Up to a couple of years ago, healthcare technology executives advocating the use of managed services, cloud, and other off-premises uses of data were mavericks. Management told us that cloud presented too much risk. One leading doctor in a prestigious institution said to me, “I would rather see my institution’s name on the front page of the New York Times because of a data breach on premise. Seeing adverse publicity because we released our data to the cloud and a bad thing happened will destroy our reputation.” Management insisted that we keep the data under the control of our institutions by keeping it in a data center. In the age of health information exchange and value-based medicine, the rising cost of that infrastructure paradigm is no longer feasible. Today we hear healthcare CIOs telling us that the preference for solutions is cloud first, and on-premises solutions must be justified: Cloud-based solutions are becoming the default choice.
This seismic shift is due to several factors:
Building and operating data centers is complex, expensive, and resource-intensive.
The network is fast and strong.
The removal of capital costs of hardware and infrastructure from budgets releases a great deal of capital for other more pressing needs.
The enactment of the HIPAA Omnibus rule, finalized in January 2013 and effective as of September of the same year, forces the vendor community to accept the responsibility for PHI and thus changed the paradigm around the feeling of regulatory protection granted to healthcare organizations when contemplating a "loss of control" of their data that was feared as they anticipated moving functions and capabilities to the cloud (http://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus/).
Artificial intelligence’s (AI's) reputation is having a significant reputational uplift. We have an Academy Award-nominated film, The Imitation Game ( http://theimitationgamemovie.com/), about arguably the father of AI, or even modern computing, that advocates passionately for the power of AI. We have IBM founding a new division, "Watson," based on the premise that cognitive computing can in fact be a profitable cloud-based business service that IBM offers.
Looking at my own domain of punditry "software for healthcare," I have to ask what, if anything, does all of this AI thaw means to the technology, operational, financial, and marketing executives in Forrester’s client base? To answer that we have to look what products or solutions have entered the marketplace that are capable of changing the core models of healthcare.
After over a year of research, we are capable of saying that cognitive computing is important to healthcare and is more than a science project. What we have found is that there is a divide between big health care business and smaller ones. The big businesses, the ones that are true centers of excellence in the provider, payer, and drug research arena are using the advances of cognitive computing machine learning and big data to innovate in fundamental ways.
Automation drove weavers from their looms in the industrial revolution. The Internet’s and tools facilitated the movement of manufacturing process for most software from the high priced markets in the US to India. So too the digitalization of health records combined with the insight that data yields and embed into work flow engines of care delivery will radically change the healthcare ecosystem.
Since I joined Forrester research, in the fall of 2013, my perceptions of what drives change has changed. I thought that the socio-political forces were driving software to change healthcare. Now I think software is driving changes to the socio-economic fabric. While we pundits are busy noticing:
EMRs being implemented.
Master patient indexes are rolling out.
Capabilities shifting to mobile.
Insurance companies rolling out tools to better track and communicating with consumers.
Startups forging new methods and business models to engage patients.
Large consumer companies making moves to gain access to our healthcare data by offering us free tracking tools.
Telehealth encounters becoming increasingly important to the administration of care.
Big data and cognitive computing changing our understanding of epidemiology and personalized care decisions.
As the healthcare industry depends increasingly on software to drive the change to value-based care from transaction-based compensation, the future of global healthcare is increasingly bound to the technology that will deliver:
Integration solutions that will allow stakeholders to share information about populations and individuals across the ecosystem.
Cloud-based solutions that will allow services to reach scale without the need for the contemporary care system or health insurance vendor to grow infrastructure.
Branded medical services, such as oncology advice engines that allow a regional cancer specialist to deliver a better quality of care because she will have, for example, access to the most advanced protocols for her patients via smart software powered by companies such as IBM but with the built-in expertise of our great medical centers such as Memorial Sloan Kettering Cancer Center.
The Rise of consumer health repositories will work against info sharing in the eco-system - crossing the divide between protected data owned by covered entities, under various global privacy laws such as HIPAA, and consumer controled data subject to the corporate policy of various business entites such as Microsoft, Apple, Samsung, and others will remain dificualt and cumbersome.
