Healthcare Musings February 2017

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Healthcare IT: "Everything that Rises Must Converge"
by Arvind Subramanian

February 2017 - The title of gifted writer Flannery O’Connor’s eponymous short story collection “Everything That Rises Must Converge” is a good expression of the powerful intersecting forces driving the next wave of value creation in the US Healthcare IT (HCIT) ecosystem. The confluence of consumerism, demographics, provider leadership/management transitions, legislation, and technology are creating strong incentives to build upon the HCIT infrastructure layer (EMR) that has evolved over the past twenty years to create the next generation of clinical decision support (CDS) applications that will enable physicians, nurses, pharmacists, and other caregivers to deliver more precise patient management and better outcomes.  These applications, embedded within clinical workflows at the Point of Care (POC) or within the primary read in Radiology, will leverage advanced quantitative algorithms, machine learning/AI, structured medical content and terminologies, and fine-tuned analytics to begin to deliver on the promise of the Triple Aim (as defined by the Institute for Healthcare Improvement (IHI): Improving the patient experience of care; Improving the health of populations; Reducing the per capita cost of healthcare).

Let’s examine some of the necessary and sufficient conditions required to deliver these advanced platforms that will propel the industry further down the path of patient-centered care and personalized medicine. This is not an all-inclusive checklist by any means, but it is a useful framework and sanity check: providers and HCIT companies have been on a long journey together and now is the time to accelerate investment—organic, inorganic, early-stage VC, late-stage VC, private equity, capital, operating—to make it happen.

The “necessary conditions” pilot’s checklist includes:

•The EMR infrastructure, both acute and ambulatory, has been put in place at some level of sophistication in 80%+ of US hospital systems and physician offices driven by normal market impetus and the HITECH Act/Meaningful Use legislation.

• First and second generation CDS on-line medical content advisory tools provided by the major information services/publishing companies to allow invaluable one or two-minute use case consults are in place as standalone POC offerings, or increasingly embedded in the EMR, with access in all form factors (desktop, tablet, mobile phone, etc.)

• At the risk of sounding indelicate, hospital system leadership profiles indicate that the 40- and 50-year demographic set, very comfortable with digital technology, are coming to power in key positions. Given the billions of dollars spent on HCIT, they are pushing hard to finally unlock patient-specific data inside the EMR and other clinical systems for utilization by applications at the POC to meet quality of care and cost reduction targets.

• The Population Health movement is underway paving the way for a data-driven, evidence-based, cohort delineated method of diagnosing and treating patients. This approach is differentiating providers on a quality continuum, which is essential as it will allow a rising tide of high-end providers to lift all boats. It will prepare all providers to compete in a world of increased clinical risk management by exposing their relative strengths and weaknesses. Clinical surveillance applications are enabling continuous monitoring of populations, generating smart alerts to drive timely interventions and preventing outbreaks of Adverse Drug Events (ADEs), Hospital Acquired Infections (HAIs), and Sepsis.

Necessary and “sufficient” are required to create real value, so the emergence of these sufficient conditions over the next few years is critical to success:

• Long awaited industry initiatives and the 2015 MACRA-ACI legislation are driving steady progress on the data access and integration front to unlock patient-specific clinical information from disparate clinical systems—lest we forget that old chestnut “islands of automation”—to feed the emerging CDS applications and downstream clinical, translational, and personal medicine databases and warehouses. Major efforts underway include EMR vendor consortiums (CareQuality and CommonWell Health), more sophisticated EMR business development practices, enhanced traditional and new structural data exchange mechanisms (HL7, APIs, CCD, FHIR), and terminology content management engines to ensure semantic interoperability. The long slow march to enable workable, and ideally seamless, interoperability has been a source of great frustration, angst, and drama for providers, vendors, payers, and patients. The interoperability train must continue unabated to enable the new era of CDS applications to fully blossom; nothing is more certain to delight all stakeholders in the system.

• The drive by CMS to move from Fee for Service (FFS) to a Value Based Payment (VBP) framework has enormous implications for leadership and management of the US healthcare system, as quality, risk and cost management disciplines will quickly separate the wheat from the chaff. This transition will likely drive positive healthcare behaviors as both patients and providers become aligned to focus on wellness and consistent and measureable management of chronic conditions, as all players are incented to avoid expensive interventions. Hospital systems will be motivated to manage and keep patients away from high-cost acute care settings, driving the growth of telemedicine and remote monitoring applications. Patients (“customers”), ever mindful of their high-deductible and high-premium plans, will be motivated to invest in better healthcare regimens and a myriad of personal and home healthcare technologies to contribute to their own wellness.

• The widespread adoption of information technology in healthcare significantly lags other industries for complex reasons, but one clear contributor has been, with a few notable exceptions, the poor, non-clinician friendly nature of healthcare software. This has certainly improved over time, but the next generation of both infrastructure (EMR) and workflow-centric applications, must achieve the design sophistication of well-accepted offerings available from Apple and Google.

The necessary and sufficient conditions are coming together to create the next wave of significant growth in HCIT. Leveraging both Moore’s Law and Metcalfe’s Law, they allow our reach and grasp to become more aligned. All industry participants and CMS must collaborate in a non-zero sum fashion to enable these conditions to thrive in order to deliver on the elusive promise of improving patient outcomes, reducing costs and enhancing the quality of the US healthcare system.

About the Author

Arvind Subramanian is the President & CEO of VC-backed HealthMyne, Inc., bringing 26 years of healthcare technology (diagnostic imaging and healthcare IT sectors) experience to this role. His career includes CEO/COO/VP/GM and other management roles in large and small companies, including GE (GE Medical Systems; GE Information Services), Wolters Kluwer (WK Health-Clinical Solutions) and a VC-backed technology startup, ProVation Medical, that completed a successful strategic exit sale in 2006. He received an "Outstanding Entrepreneur" award from NEA (New Enterprise Associates), a top-tier global venture capital firm, for his work in building and scaling ProVation Medical. Arvind received his BA & MBA degrees from Case Western Reserve University (Cleveland, OH).

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