HIMSS 2018

Another HIMSS conference is in the books. Amidst the craziness that HIMSS can be, it is always a pleasure to spend time running into friends, collaborators, and former colleagues.  There have been lots of great pieces written about 2018 HIMSS, including by Chrissy Farr and by Lisa Suennen. Here are some of my thoughts and takeaways:

1 – Where’s the Peds?

HIMSS pretty much has a little something for anybody. However, walking the exhibition hall and seeing vendor booths, attending sessions, and talking with colleagues, there was a noticeable under-representation of anything having to do with pediatric care. I’m guessing this has something to do with $$, but I would love to see more attention paid to the specific needs of children, parent caregivers, pediatric care, and children’s hospitals.

2 – Cash and Flash

HIMSS had its usual plethora of vendor swag giveaways, plush carpeted booths, sponsored parties and happy hours, steak dinners, and other signs of the amount of money flowing through the system. One couldn’t help but wonder, if the biggest challenge facing American healthcare is one of cost and value, how could we be spending this much money on HIMSS while telling each other we were there to save money?

Some great tweets on this subject:

Screenshot 2018-03-12 10.20.56Screenshot 2018-03-12 10.20.33

 

3 – Interoperability’s Day Has Arrived

With many thanks to years and years of tireless work by Ken Mandl, Josh Mandel, Aneesh Chopra, Micky Tripathi, Graham Grieve, and so many others, there was a palpable sense that FHIR APIs are crossing from “early adopter” to “mainstream.” CMS announced “Blue Button 2.0,” an API containing four years of Medicare claims data for 53 million beneficiaries that allows individuals to allow third parties to receive that data via API. The VA announced its Lighthouse platform, which gives external developers access to data and tools from the VA in order to more easily build apps to serve the needs of veterans. This is happening.

4 – 2018 HIMSS Word Cloud

AI. Cloud. Interoperability. Security. Provider Burden. API. Connected. Engaged. Consumer. Coordinated…… and Blockchain

4b – My favorite 2018 HIMSS pitch

Started off with the company saying, “even though all our founders come from an AI-background, and all our competitors use AI, we do not use AI in our product.”

5 – From EHR Implementations to Pilots to Mainstream Digital Health

Lots of thought and effort is going into thinking about how to scale innovation and move digital health into the mainstream. How can we create the infrastructure, processes, and tools to try things out, iterate, and scale innovations to get beyond the pilot trap? You can still feel the tension as people try to move past the era of EHR implementations to actually using their EHRs as an underlying platform to achieve care delivery goals like patient engagement, population health, and precision medicine. How can we best use EHRs as a platform on top of which we can integrate novel apps, analytics, and decision support?  To me, solving this at scale is the key question and challenge of the next several years.

 

 

HealthCare Innovators Podcast: Patient-Generated Health Data

I recently had the opportunity to sit down with Travis Good, MD, MBA, Co-Founder and CEO at Datica to discuss emerging trends in the use of patient-generated health data (PGHD) in healthcare delivery.

Here is a link to the Podcast episode

Thank you to Travis for a fun and engaging conversation and for all of the great work Datica does promoting a vibrant digital health ecosystem!

Doximity Dialer

Sometimes simple is the best. I recently tried a new smartphone app – Doximity Dialer – that is just that. I have been so struck by it that I have started showing it off to people at any opportunity. It is incredibly simple to use (from download to using it in <5 minutes) and solves a straightforward, but common problem. It is 8pm and you’re at home working on messages in your EHR. You need to call your patient back about a lab test result. Enter this conundrum… You can either use *67 to block your caller ID in which case the patient will think it is a telemarketer calling and not answer. Or you can leave your caller ID on, in which case the patient now has your cel phone number. While some physicians have become comfortable with their patients having their cel phone numbers, many still have not.
Doximity Dialer allows you to “trick” Caller ID into showing a phone number of your choice, e.g. your office number, to the call recipient. This means that you can make calls to patients from your cel phone, but the patient sees your office number on Caller ID.  Now, they recognize the number as their doctor and will answer the phone, and doctors do not have to feel squeamish that a patient will have their personal cell phone number.
Win-win. Simple.

