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Futurists Ponder the Possibilities
Health Data Management Magazine, March 1, 2008
Anniversaries are a good time to consider past accomplishments and future possibilities. To mark Health Data Management’s 15th anniversary, we asked five of the nation’s leading health care futurists for their reflections on the past 15 years and their predictions for where health care information technology is headed in the next decade and a half.
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In the past 15 years, health care has made great strides in applying computers to a wider variety of tasks, Kaiser says. “We used to see computers as tools—instruments to help us do the job,” Kaiser says. “But computers are not just fancy typewriters or a way to keep track of data; they’re a way to manage knowledge.”
Today’s ubiquitous computerization and global connectivity via the Internet will lead to “decentralized communities of interest that advance the state of the art,” the futurist says.
For example, academic medical centers and their “centers of excellence” will lose power because small groups of experts from around the world will hold virtual meetings to tackle problems interactively.
“Artificial intelligence, which is coming very quickly, will have the ability to know everything that’s known and suggest hypotheses and possess reasoning capacity,” he adds. “So we will become more computer-dependent.”
Once the payers for health care, including the federal government, mandate that all caregivers collect data on all aspects of treatment, this “transparency” will make it easier to weed out incompetent providers, the futurist predicts. Computers will enable total accountability, which will make it far easier to control health care costs, he adds. “Doctors who fail to practice good medicine and document it will not get paid,” he states.
Kaiser points to several important emerging trends, including:
* Computers will read a person’s neural impulses to compensate for a disability, such as the loss of a limb. For example, a computer will read brain signals and give instructions to a prosthesis to move.
* Implants will transmit a patient’s vital signs to a satellite. When the implant sends information that indicates an emerging health problem, a monitoring computer will alert an emergency team to respond before the patient even knows there’s a problem brewing.
*Ultimately, computers will be able to take commands from human thoughts. “There’s a theory developing that there’s a particle between mind and matter, and if we learn how to use it, we can use thought as an input device.”
Joe Flower CEO Imagine What If Inc. Sausalito, Calif.
“Charles Dickens stepping into a hospital at the turn of the 21st century would not feel uncomfortable with the way we keep records,” says Flower, lamenting the fact that someone from the 19th century would find handwritten notes are still the norm. “What we know as the medical record was invented in the mid-19th century, and the movement to an electronic version is the first really significant change in all those 150 years.”
In addition to ongoing efforts to digitize records, the most significant developments in health care I.T. in the past 15 years have been the development of standards for data and the refinement of data monitoring, the futurist says. By mining the data in standard electronic records, health care organizations soon will be able to pinpoint treatments that actually work, he contends.
This “data transparency,” he argues, will be “the most revolutionary force ever in the history of medicine.”
Those who pay for health care have not been able to gather the necessary information to pinpoint the quality and cost of care, Flower says. By using data mining, “we will be able to determine what works and what doesn’t and compare the costs of individual procedures as well as entire solutions to health care problems, like replacing a hip.”
Data transparency will enable the U.S. health care system to slash costs in half by eliminating wasteful, ineffective care, he predicts. The key factor, he says, will be to require doctors and hospitals to gather data and make it public. “The industry is going to resist having to put data out there,” he says. “But payers will demand outcomes data.”
Jeffrey Goldsmith Owner Health Futures Inc. Charlottesville, Va.
A new generation of CEOs in health care will pave the way to widespread adoption of information technology, Goldsmith contends. “The cultural and organizational constraints on I.T. adoption are a lot more significant than the cost of the technology itself,” he adds.
The current generation of executives views I.T. “as a series of extraordinarily painful capital investments and learning experiences,” the futurist says. “The generation of leaders 15 years hence will not have experienced I.T. as disruptive. They will have grown up with computers as an enabler of communications.”
The emerging theme for I.T. is instantaneous communication and decision support, leveraging such technologies as instant messaging and social networks, Goldsmith says. Remote clinical management technologies are already enabling some pioneering clinicians to manage dozens of patients in multiple locations, he points out. Soon, computers using sophisticated speech recognition will be able to carry on structured conversations with the user, he adds.
