The 2022 FHIR Implementation Guide is one way of responding to federal regulations to tame information blocking.
With data collection top of mind among healthcare executives these days, Carequality is making its mark as an interoperability framework enabling nationwide care coordination. One of the EHR industry’s big guns, Epic, chose to implement much of its data exchange with providers running other EHRs through the platform.
Unlike specific networks created to facilitate health data exchange, such as the CommonWell Health Alliance and eHealth Exchange, the framework approach of Carequality allows any two participating providers to exchange data without going through an intermediate network. In that sense, Carequality is similar to the set of protocols that allow the internet to function, rather than a typical web site or service. And like other interoperability arrangements, it has seen a dramatic increase in use as a result of the pandemic.
Alan Swenson, Carequality’s executive director, recently sat down (virtually) with HealthLeaders to talk about the network’s future. He spoke of plans this year to require participants to allow patients to access the data being exchanged via the Carequality framework, the federal government’s information blocking regulations, and other topics.
This Q&A has been lightly edited for brevity and clarity.
Alan Swenson, executive director of Carequality. Photo courtesy Carequality.
HealthLeaders: What report card score do you give the industry for responding to the information blocking regulation for 2021?
Alan Swenson: The large health IT vendors that are certified generally understand what's required of them. The HIEs I would say pretty well understand what's required of them. They probably are the ones that understand it the most. The ones that I'm the most concerned about are the providers.
In my experience, very few providers know anything about information blocking unless they are super users, those that take the work of Carequality or are involved in some of the other standards, bodies and organizations, beyond just being a provider. The idea that providers are going to be held accountable for information blocking, most providers have no clue what information blocking even is, let alone the implications of it. And we're going to see, as soon as we get some enforcement rules from [the Centers for Medicare & Medicaid Services], around enforcement for providers, we're probably going to have a pretty big “oh crap” moment, when all of a sudden providers see the first provider get penalized, and realize that this is something that I should have known about.
We see provider organizations who are actively exchanging huge volumes of records through Carequality with other providers. But if you call the office and ask them how to get medical records from one place to another, they'll give you a fax number, because the person you talked to at the office has no clue what Carequality is, or what interoperable data exchange is, and the information of how all of this works within the system doesn't get all the way down to the people the patients are talking to.
HL:Even when the penalty phase kicks in, and there are penalties that are known, providers may still be throwing up their hands and saying, “How can you penalize us?” We don't know how to solve the problem. And they may point back to the regulations themselves and say the regulations aren't good enough.
Swenson: One of the biggest concerns that I see is that your average provider doesn't know all of the different hops that their exchange goes through [with] Epic, or Athena, or Cerner, whatever EHR system. And the fact that that connects to Carequality or goes through CommonWell or through the eHealth Exchange or through the state or regional HIE or whatever, they may know the first hop, but then there's all these other hops along the way that for how data is actually transmitted that is completely behind the scenes and unknown to your average provider.
So when you have one provider who submits a claim of information blocking against another, or a patient has absolutely no clue how all of that works, it may have been completely out of the control of the provider. But the provider is always going to be the one who is blamed.
HL:The exchanges, such as Carequality, have knowledge of all these hops. You may have the double responsibility of better education, and maybe more innovation on figuring all this out.
Swenson: I completely agree. And there are definitely some things we're trying to do with better education. Again, we largely work with the vendors and the networks - not their end users, the providers.
HL: In 2021, Carequality’s push notifications workgroup finalized creation of a FHIR implementation guide for subscription-based push notifications to alert interested parties on a variety of clinical events. This implementation guide, which will be published in early 2022, will be a significant step forward to simplify event notifications for providers, payers, patients, and others, especially with continued focus on ADT notifications from the CMS Interoperability and Patient Access Final Rule. What role does this guide play?
Swenson: The biggest thing that we're going to see immediately with that implementation guide is access for patients. We have a policy requirement coming in Carequality that is going to require most of the organizations who participate in Carequality for treatment-based exchange today to also respond to patient requests via the FHIR-based exchange Implementation Guide. That’s a big starting point, because [according to] some of the federal regulations, certified EHRs have to have APIs available for patient access.
HL: What’s a typical scenario for this patient access? Are we talking about people using Apple Health on their mobile, things like that?
Swenson: Yeah, potentially, if Apple wanted to get connected and do that through Carequality. Today, Apple goes health system by health system, hospital by hospital, and connects with their FHIR APIs. Generally, that's done through the EHR vendors as the intermediary. They all have their various FHIR app stores that these patient apps can connect through.
