Over the past decade, we have made significant progress in the advance of digital health technologies and the tools that are created to help in the much-needed transformation of our healthcare system.
Since Steve Jobs introduced the Apple iPhone in 2007, mobile phones have become much more intelligent and opened up an entire development ecosystem that, in turn has created a significant new category of digital health—mobile health or mHealth.
With the continuing exponential growth in the advance of technology, as the price performance of computing improves on a logarithmic scale, the implications for digital health are astounding. But it is not simply the technology that has ushered in such dramatic change, but the policy framework and incentives for adoption that has spurred much of the success.
The HITECH Act, as part of the American Recovery and Reinvestment Act (ARRA) allocated billions of dollars towards the adoption of electronic health records. As a result, we have largely digitized our health information systems into databases that allow information exchange using discreet data and standardized formats.
So as we look at the ability to capture, share and effectively use health information, we are capturing a lot of data. And these data are beginning to be shared in both centralized and federated networks, and now networks of networks. In the area of effective use, our clinical analytics capabilities have been making incredible progress, and we now also are seeing the blending of claims and clinical data that provides new insights. So looking back over the years, we can be proud of the work accomplished and perhaps briefly pause for a breath.
However, the work is not nearly complete, and there is still a long way to go in making the most of digital health tools and achieving the goals of improving health, the patient experience and lowering costs. The primary means of exchange for health data among clinicians is still the fax machine. Patients still do not have adequate access to their own health data, much less control over how it is shared and used.
As Eric Topol and Kathryn Hahn pointed out recently in their New York Times opinion article, “The Health Data Conundrum,” hackers generally have greater access to our health information than we do ourselves. Cybersecurity in the healthcare space was an increasing concern in 2016 and will need to be a priority going forward. Millions of patients had their health data stolen; the current gatekeepers are proving to not be responsible stewards of our data. Patients must be put in charge if all of the technological advances are to succeed.
“We need to move on from the days of health systems storing and owning all our health data. Patients should be the owners of their own medical data. It’s an entitlement and civil right that should be recognized,” Topol and Hahn wrote.
Those perpetrating malware/ransomware and cyber attacks have been relentless and are increasing their efforts. As we explore solutions to ameliorate and defend against these attacks, one new technology on the scene that is gaining a lot of interest is the blockchain, a data structure that creates a digital ledger of transactions and shares it among a distributed network of computers. It uses cryptography to allow each participant on the network to make changes to the ledger in a secure way without the need for a central authority. In the blockchain, data is not stored in a centralized database; data is encrypted and distributed among thousands of individual computers. Due to the distributed, federated and decentralized structure, the blockchain doesn't have a central point of failure; thus, it's better able to withstand malicious attacks.
The Office of the National Coordinator for Health Information Technology (ONC) became interested in blockchain technology and launched the Use of Blockchain in Health IT and Health-related Research Challenge, soliciting white papers on the topic of blockchain technology and the potential use in health IT to address the privacy, security, and scalability challenges of managing electronic health record and resources. ONC offered cash prizes for a dozen or so winners, and they had the opportunity to present their papers at the Blockchain & Healthcare Workshop, which was hosted at NIST. This effort was funded by the Patient-Centered Outcomes Research (PCOR) Trust Fund through a partnership between ONC and ASPE. The ONC received more than 70 submissions to the challenge, 15 of which were announced as winners, but many more of them offered some compelling examples of how the blockchain can be a great asset in our healthcare technology tool kit. The winning papers can be found here.
And blockchain for healthcare is not simply a theoretical or academic exercise. Innovative Startups like Gem, Tierion, Guardtime and others are already developing blockchain technologies for healthcare. There is a new effort, The Hyperledger Project, that is also working through potential use cases for the blockchain to be used in healthcare. The Hyperledger Project is an industry-wide open source project to advance blockchain technology, which is governed by The Linux Foundation. The brilliant minds heading up these efforts leave me no doubt that this technology will have a big role to play in the future of healthcare. Blockchain has been primarily used as a platform for cryptocurrencies like Bitcoin. It is making notable progress in financial services, insurance and other finance sectors. I will discuss more of the future for blockchain in the next article in this series.
New technologies and startups are enabling patients to receive care based on different levels of severity, while risk stratification capabilities are continuing to improve through the use of data analytics and population health management. More data with better tools facilitates improved segmentation that will enable personalized medicine with digital health tools geared specifically for individuals and their unique physical characteristics.
Substantial investments from very large organizations, like IBM, Microsoft and GE, along with significant venture capital activity from targeted investment firms like Rock Health, Y Combinator and KPCB have funded a plethora of startups geared towards solving some of the fundamental problems we face in dealing with massive new combined data sets. We have huge amounts of claims, administrative and clinical data, and these data are being added to from new sources like genomic, proteomic and microbiomic information. This will be one area to look while we peer into the future and identify trends that will help to paint a picture of what healthcare will look like in this country.
As we examine where these investments are being made and what types of innovative startups are working on these issues, we can begin to categorize some of the trends and define the technologies that are making the magic happen. One area that has gained a great deal of attention is artificial intelligence, or AI. It seems to be on everyone's lips lately and has certainly become a buzzword, along with many of the technologies that enable AI: machine learning (supervised and unsupervised), deep learning and neural networks all powered by new platforms using quantum computing that provide the high performance computing necessary for these technology platforms.