But physicians won’t make electronic health records a common part of their routines until they are easier to use, the futurist contends. “They are still too complicated, with too many moving parts, a tough user interface and high cost,” he contends. Employing the application service provider model of computing will help make EHRs far more affordable, he adds.
Health care can achieve massive savings in the years to come if it successfully eliminates all the paperwork associated with adjudicating medical claims, relying on real-time transactions instead, Goldsmith says.
Today’s efforts to build health information exchanges will prove fruitless, just like the community health information networks of the 1990s, Goldsmith argues. Instead of building networks to share data—what the futurist labels as a “1970s-type idea”—he says health care should capitalize on “the revolution in data storage.” He predicts we’ll wear high-capacity data storage devices as jewelry or perhaps tattoos that will accommodate complete medical records. “If you need the information when somebody is there, doesn’t it make sense that they are the bearer of the information?” Goldsmith asks. “That would be a truly ‘personal’ health record.”
Jeffrey Bauer Chicago-based Partner Futures Practice ACS Healthcare Solutions
“Information can shape the future of health care if we push for it,” Bauer says. “I can’t see any solution to our problems other than I.T.”
Electronic health records will play a pivotal role in improving health care quality and controlling costs, he contends. “I thought 2007 was the first year where we could honestly say that the EHR software exists to get the job done,” he adds.
Doctors will jump on the EHR bandwagon once they see technology working at colleagues’ offices, he says. Mobile technologies will play a critical role in making electronic records ubiquitous, he argues. “I don’t forecast the disappearance of laptops or hard-wired machines on the desk tied to a network. But to make EHRs fully functional for the doctors and the nurses, not being tethered to a stationary computer will be very important.”
Like Goldsmith, Bauer says today’s health information exchanges are doomed to fail. “We’ve got to build the information exchange around the patient,” he argues, calling for the creation of personal Web sites to house patient’s records. He compares these sites to today’s MySpace or FaceBook pages.
In his new book, “Paradox and Imperatives in Health Care,” Bauer and co-author Mark Hagland observe: “No other industry may be more data-driven than health care, but neither is any other significant U.S. industry less prepared to use its information productively. All health care stakeholders are stuck on a paper trail, and the trail does not lead to a better delivery system or a healthier nation. Health care simply cannot and will not reach its full potential until it is supported by a state-of-the-art infrastructure of I.T.”
Ian Morrison Author, consultant, futurist Menlo Park, Calif.
Pointing to a lack of progress in the implementation of electronic records, Morrison says regulatory and reimbursement incentives will prove essential to adoption of the technology. “We’re pathetically far behind where we should be at this point in our history,” he contends.
Employing the application service provider model of computing also will lead to wider use of the technology among physicians, he says.
“Physicians, in particular, are looking for technology that saves them time, makes them more money, improves patient quality and lessens their hassles,” the futurist says. “I don’t think any system to date delivers on these points.”
But as younger physicians take over for their older colleagues, the use of technology inevitably will ramp up, he says. “What worries me is that the progress is incremental, not the sweeping changes we all had hoped for.”
Disease advocacy communities will increasingly use social networking sites on the Web to support the chronically ill, he says. Eventually, every institution’s electronic medical records must be merged with personal health records to create a complete picture of treatment, he argues.
“Computing has great potential,” he says. “But the health care system has not exploited these opportunities as well as other industries. “There’s enormous potential for mobile computing in health care. I would hope we’d see creation of intelligent devices that support physicians.” (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.healthdatamanagement.com http://www.sourcemedia.com
Sidebar
What a Long, strange trip it's been
Health Data Management has tracked the evolution of health care information technology for the past 15 years. Following is a summary of key developments, year by year, including some trends, such as community health information networks, that have come and gone—only to return yet again.
1993
The debut issue of Medical Claims Management featured a cover story on the emergence of “national claims processing networks.” The story predicted that health care would follow banking in moving to electronic financial transactions via a handful of national networks. Some 15 years later, the debate over the long-term role of regional vs. national clearinghouses continues.