We do have a number of patient apps and patient health record PHR systems that participate in Carequality today. What we will see as a larger benefit with this policy going in is that a patient app will be able to connect to Carequality and immediately exchange and get information from every health system that has their endpoints published in the Carequality directory, without any out-of-band pre-coordination or needing to go through [EHR] vendor app stores.
HL: Who is responsible for verifying that a records request was fulfilled? Does Carequality play a role in that?
Swenson: All requests for records through Carequality, at least today, are entirely synchronous transactions. So it's not somebody calling and asking, “Hey, can you send this to me through Carequality?” Rather, a system initiated a request, and within 30 seconds or so has gotten back either a response or an error message.
Carequality is not a network in the middle, so we don't actually see any of that traffic. We are a framework that provides the governance across the top of all of these implementers. We do have a number of required monthly, quarterly, and annual statistics reporting that come to us from the implementers. And part of the monthly reporting is that we do ensure that all implementers are successfully communicating between each other. We do have a process where we can help facilitate between implementers troubleshooting or a dispute resolution process if there's something larger going on there.
HL: Is that an area of much activity, this dispute resolution you mentioned?
Swenson: No, actually, which is great, and I think it’s a testament to everyone agreeing to the same framework, and the process of vetting organizations as they're applying to become implementers. The dispute resolution process has existed since the beginning, and has never actually been invoked. We certainly have had times where implementers have raised concerns about something another implementer is doing. But to date, all of those concerns have been able to be handled out of band without actually going into the formal dispute resolution process.
Network segmentation, strong authentication, and detecting unusual network behavior can slow attackers already inside your network
After a year of debilitating ransomware attacks and a presidential order partly in response, healthcare faces a cybersecurity call to action in 2022: Adopt the principles of zero trust.
According to NIST Special Publication 800-207, Zero Trust Architecture, published in August 2020 by the National Institute of Standards and Technology, zero trust security models assume that an attacker is present in the environment and that an enterprise-owned environment is no different—or no more trustworthy—than any non-enterprise-owned environment.
The importance of zero trust grew in 2021 as President Biden on May 12 signed Executive Order 14028, “Improving the Nation’s Cybersecurity,” to support US cybersecurity efforts and protect the critical infrastructure and federal government networks underlying the economy.
The executive order falls under the category of guidance, so there are no penalties for noncompliance. But one cybersecurity analyst points out that the guidance applies not just to government computing resources, but also to essential national technology infrastructures, including those operated by healthcare organizations.
“Zero trust is not a piece of technology,” says Joshua Magady, a senior consultant, section manager for the solutions architects team, and practice technical lead at the security consulting firm 1898 & Co. “It’s really a methodology.”
Joshua Magady, senior consultant, section manager for the solutions architects team, and practice technical lead at 1898 & Co. Photo courtesy 1898 & Co.
Building on the recognition that attackers are already likely inside the perimeters of enterprise networks, the zero trust methodology aims to slow or stop lateral movements by these attackers to compromise other enterprise assets, Magady says.
With each passing week, news headlines seem to bear out the assumption that the bad guys are already inside enterprise networks. Just this month, the Log4J vulnerability found in Apache Web servers demonstrates that compromises abound and won’t all be easily or quickly patched.
“Zero trust takes the stance that the adversary is already inside of your networks,” Magady says. “It’s about reducing your reliance on the security perimeter.”
Don’t think of zero trust as abandoning past approaches such as security perimeters, which still serve many useful purposes. Zero trust, when implemented well, reduces network administrators’ reliance on perimeters, and any implicit trust zones inside those perimeters now must face stronger scrutiny.
“Zero trust is really about reducing those implicit trust zones,” Magady says. “You can never remove it fully from a system, but you can reduce its scope and its size to a much smaller manageable area, where you can then have verified trust in there and not have to go with so much unverified trust.”
Prior to zero trust, people logging into computers basically authenticated once, and were then let into a network for which they were authorized.
“If you think about a castle, I dropped the drawbridge, I’m in, and now have access to all parts of the castle,” Magady says.
But in a zero-trust environment, just because that person has crossed the drawbridge doesn’t mean they have access to every location within the castle.
“I’m there watching you, monitoring you, and causing you to have to reauthenticate yourself,” Magady says.
Such monitoring can flag unusual behavior such as visitors logging in from unusual browsers, IP addresses, or geographic locations, and lock down critical network resources to ward off the actions of attackers.
Of course, that stronger authentication - how often it happens, where, and when – ends up getting weighed against the inconvenience it causes the people being reauthenticated. And zero trust isn’t exactly a new idea; many enterprise IT shops already implement aspects of it.