AI’s development in healthcare has made steady advances over the past few years and will accelerate rapidly in 2017 as it becomes an established part of healthcare organizations’ thinking. This, in turn, will drive a growing need for machine learning capabilities for systems to become more clinically intelligent, paving way for the development of the next generation of digital health.
By 2020 machine learning and related data science technologies will be widely deployed in healthcare and this will create massive change as well as some remarkable opportunity. The investments being made in this space, by both established industry players and startups, are beginning to bear fruit; there are many use cases identified where AI will help improve outcomes (a critical need in order to thrive in a value based care delivery and payment environment) and ultimately lower costs across the spectrum. This is one of the reasons why venture capitalists and corporate interests are taking such strong positions in the healthcare/AI market.
So we have developed a policy framework for moving to a value-based care system with the necessary technology infrastructure to support it, and we're actually beginning to see some successful business models emerge. The success of the accountable care organization (ACO) was obvious in 2016. Of course, not every model improved care and lowered costs, but the progress has been discernible, especially in the commercial market.
In fact, 2016 can be viewed as a turning point in many ways, particularly in terms of the exponential advance of information technology and also with regard to the business of healthcare moving to a system that rewards value over volume. We are truly beginning to see a health system emerge which pays for the quality of care rather than the quantity. This is transformational, and it enjoys the greatest success in the private market driven by a desire to help others while also fulfilling the fiduciary imperative of business. We need to start getting our money’s worth and stop wasting resources for poor outcomes. I have a number of friends who are clinicians, and one physician friend of mine told me a few years ago that she wanted to get paid for what she did for her patients rather than what she did to them.
The Affordable Care Act, a highly politicized lightening rod, provided a good bit of funding and energy towards moving towards value-based care delivery and payment models. But as research from Leavitt Partners has shown, it is in the commercial Medicaid sectors of the ACO market where we have seen the most growth and success. Data from SK& A in their listing of the Top 30 ACOs shows that those with commercial contracts are succeeding, while government-run ACOs, in many cases, are faltering. And with the change in administration and leadership in Congress, that trend will continue and indeed accelerate. The company where I work, Medicity, which is a business of Aetna, has great expertise in data exchange, data analysis and population health management. If anyone is confused about all of this and unsure where to turn feel free to reach out; I am pretty easy to find.
It is critical to have an IT infrastructure that supports value-based care if clinicians, patients and provider organizations are going to thrive in this new environment. And these digital health tools we have been discussing are key enablers of success in a transformed health system. Whatever happens in Congress with the ACA, and however the new administration approaches reforming our broken healthcare system, the rapid movement towards value-based care delivery and payment models will continue. Remember, when all is said and done, in Washington, DC a lot more is said than done.
But 2016 was a good year for digital health and health information technology solutions, even from a government policy perspective. Looking back through various lenses such as policy, through both clinician and patient perspectives, seeing improvements in computing capabilities (such as quantum and cognitive computing) and considering the advances in software and digital tools enable us to take a kaleidoscopic view of the current landscape and provides a holistic and realistic viewpoint on the current state. Some of the highlights of the past year shed light on the progress we've made and lay a foundation for the future. Some of the highlights:
In 2015, the Congress passed and President signed into law the Medicare Access and CHIP Reauthorization Act (MACRA), which enacted clinician payment reforms designed to promote quality and value of care, moving away from a fee for service model to a value based system. These reforms, which CMS terms the Quality Payment Program (QPP), are a significant shift in how Medicare compensates clinicians and has required CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care.
CMS issued final regulations regarding implementation of MACRA on October 14, and the first performance year began this January 1. The first payment adjustments (upward or downward) for those who take care of Medicare beneficiaries begin taking effect on Jan. 1, 2019. With the change in Administration in Washington, and the Senate also changing hands, many have wondered what will happen to MACRA. I can tell you this: MACRA is the law, and it is not going anywhere. There will certainly be a shift in the regulatory approach in the new White House, but there is little appetite to take Congressional action, especially since the law passed both Houses of Congress with huge bipartisan majorities. There are some very important health IT and digital health components necessary to succeed in this program, which I will discuss in the next article.
On December 13, President Obama signed into law a House-Senate compromise version of the 21st Century Cures Act. Health IT is mentioned in more than 30 sections throughout the bill. Some key health IT related provisions address important issues including regulation of health IT, interoperability, and information blocking, as well as patient access to their health information and patient data matching. The Cures Act is going to reshape medicine over the next decade (much more about this in the next article where we will examine the future of digital health).
There were also some important policy changes at the state level, such as Georgia legislators’ enacting new standards for health insurance provider directories to ensure that consumers get accurate information about the providers and facilities that their health insurance will cover.
Also Florida's Gov. Rick Scott signed bipartisan legislation to protect consumers from surprise medical bills. The measure would limit the costs when patients use an in-network facility but end up receiving care from out-of-network providers for reasons out of their control.
And then Vermont lawmakers became the first in the nation to pass legislation requiring drug manufacturers to detail the pricing information for as many as 15 prescription drugs on which the state spends significant healthcare dollars. And there are a number of other state-led efforts towards driving change in the system from a number of different lenses.
So substantial progress has been made, although we still have a tough road ahead. But the way is clear and I am very optimistic that things are going to look a lot better in 2020. We will need 2020 vision to see through the fog and grasp a vision of healthcare in 2020.
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