The first issue also included a story that outlined how electronic medical records might some day enable providers to automatically generate all the charges necessary to assemble a bill—or what’s now called automatic charge capture. And another story foreshadowed the development of standards for transactions—an effort that culminated with the passage of HIPAA three years later.
A major topic covered during the magazine’s first year of publication was the testing of Community Health Management Information Systems, or CHMIS, which soon would evolve into Community Health Information Networks, or CHINs. These precursors of today’s health information exchanges traveled a rocky road; most CHINS were extremely short-lived.
1994
The magazine was renamed Health Data Management in its second year in recognition of its broader coverage of clinical as well as financial automation.
The January cover story touted how major banks had dived into the health care transaction market and would soon be a force to reckon with. Within about a year, most of the banks had taken a U-turn out of the market once they discovered electronic health claims were far more complex than electronic bank deposits.
Other key issues included the potential role of electronic health records as Congress and the White House weighed health care reform (remember the Clinton plan?) and the dawn of outcomes research fueled by data in electronic records. A special report mid-year proclaimed telemedicine was “poised to revolutionize the practice of medicine.”
1995
The cover story of the January issue asked: “On-line Claims Adjudication: Does It Meet a Need?” Thirteen years later, the January 2008 cover story outlined some pioneering efforts by a handful of payers to move forward with real-time adjudication of physician claims. So much for rapid progress.
Microsoft’s Bill Gates jumped on the CHIN bandwagon, predicting the networks would be ubiquitous by 2000—sorry Bill.
The magazine offered a forecast of the use of clinical decision support, profiling the value of integrating clinical treatment guidelines with electronic records.
Our first major story on the “allure” of the Internet outlined many potential uses for the “emerging information superhighway.” The story said that today’s Internet “was like the Model T in the history of the development of the automobile.” That turned out to be very true, indeed.
The Innovator of the Year award honored, among others, Jacobi Medical Center for a project that was way ahead of its time—the development of an electronic record of both inpatient and outpatient treatment and a data repository.
Using computers to help prevent medical errors was a hot topic, as a result of several high-profile cases. And some HMOs began trying to promote the use of electronic records as a way to manage costs and quality.
1996
In August, Congress passed the Health Insurance Portability and Accountability Act, which included “administrative simplification” provisions that were far from simple. The provisions dealt with data security and privacy and called for standards for a variety of electronic transactions.
The magazine examined the potential role of an emerging technology—speech recognition. During the next 12 years, Health Data Management would feature many updates on this technology, which was continually refined until it became relatively commonplace among radiologists and pathologists and began to spread to other specialties.
The CIO’s role continued to evolve as more hospitals filled this position. More of these technology leaders joined the executive team and participating in strategic decisionmaking. A new study determined the average CIO’s salary was approaching $100,000. Many CIOs began to launch an ambitious new architecture called client/server. And intranet projects came on the scene.
As hospitals joined integrated delivery systems, they tackled the challenge of building enterprisewide networks — a challenge many of these organizations continue to face today.
1997
Claims clearinghouses predicted they’d soon use the Internet as their primary conduit for transactions. Given the slow pace of the shift, “soon” appears to have been an overly optimistic term.
CIOs and others began assessing the potential for a new operating system from Microsoft called Windows NT and assessing whether it would ever supplant Unix. The annual HIMSS survey found use of the Internet had doubled in the past year, and 20% of organizations had developed an intranet.
A story in the April issue identified the emergence of wireless technologies and predicted “portable computing” could fill a need. Talk about an understatement. More clinics began experimenting with what were then called “computer-based patient records.” A May cover story identified obstacles to progress, including “getting physicians to learn new ways of recording patient data.” The more things change, the more they stay the same.
Kaiser Permanente’s new CIO announced its first national information technology strategy, ending the autonomy of various regions. Kaiser was to re-invent its strategy several times before entering a 21st century mega-contract with Epic Systems Corp.
Providers began ramping up their efforts to use I.T. to cope with managed care capitation, under which payers paid them a fixed amount per month for meeting all of a specific population’s health care needs. But the payment model never took off nationally. A story in November warned of the looming Year 2000 bug.
