“An unsustainable system must either change or break down"
Open Data and the Internet of Everything are changing every market and sector, allowing information to be created, processed and shared faster than ever before. But is this absolute freedom always a good thing? How will it affect new medical ventures? Jerry Kolosky, a renowned e-Health expert and HITC consultant whose line of work has made him team up with firms like WebMD, SigmaCare and Panasonic, shares his thoughts on this and other matters.
SH.- For some years now, self-diagnosis has become a big problem. Many patients Google their symptoms, often exaggerating them, and arrive to the doctor with a fabricated medical record. This is quite a paradox, since one of the pillars of e-Health/m-Health is the use of information. How can this misuse of information be prevented?
K - Emerging healthcare networks in support of patient self-management and “care-in-place” will generate vast quantities of both objective and subjective information, mediated by data analytics and triage decision-making at the intersection of the clinical decision-support network and human intelligence. To the extent the patient has begun to acquire knowledge around their specific condition - from sources both reliable and less so - is on balance a positive, though bringing with it a new set of risks.
On the plus side, a deep level of patient engagement in the management of their own health is both desirable and inevitable, given the runaway cost of healthcare in an era of aging global populations. Of course, medical information can be misunderstood or misused. For this reason, and many others, information technology can and should only augment - and never replace - expert clinical judgment. On the other hand, the same network can be used to deliver high-quality, relevant, actionable, condition-specific, multi-media-enabled patient educational content to the point of need - thus opening new possibilities that are, on balance, amazingly positive.
SH.- Many new Start-ups appear every day, bringing new applications and solutions into the sector. However, not all of these technologies and devices can be regulated and approved by the proper administrations before reaching the clinics, or before they start being used by professionals. What is your stance on this matter?
JK - In the United States, all medical devices must pass the regulatory process required by the FDA, i.e. Food & Drug Administration. Within the FDA, the Center for Devices and Radiological Health (CDRH) regulates companies that manufacture, label, or import any medical device offered for sale in the US. To the extent to which these devices generate, manage, or otherwise touch protected patient health information (PHI), they’re also subject to the stipulations of HIPAA (the Health Insurance Portability and Accountability Act). The HIPAA privacy rules protect the privacy and security of individually identifiable health information.
In other parts of the world - with radically different institutional structures, and extreme needs - more daring approaches to healthcare innovation can be employed. For instance, a California-based technology company called "Not Impossible Labs” is utilizing crowd-sourcing and other fascinating techniques to enable high-tech devices to reach people in dire need - all over the world. For instance, Not Impossible is using 3D printing to provide artificial hands and arms for amputees in war-torn South Sudan. In November of 2013, Not Impossible printed a prosthetic hand that allowed a Sudanese teenager to feed himself for the first time in two years.
SH.- Since we just spoke about start-ups, the increased offer of incubation programs and benefits has allowed more innovators to develop and present their ideas. What advice would you give to these young new talents, if they want to succeed in the field of e-Health? Will they have an easy time against their competitors, or will competition be fierce?
JK - In my view, the inherent local delivery of care, fragmentation of healthcare stakeholder interests, clinical rather than business perspective of providers - and many other factors - render healthcare particularly conservative in respect to change in general and the adoption of information technology in particular. The Silicon Valley notion of “creative destruction” via innovation - the notion of a catalyst suddenly changing “everything" - simply does not apply to healthcare in the way it has broadly to society. Facebook stands as a prime example of catalytic global innovation at a societal level. And, we’ve seen progressive waves of the digital revolution wash over and change many other industries - some with profoundly transformative impact, such as with the music, publishing, and retail sectors. And yet, healthcare remains singularly resistant to transformation via IT.
The paradox is this: hungry, nimble young startups are ideally positioned to drive healthcare innovation, but the inherent conservatism of the industry is such that large organizations are trusted for their longevity, stability, and ability to deploy & support massive, stable solutions for the long haul. And yet they are slower to innovate, and reluctant to deploy transformative solutions that undermine hard-fought legacy market positions.
The rise of a connected healthcare ecosystem begins to resolve this paradox. Large companies are well-position to build and support a device-agnostic, analytics-driven healthcare ecosystem - and to support the standards and workflow processes required to facilitate true interoperability - while tiny innovators are free to create the edge devices, such as wearable monitors, communications devices, and analytical algorithms that facilitate the optimization of the user experience and power the analytic engines that drive the network.
SH.- Does the American healthcare system give the same opportunities to up-and-coming enterprises, or does it tend to favor already established ones?
JK - While legacy players with strong market positions in the areas of health information management, coding and reimbursement, and electronic medical records technologies have obvious advantages, the new era of connected care is creating wide open frontiers of new opportunity.
Start with this premise: inevitably, an unsustainable system must either change, or break down. On a global scale, we’re facing the inexorable tectonics of demography. In the US, for instance, 10,000 "baby boomers” on average will reach age 65 each and every day for the next 20 years. On balance, 80% of those retirees suffer from one or more chronic conditions - and the management of chronic conditions is consuming nearly 75% of the US healthcare spend. With total healthcare expenditures now exceeded 17% of US GPD, change is inevitable.
And thus, the pressing need for innovative models of care delivery, value-based reimbursement, payer-provider alliances, and patient self-managment. Technology is one of the keys to making this all happen. And, indeed, solving the healthcare crisis is one of the critical policy challenges of our time.
