, and many, many others also in the mix – but if they don’t have their oar in the data waters (and rowing hard), they’re going to get left behind. 

For centuries, medicine was the art of laying on the hands.  Some say 20^th century medicine was the era of antibiotics/prescription drugs, plus advanced imaging.  Many pundits predict that medicine in the 2st century will be all about genetic therapy.  Perhaps so, but I think it will be about the data.  Let’s hope we use it well.

Very Wired Meets Very Tired

By Laurie Gelb, January 24, 2012

We recently moved to a new city, so I set us up with docs at a Very Wired Hospital (we'll call it VWH) that boasts a fully integrated health system and enterprise EHR. My husband sees many specialists, so we've made several visits there already. I was excited that he would finally have a single record.

The yield to date on my attempt at integration: six paper vintage 1980's medical history forms and one woefully inadequate oral interview. One doc's explanation for the manilla madness was "It's for billing [so we can charge for appropriate complexity]." My contributions to these mostly took the form of "see attached" scribbles, referring to my own far superior pt summary sheet, tailored to each specialty...hm, why not specialty-specific intake forms? In the outcomes age, is that really so radical?

I did finally see a specialty-specific form from podiatry. It arrived via snail mail, barely in time-- "We can't use e-mail [to send the form] because it could be hacked." Somehow, though, sending us e-mails about billing detail is OK. It evidently hasn't occurred to VWH yet that PDF forms can be hosted on Web servers.

I could go on and on about VWH (the wall-to-wall paper at every elevator bank is staggering, the appointment and patient tracking process archaic, and yet its reputation allows stratospheric list pricing to plans), but let's focus on EMRs and payor initiatives. It's probably pretty evident that when its flagship providers lag in HIT, no network can realize optimal value from performance management.

BTW, the mail order debacle I wrote about a few months ago culminated in a pharmacy customer service e-mail asking my husband to reply to a general mailbox with his name, DOB, phone and all the incorrect rx he saw on his Web record. We politely declined, for obvious reasons. Somehow the duplication was resolved without this step.

Unfortunately, I very soon thereafter invested 2 weeks of calls in a routine refill that was repeatedly rejected [by the all-knowing, all-seeing adjudication app] for no reason that anyone at the plan, PBM, mail or retail pharmacy could pinpoint. Finally, I was put through to someone at the PBM who was able to determine that the latest PA had no refills appended instead of the 3 that it should have. Do you think that was put on anyone's future checklist? Let me know if the Easter Bunny stops by.

So how does a provider's EMR, however implemented, benefit payors? There could be lower processing costs secondary to more accessible documentation/claims denial support. The EMR should support health outcomes research, disease management, cost management, UR/QA, contracting...so many possibilities.

Many payor networks are building/upgrading their own data warehouses, and, increasingly, aggregating them with other networks.  Plans and providers are sharing via HIEs, pilot projects, academic research and more. In some geographies, public sector HIEs are being superseded by private efforts. Usability on the local level increasingly benefits from...wait for it...local oversight.

In any geography, though, we're drowning in a sea of input screens and datasets that don't reflect real people, workflow or medicine. Transaction and opportunity costs are soaring when you consider the dollars flying out the door due to long and no fixes for often undetected errors, like my husband's pharmacy döppelganger.

What can we control out of all this? Process! 2012 can be the year of common sense, when we give up tweaks to a patchwork, hands-off patient/member/customer flow in favor of [cliché alert] collaboration with those on the front lines (docs, nurses, physician extenders, call center reps, admitting reps, PBX operators and anyone with a finger on the flow) to image and set the break rather than cover it with a cast and good wishes.

Mystery-shop your PBM, clinics, DM vendors, hospitals, plans, call centers, anyone who touches those who pay your salary. Assign the same task to anyone who says, "There's just not that much we can do." If that doesn't work, a few uninterrupted call center hours just might do the trick. Rather than rearrange the deck chairs, as recent tragedy reminds us anew, some people just don't work out in their jobs.

Health Care Data Predictions for 2012

By Clive Riddle, January 6, 2012

The Ponemon Institute just released this list of top 2012 predictions in healthcare data, that they edited from various health care data thought leaders:

1. Healthcare organizations will not be immune to data breach risks caused by the spread of mobile devices in the workforce, according to Dr. Larry Ponemon, chairman and founder, Ponemon Institute. In the recent benchmark study, 81 percent of healthcare providers say they use mobile devices to collect, store, and/or transmit some form of PHI. However 49 percent of those admit they are not taking steps to secure their mobile devices.
   
   
2. Class-action litigation firestorms are imminent, says Kirk Nahra, partner, Wiley Rein LLP. Class-action lawsuits will be on the rise in 2012, as patients are suing healthcare organizations for failing to protect their PHI. 2011 saw several class-action lawsuits for organizations, some of which involved business associates, due to breached patient data. Regardless of the outcomes, these lawsuits are a significant risk and tremendous expense for companies affected by them.
   