1998
Some pioneering provider and payer organizations began to make wider use of the Internet, building interactive Web sites and even turning to e-mail for doctor/patient communication. Some also started experimenting with data mining, using information stored in repositories to track outcomes and improve quality. And hospitals began hiring their first chief security officers as they prepared for new HIPAA security and privacy rules.
A handful of surviving CHINS tried to re-invent themselves by capitalizing on the Internet. Our story on the subject coined the phrase “Chintranets.”
A story in the December issue asked the question, “With worries galore, should health care rely on the Internet?” Skeptics raised concerns about both availability and security.
1999
As the new year dawned, CIOs were “racing” to evaluate whether their systems were really ready for the Year 2000. Fears about the Y2K bug led to a slowdown in demand for new software, and the stocks of several major vendors took a hit.
Meanwhile, CEOs were beginning to get more involved in I.T. decisions as the price tags—and strategic importance—of technology projects grew. A number of health care organizations unveiled second-generation Web sites with interactive functions, such as enabling patients to search for providers and send e-mail to doctors. And more health care organizations began using clinical decision support systems in tandem with electronic records.
The Clinton Administration unveiled the privacy rule to carry out a HIPAA mandate. And some organizations began implementing virtual private networks to make Internet-based transactions more secure.
Late in the year, the Institute of Medicine report, “To Err is Human,” claimed medical errors annually caused up to 98,000 deaths in the United States. The report served as a strong, long-term catalyst for using information technology to avoid errors.
2000
The new millennium dawned with virtually no reports of major problems caused by the feared Y2K bug.
Wireless technologies began to gain momentum as organizations concluded that providing better access to clinical data at the point of care could improve quality.
The number of “dot.com” startups capitalizing on the Internet craze and available investor capital mushroomed. A story in the June issue offered advice to CIOs on how to ensure that working with “new and untested dot.com companies will pay off.” The “buyer beware” advice proved to be right on, because dozens of these startups eventually disappeared as tech stocks plunged.
A growing number of practice management software companies began offering access to their software through the new application service provider model of computing. The model, which enabled users to access applications as needed via the Internet, avoiding a heavy investment in servers and other hardware, had an uphill climb in winning acceptance.
Picture archiving and communication systems, or PACS, began to become more common among larger hospitals. By the middle of the decade, the technology was widespread, even popping up at tiny critical access hospitals.
2001
With a second report from the Institute of Medicine, the spotlight continued to shine on medical errors. Providers worked to identify information technologies, including decision support systems and automated order entry, which could help prevent errors.
A soft economy wreaked havoc with I.T. stocks and squeezed hospital’s technology budgets. HIPAA compliance was the top business issue facing CIOs, the annual HIMSS survey showed. The 9/11 terrorist attacks virtually brought the nation to a standstill, and ultimately led many organizations to reassess their disaster plans.
A handful of doctors began testing personal digital assistants, or PDAs — the earliest handheld computers. Organizations of all sizes were drafting plans to comply with various HIPAA mandates, including the privacy and security rules.
2002
Handheld computers continued to gain momentum as more organizations rolled out devices that caregivers used to access drug references, write prescriptions and capture charges.
A special report in May lamented the slow pace of adoption of electronic medical records, with experts predicting it could take decades for the software to become ubiquitous. CIOs debated whether to rely on a single source for most applications or a best-of-breed approach. Computerized physician order entry began to gain a bit of traction as a way to reduce medication errors. One survey showed patient safety as a strong driver for growing investment in clinical information systems.
The stocks of many health care I.T. vendors continued to fall throughout much of the year as the entire stock market continued its post dot.com decline.
2003
A growing number of hospitals were adding physicians to their information technology team, some with the title of chief medical information officer. Some experimented with a new hardware option: the thin client. These computers of various shapes and sizes lacked a hard drive and accessed applications from servers, much like the old days of “dumb terminals” linked to mainframes. In the mobile arena, a new generation of Tablet PCs began to pop up at a few pioneering organizations. And “computers on wheels” were rolled out at hospitals throughout the country.