“Most organizations already have some elements of zero trust in their enterprise infrastructure or are on their way through implementation of information security and resiliency policies and best practices,” states Zero Trust Architecture.
“It’s a multi-year investment,” Magady says. “One of the things companies can do is to take their existing flat networks and segment them. It’s really grouping all of these security best practices that we’re already supposed to be doing, and then call it zero trust.”
Zero trust also requires enterprise security leaders to consider not just on-premises implementation of zero trust, but implementation in its cloud-based resources as well.
“Part of that zero-trust implementation is you’re moving the authentication closer to the service that’s being consumed,” Magady says. “If I had some financial application hosted in the cloud, I’ll put my authentication proxy right in front of it. You hit the proxy first and authenticate yourself, and then get passed on to the application.”
By contrast, some older security technologies such as virtual private networks (VPNs), permit access to all resources without the nuanced security considerations Magady described.
1898 & Co. is a business unit of Burns and MacDonald, a family of companies comprising 7,600 engineers, construction professionals, architects, technologists and scientists involved in many industries providing critical infrastructure in the US. Magady says healthcare organization IT infrastructure falls inside the definition of critical infrastructure, and healthcare organizations should take heed of Biden’s May 12 executive order.
And just because the May 12 EO doesn’t penalize healthcare organizations that don’t act, that doesn’t mean they’re off the hook with regulators. Magady points out that other government directives impose penalties on healthcare organizations for data breaches, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
“We’ve got to do better than what we’re currently doing, especially when it comes to critical infrastructure,” Magady says.
As such, fully implementing zero trust architectures in healthcare IT can definitely provide protection against ransomware attacks and the other threats IT faces in 2022.
“I may not be able to prevent it in its entirety, but I can substantially limit how effective it is,” he says.
Children’s Mercy Hospital of Kansas City is testing out a new decision support tool that addresses one of today’s biggest barriers to healthcare access.
Taking the next step in leveraging the social determinants of health (SDOH), a Kansas City health system has found a way to present patient-relevant data in its electronic health records.
The Envirome Web Service (EWS), described in a recent issue of the Journal of Biomedical Informatics, provides personalized SDOH data for each patient in the EHR. It securely geocodes patient addresses in real time to link their records with publicly available contextual data, while giving clinicians summaries of the data without interrupting their workflows with additional alerts.
The initial push was to build and deploy the service within Children's Mercy Hospital of Kansas City, but define it in a way that it could be implemented outside of the Missouri-based health system, according to Mark Hoffman, chief research information officer at Children's Mercy.
"We have a number of grant proposals that are under review that we hope will position us to get to the next round of organizations using this envirome technology," Hoffman says.
Mark Hoffman, chief research information officer, Children's Mercy Hospital of Kansas City. Photo Courtesy of Mark Hoffman.
The research involved surveys, focus groups, and a formal review by hospital staff. During 2020, 1,034 providers, including physicians, nurse practitioners, and residents, viewed the EWS, amounting to a total of 29,165 sessions.
The study also found that 6.1% of the providers chose to maintain the EWS in their custom workflows, logging more than 100 EWS sessions during the year.
"10% saw the data at a fairly frequent level, which I think is gratifying for this work," Hoffman says. "We were very pleasantly surprised with the level of adoption."
The researchers surveyed providers affiliated with the University of Missouri at Kansas City to gauge their interest in an EWS and about their general interest in SDOH, including community-level socioeconomic, food desert, air quality, and water quality data. Results from this survey helped guide the development of the initial EWS.
Researchers then designed a set of simulated patient profiles, designed to display examples of indicators in which the survey respondents were interested. These simulated profiles were brought before focus groups to evaluate and refine the content and design of the EWS.
"If you review the literature on social determinants, much of it focuses on asking the patient specific questions that provide individual-level social determinants,” Hoffman says. “And there's still a need for that, but most providers, especially during this period, where we're dealing with provider burnout, anything that asks them to do even more in their interactions with patients is a concern.”
"So our strategy is also keeping an eye on that provider burnout issue, where we want to present meaningful, useful, publicly available data at the time they need it, while the patient's with them, without requiring them to do any additional work."
At the same time, having the SDOH information readily available in the EHR helps clinicians have sensitive conversations with patients about these factors.
EWS complements but does not replace other SDOH tools and data. Some provider-patient conversations can make a difference in patient SDOH factors, such as compensating for living in a food desert. Other factors, such as air pollution or other environmental exposures near the patient's residence, more directly inform the work of public health colleagues of clinicians, Hoffman notes.
"Even if we can't influence those mitigations, we can at least offer some guidance to the patients," he says.
The initial implementation of EWS was created to work with the Cerner Millennium EHR.