The Ebola outbreak serves as a portrait of the fact that the health systems of the globe must be radically interconnected in order to ensure that global outbreaks like this have a chance of being contained. We are not in the 19th century where the massive migrations of populations took place using slow-moving transport and thus where the incubation periods of most diseases would have in all likelihood passed before a person approached a border.
Today I can be infected by a disease, and within hours be on a plane that crosses the world. Traditional public health precautions of quarantining the sick will not necessarily be effective. And so we must think though a better manner of managing what is fast becoming a continental pandemic and could easily become a global pandemic.
The picture above is from the emergency room entrance at Mt. Sinai Hospital on the corner of 100th street and Madison Ave. in Manhattan.
For those of us who write and think about the future of healthcare, the story of rapid and systemic change rocking the healthcare system is a recurrent theme. We usually point to the regulatory environment as the source of change. Laws like the Affordable Care Act and the HITECH Act are such glaring disruptive forces, but what empowers these regulations to succeed? Perhaps the deepest cause of change affecting healthcare, and the most disruptive force, is the digitalization of our clinical records. As we continue to switch to electronic charts, this force of the vast data being collected becomes increasingly obvious. One-fifth of the world’s data is purported to be administrative and clinical medical records. Recording medical observations, lab results, diagnoses, and the orders that care professionals make in binary form is a game-changer.
Workflows are dramatically altered because caregivers spend so much of their time using the system to record clinical facts and must balance these record-keeping responsibilities with the more traditional bedside skills. They have access to more facts more easily than before, which allows them to make better judgments. The increasing ability of caregivers to see what their colleagues are doing, or have done, across institutional boundaries is allowing for better coordination of care. The use of clinical data for research into what works and what is efficient is becoming pervasive. This research is conducted by combining records from several institutions and having the quality committees of individual institutions look at the history of care within their institutions to enhance the ways in which they create the institutional standards of care. The data represents a vast resource of evidence that allows great innovation.
As per the FDA press release "the diverse and rapidly developing industry of health information technology requires a thoughtful, flexible approach,” said HHS Secretary Kathleen Sebelius. “This proposed strategy is designed to promote innovation and provide technology to consumers and health care providers while maintaining patient safety. Innovative health IT products present tremendous potential benefits, including: greater prevention of medical errors; reductions in unnecessary tests; increased patient engagement; and faster identifications of and response to public health threats and emergencies. However, if health IT products are not designed, implemented or maintained properly, they can pose varying degrees of risk to the patients who use them. The safety of health IT relies not only on how a product is designed and developed, but on how it is customized, implemented, integrated and used"
Everybody at HIMSS, the annual health care IT conference (http://www.himssconference.org/) is telling the same story. Regulations and the need to reduce the burden of healthcare costs on the American economy is driving innovation to more efficient models of care delivery. The engine behind this drive is a changing model of incentives that reward quality and punish uncoordinated poor-quality care.
Mark Bertolini, CEO of Aetna (HIMSS keynote speaker)
There is a great deal of wildly divergent and sometimes seemingly fabricated information on the size of the US and global healthcare market. For 2014, here are the numbers that I will be using, with my sources, and assumptions and notes.1
But what are the trends, and what are the best practices?
We are hearing from all the pharma stakeholders four stories that are driving the questions that are being asked of the data:
Pharma needs to get away from its focus on molecules and pivot to a holistic view of disease. As per a senior IT manager at a major pharma in a meeting with me last week: "We have to deliver whole solutions, and not just pills."
Pharma needs to understand prescribing behavior in the formulary and in the physician's office better in order to influence it and thus drive sales. As per a senior marketing manager from a meeting recently: "In the old world, we just sprayed and prayed," meaning that the marketing campaigns aimed at the physician did not discriminate as to who that physician was.
Genomic-based drugs are driving changes though the amounts and types of data that the industry must manage.