Could voice control of the EHR improve physician efficiency and satisfaction?

Farhad Manjoo, the NYTimes tech reviewer, wrote a story this week about the Amazon Echo, a device for the home using the Amazon Alexa voice recognition service to allow natural-feeling interactions with web searches and web-connected home devices. My immediate reaction was that this will be the human-computer interaction with the future EHR.

Where we now use the mouse and keyboard to search endlessly through complicated menus, in 5-10 years, we will instead be able to say aloud, “Order Mrs. Jones a metabolic panel, lipid panel, and A1C to be done today and again in 6 months. Send the order to the Quest lab. She also needs a bone density scan ordered to screen for osteoporosis. Make sure she has this scheduled and completed by the end of the year. Make a referral to Dr. Smithson in Cardiology for management of coronary artery disease. Send in a one-year refill of her metformin. At the end of our visit today, please send a letter with my full note from today’s visit to her primary care physician.”

As a physician speaks these orders, his shopping cart menu will build on-screen, allowing for verification that the system selected the right items. What now takes several minutes and immense cognitive effort could instead be completed with natural speech and minimal effort in far less time.

I hear from colleagues all the time that they are overwhelmed when using EHRs with too many buttons, menus, and too much clicking around. They feel disconnected from the patient sitting in their office, and that the computer screen has intruded in that relationship. Perhaps a natural language voice recognition system like Alexa is one step closer toward a more satisfying and connected experience for everyone.

The Four Key Features of EHR Integration: Move Beyond “Data Dumping”

A rapidly growing number of health innovations such as mobile apps, diagnostic tools, and sensors are being developed with a focus on enabling health and wellness outside of the traditional medical office visit. As Eric Topol points out in his new book, The Patient Will See You Now, many of these tools will help people independently understand and manage their health. A long history of medical paternalism will be overturned as health information is returned to the individual and autonomy restored. This is a great trend.

However, we do not have to create an “either-or” dynamic where some health information is held by the healthcare system and other information by the individual. These new technologies will be maximally useful when they enable and facilitate a deeper, richer dialogue within the context of existing doctor-patient relationships. To achieve this more coherent and comprehensive healthcare, we need to bring together the patient, her digital health information from new sources, the doctor, and the EHR.

These concepts of interoperability and EHR integration are being widely recognized as crucial over the next few years in healthcare, as evidenced by the JASON Task Force’s recommendations and the formation of the Argonaut Project.

What concerns me as a practicing physician and informaticist is when I hear people discuss EHR integration as if it means only this:

Data Dump

This represents the idea of taking every single data point collected by mobile apps, sensors, and other tools and passing it all straight through into the EHR. I am always reminded of one of my favorite scenes from I Love Lucy, but instead of desperately trying to stuff chocolates into my cheeks and clothing, the medical conveyer belt could make physicians unable to keep up with massive quantities of inbound data from patients.

I Love Lucy

I think it is this sentiment that has led to articles like this one posted in August 2014, saying that “doctors don’t care about your FitBit data.”

Doctors Dont Care About FitBit Data

I disagree. The truth is that I might care about your FitBit data, depending on the clinical situation, the context of that data, and the way in which it is presented to me. I just don’t know yet. I think it is very likely that there will be many of these situations where your activity tracker data matters a lot! We can do better. We can use new information sources when they are helpful and add value by weaving together a comprehensive view of a patient’s health information that facilitates better conversations between individuals and their doctors, and thus better care. This means that patient-generated data cannot be siloed off from the EHR. It instead must be incorporated into clinical workflows as part of the EHR. To achieve this vision of a more complete EHR integration, I think we need the following:

Four Key Features of EHR Integration

1: Discrete data points: I know, I know. Didn’t I just say we don’t want this? I actually believe we still do want access to discrete data. It just cannot be the beginning and then end of integration. Also, this refers not just to data coming in to an EHR from outside, but clinical data flowing out from an EHR to an app or analytic tool, such as your medication list, medical history, or recent hemoglobin A1c values.

