The health care system in this country has been undergoing a major change over the past ten years and the pace of change is accelerating. We are now at an inflection point and it will never be the same again. This post examines the external forces that are driving the change and highlights the potential and likely effects.
Over the past few years, the federal government has enacted a series of legislations and regulations related to Health IT that have created a profound long-term impact on the nation’s health care system. Some of the key laws are:
- HIPAA 1996: Although this law primarily focused on protecting health insurance coverage for workers and their families, it was the first shot aimed at increasing the efficiency of the nation’s health care system. It required the establishment of national standards for the use and dissemination of health care information, created a unique National Provider Identifier (NPI) enabling covered providers to participate in standard transactions, and laid the groundwork for strong security and privacy protections for patient health data.
- HITECH (as part of ARRA) 2009: This act proposes the meaningful use of interoperable electronic health records throughout the US health care delivery system as a critical national goal, with a financial incentive to providers and hospitals who can demonstrate that they have engaged in efforts to embrace this technology.
- ACA 2010: In addition to consumer protections, this act has a strong focus on improving the quality and lowering costs of health care services, including a Patient’s Bill of Rights, an emphasis on preventive services, and encouraging integrated health systems.
Taken together, this series of laws lays out a blueprint for health providers and organizations to follow. It strongly promotes the use of electronic records, interoperability, integrated care, patient empowerment and a focus on prevention, with the ultimate goal of driving down costs and improving the quality of care.
CMS Cost Reduction
As one of the largest payers in the industry, the Centers for Medicare and Medicaid Services (CMS) have a huge impact on the US health care system; even private insurers eventually tend to be consistent with CMS guidelines. In an effort to promote higher efficiency and reduce fraud within the health care system, CMS policies in recent years have been on a long-term path towards reduced reimbursements, increased documentation and stricter standards. As an example the recent introduction of the readmissions reduction program and associated penalties is forcing hospitals to put more focus on post-acute care and data interoperability for discharged patients.
Engaged Consumers (Patients)
At the end of the day, we’re all patients. Today’s consumers have unprecedented access to information (both accurate and misleading) about themselves and their conditions, thanks to Google, the world-wide web and a plethora of connected low-cost monitoring devices. There is an accelerating trend toward self-confidence, self-help and advocacy among patients in the US and all over the world. Tomorrow’s patients will be equal partners with their health providers in the planning and implementation of their treatment plans.
Software and hardware technology is making great strides in many areas of health care. Together these changes build on each other, creating an unprecedented climate of advancement in health technology.
Broadly, these innovations can be classified into a set of distinct groups:
- Cloud Computing: The increasing popularity of data center infrastructure and platforms as a service (IaaS/PaaS) has brought a new level of flexibility, scale and reduced cost to software applications that collect and analyze large-scale data sets. Advances in container and cluster management enable applications to run complex machine learning strategies on these massive data sets at a reasonable cost.
- Smart Devices: Smartphones are the true “personal computers” of our age; they are easily available, low-cost, always nearby, and almost ubiquitous even in less developed regions of the world. Any health technology for patient interaction, for example frequent mobile vision testing for patients with diabetes, can be quickly rolled out globally with ease, simply by turning it into an iPhone or Android app.
- Sensors: Powerful low-cost sensors - such as wearables, ingestibles and in-home devices - that can provide actionable, continuous, real-time data to health providers are becoming more common and will be deployed routinely for patient monitoring in the future.
- Biotech: Sensors, devices and algorithms in the fast-growing biotech industry continue to move forward. For example, an iPad-sized DNA sequencer can make this type of sequencing commonly available at low cost.
- Data: A massive focus on Big Data technologies and solutions has dominated the tech industry for the past few years, creating revolutionary techniques for handling data at scale. New open source software technologies for non-relational databases, data ingestion pipelines, map-reduce and other parallel processing algorithms, predictive analytics and unstructured data mining enable data collection and aggregation, analytics processing and visualization of results on large scale data streams in near real-time at a reasonable cost.
- Interoperability: As a key focus of the national health IT policy as articulated by the Office of the National Coordinator (ONC), the need for health data interchange among disparate health systems has created a slew of new technology solutions, including integration and interface engines, transport protocols such as the DIRECT project and data formats like HL7 CCD.
- Personalization: A key attribute of many of the new health technologies is personalized solutions and products; for example, applications that adjust to the user’s preferences, 3D-printing for custom manufacturing, medications that are specific to the patient’s DNA, and the potential uses of nanotechnology for a specific individual.
- Security and Privacy: In health care, more than in most other domains, the security and privacy of patient clinical data is extremely important, with enforcement and penalties encoded by the HIPAA Privacy Rule. An entire subset of the health technology industry is focused on products and services to help covered entities and business associates stay in compliance with these regulations.
In conjunction with the strong focus on improving health care in government and industry, in the past few years there has been a surge in venture capital investment in this domain. There is tremendous excitement in the tech community about health care opportunities, with lots of startups and increased innovation in this area.
Patient Health as a Service (PHaaS): The new Economic model
The continuous and glaring focus on reducing costs is driving the health care system towards a new economic model that generates revenue by focusing onkeeping the patient healthy and out of the system rather than by getting reimbursed for services rendered. Conceptually this is similar to providing regular maintenance for a car rather than services when it breaks down. The biggest advantage of this new model is that it aligns incentives much better between the health care system and the patient.