   
3. Social media risks in healthcare will grow, according to Chris Apgar, CEO and president, Apgar & Associates, LLC. As more physicians and healthcare organizations move to social media to communicate with patients and promote services, the misuse of social media will increase as will the risk of exposure of PHI. Often healthcare organizations do not develop a social media use plan and employees represent a significant risk, potentially exposing PHI through their own personal social network pages. These risks can lead to patient vulnerabilities, data breaches, civil penalties, loss of business and more.
   
   
4. Cloud computing is not a panacea; technology is outpacing security and creating unprecedented liability risks, suggests James C. Pyles, principal, Powers Pyles Sutter & Verville PC. With fewer resources, cloud computing is an attractive option for healthcare providers, especially as Health Information Exchanges (HIE) increase. However, privacy and legal issues abound, such as compliance with HIPAA privacy and security regulations and allocation of liability when a privacy breach occurs. A covered entity will need to enter into a carefully written business associate agreement with a cloud computing vendor before disclosing protected health information and should ensure that it has adequate cybersecurity insurance to cover the direct and indirect costs of a breach.
   
   
5. Growing reliance on business associates will create new risks, believes Larry Walker, president of The Walker Company. Economic realities will force healthcare providers to continue to outsource many of their functions, such as billing, to third parties or business associates (BA). However, BAs are considered the "weak link in the chain," when it comes to data privacy and security. 69 percent of organizations that participated in the Ponemon study have little or no confidence in their business associates' ability to secure patient data. Third-party mistakes account for 46 percent of data breaches reported in the study.
   
   
6. Organizations risk reputation fallout, according to Rick Kam, president and co-founder of ID Experts and chair of the American National Standard Institute's (ANSI) "PHI Project," a project to research the financial impact of a healthcare data breach. Identity theft and medical identity theft resulting from data breach exposure are causing patients financial and emotional harm, often resulting in patients seeking out different medical providers. According to the Ponemon study, the average lifetime value of one patient is more than $113,000.
   
   
7. Mobile will explode in healthcare, believes Christina Thielst, health administration consultant and blogger. The use of tablets, smartphones and tablet applications in healthcare is growing exponentially. Nearly one-third of healthcare providers use mobile devices to access Electronic Medical Records or Electronic Health Records (EMR/EHR) systems, according to a CompTIA study. Providers will need to balance usability, preferences, security and budgetary concerns, as well as adopt written terms of use with employees and contractors using personal devices at work.
   
   
8. Increased emphasis on willful neglect leads to increased enforcement of HIPAA, according to Adam Greene, partner, Davis, Wright, Tremaine LLP. The focus over the next year will be on the 150 HITECH Act audits and publication of the final rules implementing modifications to the HIPAA regulations. But the biggest changes may be at the OCR investigative level. Expect OCR to more aggressively pursue enforcement against noncompliance due to "willful neglect" starting in 2012, resulting in a sharp uptake in financial settlements and fines in the coming years. 2012 will be the year that OCR expects everyone's training wheels to have come off their privacy and security programs.
   
   
9. Privacy and security training will be an annual requirement, says Peter Cizik, co-founder and CEO, BridgeFront. Healthcare organizations have gotten better at putting procedures in place, but staff are still not following them. Because the majority of breaches are caused by human error, not technology failures, targeted training and awareness programs are one of the most effective ways to prevent data breaches.
   
   
10. Rise in fraudsters will increase fraud risk education, according to Jonnie Massey, supervisor, Special Investigations Unit, Oregon Dental Service (ODS) Companies. Pressure, opportunity and rationalization: these three dangerous elements of the triangle can lead to committing a healthcare-related crime. During hard economic times, there are more fraudsters and more opportunities for them to gain or keep a healthcare benefit they are not entitled to. Educating those at risk for fraud and communicating consequences may deter someone from stepping over the line or help those at risk to prevent them from being a victim of healthcare fraud.
    
    
11. Healthcare organizations will turn to cyber liability insurance, according to Christine Marciano, president, Cyber Data Risk Managers LLC. As healthcare organizations continue to implement their EHR systems, they will consider options to protect themselves and their patients. When a healthcare organization or other HIPAA covered entity suffers a data breach the cost can be damaging not only to an entity's bottom line, but also to the reputation of its brand. With the increased vulnerabilities and as part of a data breach response plan, healthcare organizations will increasingly turn to a cyber security/data breach insurance policy

Calling Mr. Watson

By Kim Bellard, October 24, 2011

I was going to write something about the recent controversies about the PSA test or Pap test, but the effort by the U.S. Preventive Service Task Force to use documented evidence in determining the value of periodic testing seems almost certain to be overcome by the combination of tradition, emotional responses, and self-interest by impacted parties, so I’ll let that go for another day. 

Instead I’ll turn my attention to one of my favorite topics, the use of technology to improve the delivery of health care services. 