SH,- eHealth strives to put the patients as the axis of healthcare, the most important spot, but today´s traditional healthcare, affected by crisis, seems to only worry about reducing costs. How can we balance this situation?
JK - The challenge here is the alignment of incentives. On a global basis, widely divergent social and cultural traditions have given rise to various modes of reimbursement of healthcare services. In the United States, by way of example, the “fee for service” model upon which much of our healthcare system has historically operated has reinforced the frequency of procedures rendered - not the quality of outcomes nor the cost efficiency of service delivery.
An emerging set of alternative models, collectively known as “Accountable Care,” has begun to take root and grow here in the United States. The intent of Accountable Care is to incentivize clinical quality while simultaneously fostering cost efficiency by promoting voluntary provider / payer alliances in which financial savings for the delivery of care to defined populations are shared on the basis of objective outcome metrics.
Given the legacy and power of the fee-for-service model, a shift toward Accountable Care is proving to be a slow and laborious process driven by both the carrot of financial incentive and the stick of financial penalty. For instance, provisions within the Affordable Care Act (aka ObamaCare) established the Hospital Readmissions Reduction Program which reduces payments to hospitals with "excess readmissions” of discharged patients with specific conditions.
Philosophically, the intent of Accountable Care is to gradually shift the delivery of appropriate, effective care into the setting of lowest possible acuity - and to facilitate prevention rather than intervention. To do so, requires the secure capture, management, and delivery of actionable healthcare information across multiple care settings, and the provisioning of tools that enable patient self-management. This model is being described with new terms such as care-in-place, connected care, and eHealth.
What all these concepts have in common is the use of networked technologies to provide clinical decision support and proactive care management. Technology overlays to proven clinical pathways - such as those blazed by visiting nurses within the home - will enable the care network of the future, thus bridging the gap between the intent of healthcare reform. and the practical challenges of the delivery of care-in-place.
SH.- Those who have worked with you define you as a remarkable technologist in IT related to health, with a visionary focus for healthcare management. How would you define your work to our readers?
JK - My life’s mission is to facilitate, to the best of my ability, the creation of an intelligent, adaptive, technology-enabled healthcare ecosystem that can continuously evolve to meet the challenges of caring for aging societies and enable global population health management.
SH.- As a renown HIT expert, you are fully devoted to your projects as well as being engaged in the entire HIT sector. You were also exploring the possibilities of IT in healthcare and medicine through a number of web-based healthcare startups, in areas such as electronic prescribing startups, years before other firms considered the Internet a viable solution. And how were the seeds of such ideas planted?
JK - Given enough time, one begins to observe patterns. So, for instance, in the United States during the mid-2000’s there was a scrum of entrepreneurial and regulatory activity around an emerging healthcare technology known as electronic prescribing or e-Prescribing. And at the moment of general acceptance of this new technology, it became an expected - and in fact, required - feature of a broader solution of known as the electronic medical record (EMR).
And a similar dynamic is at play today with a technology known as Remote Patient Monitoring (RPM) - that is, technologies that capture relevant biometric information at a distance for the purpose of proactive chronic disease management. In my opinion, that technology will soon become an expected feature of a payer-sponsored risk management solution.
So, the challenge is: to observe patterns over time and envision how all the pieces of the puzzle will fit together - in four dimensions.
SH.- Several technology & medical experts praise your knowledge and your out-of-the-box style of tackling new problems and finding new ways to improve healthcare. In your opinion, what are the new paths to be explored, if one wishes to remain as a strategic leader in the HIT sector?
JK - As I’ve outlined here, my focus is centered on the creation of a technology-enabled healthcare ecosystem, which is, in the language of Silicon Valley, a “platform."
A healthcare service delivery platform can enable innovative modes of healthcare delivery supported by secure, networked technologies, a flexible legal framework, user experience optimization, and technical / workflow interoperability across the continuum-of-care.
Integrated, multi-setting subacute eldercare represents a microcosm in which a device-agnostic, coordinated-care platform can both serve as a model for system-wide, population health management and catalyze the ongoing evolution of value-based reimbursement modalities in the coming age of Accountable Care.
ne of my key assumptions is the deployment of innovative healthcare information technologies must occur in an incremental, adaptive fashion, with each stage building on the prior in a manner that maps to the appetite for uptake by human, regulatory, and technical systems. Thus, Remote Patient Monitoring (RPM) - now in the spotlight due to hospital readmission avoidance penalties - is a necessary first step toward integrated care management under Accountable Care payment models
Optimization of the user experience (for all user classes in the care ecosystem) is a necessary prerequisite for rapid adoption and ongoing utilization. Looking forward, acceptance by physicians assumes mediation by a clinical call center - that is, fixed or virtual environments in which nurses make triage decisions based upon objective and subjective data triggers, monitor care plans, and manage voice, video, and text-based communications. All forms of “clinical decision support” (an emergent property of the ecosystem itself) must augment though not compel treatment choice and physician autonomy.
As such a system matures, data analytics can help identify "at risk" cohorts, rationalize technology deployments on a cost / benefit basis, link clinical outcomes to quality-based reimbursement metrics, monitor service utilization, and support efficient transitions of care.
Thank you for this opportunity,