Rising from the ashes of the dot.com bust, many health care organizations discovered valuable uses for the Internet, including using it as a conduit for claims and related transactions. As PACS became more pervasive, hospitals struggled to integrate them with their radiology information systems as they attempted to go “filmless.”
2004
In an effort to jump-start the use of electronic records at doctors’ offices, the American Academy of Family Physicians endorsed nine records vendors who agreed to offer its members discounts.
More hospitals and clinics began installing wireless networks as prices declined. And some began linking medical devices to their records systems. A few began experimenting with the Linux open source operating system. Some implemented radio frequency identification technology, or RFID, to track medical equipment. And others tried out the new Voice Over Internet Protocol telephones in an effort to cut their communications costs.
With the looming 2005 deadline to comply with the HIPAA security rule, health care organizations started taking a closer look at biometrics and other security technologies. And more nurses became involved in I.T. decisions as hospitals tried to gain buy-in from the dominant users of clinical systems.
Personal health records came on the scene as organizations experimented with allowing patients, especially the chronically ill, to enter data into their Web-based records.
2005
For some, all the talk of local, regional and national networks felt like déjà vu all over again. At the giant HIMSS conference, dozens of vendors touted their readiness for regional health information organizations, or RHIOs, echoing the CHIN hype of the mid 1990s.
Meanwhile, large integrated delivery systems tackled their own, internal networking challenges, attempting to truly “integrate” all their sites by sharing data.
Several managed care organizations began offering physicians free e-prescribing software along with, in some cases, free hand-held computers, in hopes of persuading doctors to stick to their cost-effective drug formularies.
A growing number of provider and payer organizations turned to Web portals to improve service to their increasingly Internet-savvy customers.
The magazine’s annual CIO survey confirmed that many organizations were spending a much larger percentage of their I.T. budgets on clinical systems as they attempted to improve the quality of care and reduce medical errors. Similarly, a Harris Interactive survey of nurses found 80% believed I.T. was a major contributor to better patient safety.
2006
As the number of RHIO projects across the nation doubled to about 200, observers began to question whether the networking efforts were over-hyped, echoing concerns about CHINs a decade earlier.
A year before the release of Apple’s iPhone, health care organizations already were investigating the role so-called “smart phones” could play in improving access to information. In what struck many as “the revenge of HIPAA,” a new government report ripped the Department of Health and Human Services (the HIPAA security rule enforcer) for providing inadequate security for its own information systems.
A growing number of physicians began using the Internet for exchanging secure messages with their patients for routine cases. Some began being paid through “pay for performance” initiatives, which required that they thoroughly document the care provided.
In July, the Certification Commission for Healthcare Information Technology certified 22 ambulatory EHR products as meeting its standards. Some predicted that the market eventually would squeeze out those vendors who failed to achieve certification. The effort spread to inpatient records systems in 2007.
More payers, including Wellpoint, began offering personal health records to their enrollees. The Department of Health and Human Services published two rules that eased the so-called Stark restrictions on hospitals donating information technology to physicians and group practices.
2007
The magazine identified two emerging trends: the marriage of genomics and I.T. and the use of biosurveillance data to thwart public health threats. Hospitals began experimenting with donating clinical systems to area physicians, taking advantage of the relaxation of federal prohibitions.
A favorable IRS ruling on the issue early in the year provided yet another catalyst. The National E-Prescribing Patient Safety Initiative set the lofty goal of offering free e-prescribing software to every U.S. physician. Hospitals stepped up efforts to refine their medication reconciliation programs, making sure they had complete records of both inpatient and outpatient medications.
Some 1,900 physicians served as chief medical information officers as more hospitals made a concerted effort to involve doctors in I.T. strategies. More hospitals hired directors of nursing informatics as well.
When Medicare announced it no longer would pay for treatment of hospital-acquired infections or treatment of conditions caused by medical errors, hospitals took a closer look at the role I.T. could play in preventing infections and errors. By year’s end, two studies determined that most fledgling RHIOs had yet to become operational, yet again calling into question their viability. As consumer-driven health plans slowly became more common, payers used I.T. to enable patients to more easily determine their self-pay balances and discern the cost of care.
(c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.healthdatamanagement.com http://www.sourcemedia.com
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