I’m enough of a science-fiction fan to believe that I should be able to get medical advice and consultation whenever and wherever I am, from an appropriate expert (or at least a qualified person with real-time access to any necessary expertise), using real-time biomedical and other readings.  I’m glad to say that this is rapidly moving from science fiction to reality.

Earlier this month, California passed AB 415, the Telehealth Advancement Act.  The bill updates California’s prior telemedicine law, and makes various improvements to allow wider use of telehealth in California.  It allows broader use by more types of providers, removes rules requiring documentation of barriers to in-person visits, and eliminates restrictions on reimbursement for services provided by email or telephone, among other things.  The bill’s proponents claim it should save up to $1.3 billion per year to the state’s Medi-Cal program, much of which comes from electronic home monitoring programs for patients with diabetes or potential heart failure. 

Several studies (e.g., University of Texas Medical Branch and UnitedHealth Group) argue for telehealth’s particular value in care delivery for rural populations, where access to in-person services may be especially problematic.  Again, closer monitoring of patients with chronic conditions is cited as an opportunity for improved care and lower costs. 

Meanwhile, the Mercy health system has announced plans for what it calls the nation’s first “virtual care center”.  It will bring together a variety of existing and planned telehealth programs, such as the Mercy SafeWatch program.  This program is an electronic ICU, monitoring 400 beds in 10 Mercy hospitals to provide around the clock support from specialists and ICU nurses to the bedside practitioners.  Mercy plans to spend $90 million on building the center and another $590 million in technology to support their multiple initiatives. 

Similarly, Washington Health Center, in Washington D.C., announced CodeHeart, a mobile application it developed in conjunction with AT&T.  It allows cardiologists to view video and test results while a critical care patient is in transit, allowing them to better prepare for the patient’s arrival in the emergency room, where time is usually of the essence.

It’s no surprise that telehealth is a hot topic.  Manhattan Research claims that 75% of physicians own an Apple mobile device – iPhone, iPad, or iPod – and 26% of U.S. adults have used their mobile phones for health information and tools.  Mobile is rapidly becoming crucial to telehealth, supplementing prior video-conferencing capabilities.

The barriers to telehealth are no longer technological, since the increased availability of broadband connections and more robust mobile platforms have made possible a wide variety of options.  The real barriers are artifacts of historic practices, especially related to reimbursement and licensing.

Reimbursement for telehealth remains uneven.  Medicare, for example, covers some telehealth services, and is expanding its rules for 2012, but still does not do so uniformly.  For example, it is more favorable to beneficiaries in rural areas than in urban areas, and only covers live interactions, not so-called “store-and-forward” methods used for images and certain other patient information.  Fourteen states require private payors to cover telemedicine, but the rules are not consistent across states, nor do they necessarily speak to reimbursement equivalence. 

Licensing is an issue because health care practitioners are licensed by the state in which they practice.  Telehealth, of course, is not bound by geographic location, but under current laws providers in one state cannot treat patients in another state unless they are licensed in that state.  Practicing in multiple states thus is onerous. 

Both of these issues can be overcome, but it will not be easy.  Most private payors follow Medicare’s lead in reimbursement policies, so if and when Medicare makes progress in how aggressively it wants to use telehealth, the private sector should follow.  The reluctance of payors is understandable; the practice of telehealth is still in a relatively early stage, and many payors are concerned that paying for telehealth could lead to an explosion in costs.  In an ACO world, where ACOs have strong incentives to live within a global budget or budget target, employing the use of cost-effective telehealth services should seem entirely logical.  In a predominantly fee-for-service world, perhaps not, or at least not necessarily. 

As for licensing, state licensing agencies are not surprisingly reluctant to cede oversight.  They can justifiably claim that patients could be at risk by treatment from practitioners over whom they have no control and no assurance of competence.  While valid, we seem to be able to conduct inter-state commerce in other fields without abandoning consumer protection.  It argues for more uniform licensing practices and reporting across the states, lessening any particular state’s concerns.  Indeed, the American Telemedicine Association has launched an initiative – FixLicensure.org – to make licensure more appropriate for 21^st century capabilities and practices, including telemedicine.  E.g., why should my access to the best doctors be subject to my physical location?

Licensure will become even more problematic with the evolution of expert systems or artificial intelligence.  This is starting to become real; take, for example, the recent collaboration between Wellpoint and IBM’s Watson technology.  For readers not familiar with Watson, it is the system that beat the Jeopardy champions of champions.  Wellpoint plans to use Watson to help suggest treatment options and diagnoses to doctors.  With so much medical knowledge, and with that knowledge increasing exponentially, such assistance seems inevitable, not to mention highly desirable.  Still, at what point will that kind of assistance be considered practicing medicine?

History buff may recall the apocryphal story that Alexander Graham Bell uttered, “Mr. Watson, come here – I need you” into the first working proto-telephone, launching the era of electronic voice transmission.  It seems ironic, yet somehow fitting, that Watson may again be critical to launching of another technological revolution.