2: Analytics and decision support: We need intelligent rules, filters, and analytics to help route information at the right time to the right person and right place. These rules will work best if they can use data from inside the EHR along with these new, patient-generated data sources.

3: App and workflow integration: Talented and innovative software developers and others are creating new ways of presenting information, such as disease-specific data visualizations. We need to make it easy for physicians to access these within the context of their daily work in the EHR. Physicians are not going to launch and log-on to their EHR and three different applications to compare data, no matter how snazzy and how much media buzz your new app has. Moreover, we should be able to do clinical documentation, make a therapy change, or order further diagnostic testing from within the confines of a new tool and have that documentation, prescription, or lab “order” feed back into our EHR for action. This will keep your medical chart and health record more comprehensive and easier to follow, with less information scattered around different places.

4: Communications integration: Finally, with all of this information passing back and forth, each system is going to be capable of sending and receiving messages between the doctor, patient, family members, and other care team members. Nobody will want to log-on to every individual account to check messages. So, we need to be able to intelligently integrate and route messages so that each person can send and receive messages from the “hub” application that makes most sense to them.

At the UCSF Center for Digital Health Innovation, we are excited to be working toward this vision of comprehensive, workflow-driven EHR integration.

(This post is based on a talk I gave at the Diabetes Technology Meeting in Bethesda, Maryland in November 2014.)

“But who is going to pay for it?!” — New Medicare Billing Codes for 2015 Include Remote Chronic Disease Management

“But who is going to pay for it?!”
This has been the common refrain for years. The world of diabetes care experienced this dilemma relatively early-on, as some of the earliest digital health tools were in the diabetes field. When home glucose monitoring became easier and more ubiquitous, and then continuous, people with diabetes were all of a sudden collecting loads of data at home that might dramatically impact their care… and then waiting 3 months to come in to the office to discuss that data. I am asked this question all the time about the startup company I advise, Tidepool, because Tidepool facilitates better and easier remote diabetes care.
It is not just diabetes. In general, there has been more hype and excitement over digital health than impact in clinical practice. A significant reason is the mismatch between payment models and digital health use cases. We still largely live in a fee-for-service world, where we are paid to provide care during a “face to face” office visit and everything is measured by having a “billable encounter.” Most digital health tools, by bringing platforms, apps, sensors, devices, and analytics onto mobile and onto the consumer at home or at work, facilitate care happening outside of my exam room. This does not generate a “billable encounter” and there is no “face to face” office visit.
I don’t think I’m revealing anything new here by saying that it has been beyond a tough sell getting the healthcare system to implement digital health innovations in a fee-for-service environment. How enticing is it to anybody to do a lot of work for free? Doctors do it, but begrudgingly and in small batches.
As for Tidepool, we’ve known that it would be a tough sell initially, but had faith that payment models would change and that we would be ready when they did. I’ve written before about how I’d like to see my future practice operate once payment models changed. And now they are continuing to do so.
Medicare now looks to be slowly facilitating change to align payment models with exciting new technologies. As many media outlets are reporting (see CNN Money, iHealthBeat, Modern Healthcare, mHealthNews), CMS has announced that it will add new telemedicine billing codes starting January 1, 2015 (the CMS document is here). Doctors will be able to start billing Medicare using the 99490 and 99091 CPT codes for providing non-face-to-face, remote care, for patients with chronic conditions. Medicare has never in the past paid for the provision of these services.
A huge caveat that, in my opinion will continue to stymie progress, is that Medicare will still require patients to be in rural areas for these payments.
But, this remains a step forward toward the holy grail of aligning payment models and incentives with new digital health technologies. Paying doctors to provide remote, non-face-to-face care for patients with chronic diseases is the right thing to do for patients and for the healthcare system. Digital health innovations that would sputter under current payment models may take flight once remote care is reimbursed.