Some of the characteristics of this cost-conscious model are the following:
- A focus on prevention rather than episodic services
- Concierge health plans, such as a monthly fee for unlimited primary care
- Increased financial incentives for preventive services, screenings, improved nutrition and regular exercise
- A focus on early detection, increased follow-up, and monitoring of chronic conditions to reduce ER visits and hospital admissions
- Increased cost transparency and consumer choice for medical services
- Remote care: Telemedicine, remote dispensing, and other similar approaches
- Continuous monitoring: Sensor data, devices, smartphone apps
- Pushing services down the provider cost chain: PAs, NPs, increased pharmacy services, offshore support, reliance on automation
Automation and AI: The Robot will see you now
Hardware and software automation is still in its infancy within the health care system, but with the increased focus on reducing costs we are likely to see a sweeping change in the future similar to manufacturing automation using industrial robots in the 1980s and 1990s.
Improvements in health care automation technology are already under way in many areas:
- Robot-assisted surgery (especially microsurgery)
- Ingestible sensors, smart pills and bottles
- Cheap, rapid, easily-accessible lab results (like a blood test)
- Electronic, semantic patient data for demographic, clinical and fitness parameters
- AI-assisted diagnosis and measurement
The Big Data Revolution: Measure Everything!
New technology improvements have made it possible to collect, aggregate, analyze and visualize staggeringly large-scale data in near-real time at a reasonable cost. These new technologies will revolutionize health care both at a macro and a micro level.
At a macro level, it will enable public health systems and health organizations to manage the overall health of their entire patient population, looking for trends and automatically highlighting potential patient issues for proactive intervention.
At a micro level, it will be possible to continuously track an individual patient’s condition, treatment and progress remotely, and compare those parameters with nominal values against the backdrop of the entire population of similar patients.
The Big Data technologies available now for data storage and algorithmic analysis enable researchers to track and analyze exponentially larger data sets for treatment and research; so it is entirely possible to test a new theory against the entire data set, rather than extrapolate from a statistical sample of the population. This could change the way medical science researches diseases and their cures. Machine learning and predictive analytics based on this data could lead to unexpected discoveries.
Finally, automation and data analytics taken together enable physician scientists to make a systematic, objective evaluation of treatments and medications; AI assistance based on these evaluations can be used to enhance and support the traditional approach of physician experience and intuition, as venture capitalist Vinod Khosla argues in his influential paper: 20-percent doctor included.
Patient-centered Care System
Another likely outcome is a shift in focus towards a health care system that proactively reaches out and engages with patients on their terms: wherever they are and whenever they are available, as opposed to the current model where patients engage with health providers at specific locations at specified times.
A patient-centered care system will look very different from the current status quo:
- The health system will proactively reach out to the patient wherever they are, through a variety of devices and technologies
- The emphasis will be on localized services: remote care, home health, telemedicine, local pharmacies, ingestible sensors, monitoring devices
- An increased focus on compliance, post-acute care, and managing chronic conditions
- A holistic integrated approach to patient health: health maintenance, not pay per service, as mentioned earlier
- Continuous monitoring with automatic follow-up, similar to a home alarm system
- Personalized medication (genome- and symptom-specific) and customized delivery through a combination of in-person, mobile and automated services
- A focus on what is “normal” for this patient? For example, diabetes may turn out to be many different diseases, all of which have the same symptom of blood sugar issues
Integration: Interoperability and the Care Team
As the concepts of Meaningful Use and Health Information Exchange (HIE) take hold across disparate components of the health care system at all levels, widespread integration will make it possible to provide patient data visibility across the entire care team, including patient caregivers.
This broad-based integration will have a big impact not only on how care is provided, but also on the health organizations themselves - leading to the formation of vertically integrated health care systems or groups (ACOs) comprised of hospitals, emergency rooms, ambulatory clinics, labs, home health providers, pharmacies and even payers. These integrated organizations can not only track all aspects of the patient’s health but can combine that data with provider workflow and financials as well. As an example, coordinated care organizations in Oregon have been transforming the health care system in that state.
With the increased prevalence of deep cost consciousness, integrated care organizations and bundled payments, we are likely to see a broad consolidation of many small players into a few large entities that have the resources to deal with the new financial, technology, data and interoperability requirements.
Global Access to Healthcare
This to me is the most exciting development of all. The combination of algorithmic approaches, diagnostic support, telemedicine and low-cost tests means that high-quality health care can be made uniformly available in economically-challenged and isolated locations of the world.
We are already entering a phase where, in the near future, practically everyone will have access to a smartphone; these powerful computing devices are low-cost, easily accessible and nearly ubiquitous. At the same time, Cloud technologies with economies of scale are making computing and storage power progressively cheaper. Taken together, this will make it economically possible to provide prevention and monitoring health technologies to everyone, a true global democratization of health care.
The Future is Now
All of the effects listed above are interdependent and build on each other, which will lead to dramatic sweeping changes in health care within the next decade. The biggest hope is that it will lead simultaneously to better patient outcomes andreduced health care costs.
This type of industry-wide change is not new. The automation and optimization wave that swept through manufacturing in the late-80s and early-90s revolutionized how physical products are made; similarly ERP systems transformed how organizations collect, manage and interpret data from their business activities.
These types of changes not only impact and transform entire industries and economies, but they change the way we live. The current sweeping changes in health care have the potential to do just that on a global scale.