What I Learned At Epic UGM… And Other Random Thoughts

Epic’s User Group Meeting (UGM) is a Healthcare Conference
The Epic EHR is so ingrained in healthcare now that the UGM conference is really a healthcare conference, not an IT conference. This was a conference where more than 10,000 healthcare professionals met to share best practices about how to run a healthcare organization and deliver care, and oh by the way, the tool you’re using is this software called Epic.

There were clearly dominant themes this year among the priorities of the healthcare organizations in attendance:
1— Population health and ACOs
2— Patient-______: patient-engagement, patient-centeredness, patient reported outcomes, patient collected data, patient portal, etc
3— Health information exchange
4— Capture and use of discrete data by physicians
5— E-visits and video visits to improve access (and maybe end the long reign of the office visit)
6— Algorithms and analytics, especially with combining of multiple data sources
7— Personalized medicine using genomic data and home-collected data alongside traditional clinical data

Epic Should Do SaaS
If I were Epic, I would develop a SaaS (Software as a Service) version (call it “EpicLite”) and cannibalize my own business from the bottom up. Epic is making some fantastic improvements to their software, but a major complaint you hear around the lunch tables at UGM is that no organization has the resources to implement all of Epic’s features and functions. Epic has made their software endlessly customizable in an attempt to please customers who asked them for such customization. But the end result is that we all bog ourselves down. I’d like to see Epic push back a bit more against what we all tell them we want, be bolder, and push out software to us all that just works out of the box. They can start with the “EpicLite” version and sell it to organizations less complex than the very large customers they most frequently serve now. Follow the 80/20 rule, pick the things that work best, and give it to people. I promise that we will complain, but then we will deal with it and save a lot of money and effort. They could then slowly move up-market with this SaaS version to sell it to the more complex and large customers in true Clayton Christiansen-esque disruptive innovation to disrupt their own core business. To analogize based on one of Christiansen’s examples, they won’t want to be selling mainframes in ten years when everyone wants PCs.

Open.Epic and Apple HealthKit Integration
I’ve heard a lot of skepticism about this effort over the past year because Epic has always had the reputation of being a very closed system, but Open.Epic should change that perception. I think that this is going to be a big deal. I believe that a major reason for the lack of success of many digital health apps is that they are silos and built in standalone fashion. Let’s face it: the EHR is the hub of clinical workflows and no matter how cool and important your app is, it is still just an add-on. Apps cannot be successful if they don’t fit into clinical workflows. Therefore, to be successful, the workflow of using an app needs to blend in with the use of the EHR. Epic publishing APIs through Open.Epic for people to connect apps in is a game-changer and will enable an entirely new generation of apps that bolt on alongside the EHR.

Similarly, I think the Epic and Apple Healthkit integration will catalyze many of the currently stagnant use cases for sensor and device data, as it will now easily feed into the clinical environment.

Random Thoughts and Impressive Numbers
I found myself wondering what Epic would be like if it were in Silicon Valley instead of Wisconsin. I don’t think it would be very Epic-like. You probably wouldn’t see them announcing next year’s product releases in the form of a musical.

It is hard to tell how much the healthcare system is shaping Epic’s software development plan versus the other way around. I’m sure it is some of both.

Epic is incredibly successful at energizing its customers and getting them to evangelize and espouse the virtues of their product for them. And we all pay to fly out to Wisconsin to do it! When I walked by it, their usability testing lab had a more than half-hour wait to get in and a line down the hallway.

54% of the US and 2.5% of the global population have an EpicCare chart. There were 5,000,000 Epic<—>Epic information exchanges in Aug 2014.