"One of our goals is to work with one of our local partners that has an Epic EHR," Hoffman says. "We expect there will be some work, but intentionally use standards. For example, the authentication part of the process is based on the FHIR [Fast Healthcare Interoperability Resources] authentication standards, so we're not coupled to the Cerner authentication."
Before EWS can find a home in any of today’s EHR app stores, Hoffman's team wants to determine a broader deployment strategy with additional sites and organizations.
"Certainly, working with one or more of those [EHR] vendors would be one viable option that would scale nicely," Hoffman says.
The research team is also looking at a variety of options to sustain its efforts through various funding sources, he adds.
Other projects at Children's Mercy focus on aspects of SDOH, such as health equity issues. Ongoing research will determine how various SDOH efforts are influencing outcomes.
"There's always a constant set of follow-up research that can derive from those," Hoffman says.
"By taking steps like this to address the other half of health needs that are based on extrinsic factors, it really puts us in an excellent position" to complement Children's Mercy's already strong leadership in genomic medicine, Hoffman says.
Companies like IKS Health offer asynchronous virtual scribe services that integrate with various EHRs and population health management systems.
An asynchronous virtual scribe service that pairs physicians with a virtual physician partner is giving physicians an accurate, comprehensive clinical note for each patient visit, allowing them to return to the bedside interaction and clinical decision-making that inspired them to enter healthcare at the start.
IKS Health, which developed Scribble for healthcare, employs nearly 5,000 employees and focuses on business optimization supporting healthcare providers through every function of the patient visit. CEO and founder Sachin Gupta has been steering the company for 15 years.
In this Q&A, Gupta discusses the many changes and challenges for companies like his in an industry challenged to interoperate and prove its value during the ongoing pandemic.
HealthLeaders: From IKS’ perspective, what are the primary challenges physicians and clinical staff face today? What are your clients’ most prominent concerns? How does IKS address those concerns?
Sachin Gupta: The most immediate and concerning need is related to administrative burden and workforce shortages. Today, the industry is asking our clinical talent to do more than ever in less time, having piled administrative tasks onto our most discretionary workers (and) encumbering them when they should be connecting with and diagnosing patients. Additionally, new technologies that never accounted for how physicians naturally work and, worse, continue to layer on top of existing technology (are) adding more time to providers’ days to the detriment of the patients’ experience.
Therefore, it is no surprise that we face unprecedented levels of physician and clinical staff burnout. The gap between open jobs and the talent needed also continues to grow, with more open healthcare jobs in the US than there are workers to fill them by approximately half a million workers. We see this impacting our clients daily, where one organization operates understaffed by approximately 300 MAs every day.
When health providers can dedicate more time to their patients and less time on administrative chores, they are more likely to want to continue working and increase the number of patients they see, ultimately providing better clinical outcomes and improving their organizations’ bottom lines. (Companies like) IKS help organizations focus on the provider patient experience and identify tasks throughout their enterprise which can be streamlined, either with people, technology, or both. By standardizing, centralizing and, where possible, automating tasks to reduce administrative burden and enterprise waste, (companies like) IKS collect trends and analyze data that provide insights that improve everything from preventative care to collection rates. Not only does our work improve the physician experience, but it creates a smarter, scalable operating models, while enabling organizations to thrive.
HL: What do you think the answer is to improve the physician/patient relationship? How does improving back-end support drive better care?
Gupta: The simple answer is time and insight. We can declutter the in-office experience by determining which administrative tasks can be centralized and standardized.
(The goal is) localized and individualized care, where the patient-provider relationship is paramount and "human-in-the-loop" healthcare helps to unlock the value of technology, evaluated by a discerning expert, that ultimately takes insights and data and reinserts that into the physicians’ workflow for a more meaningful provider-patient relationship. Imagine the impact of an unencumbered physician, armed with meaningful information about the patient sitting in front of them.
HL: Has the pandemic impacted the services that IKS provides? Have your clients’ needs changed?
Gupta: The pandemic raised many questions about which business models work best in healthcare. Many have argued that shifting to value-based care sooner would have mitigated much of COVID-19’s impact on the industry, while others have realized that many fixed costs were negatively impacting their businesses. (Companies like IKS) help, shift healthcare organizations to variable cost models, which create flexibility during moments of significant change for businesses. During the height of the pandemic, as our clients’ number of visits significantly decreased, we were able to help clients rescale and ultimately grow their businesses in the months that followed.
The pandemic also forced organizations to operate outside of the four walls of their offices. Paired with the need for talent and stark competition for that talent, organizations are considering remote workers outside of their immediate geography. The result has been expansions of our scope within existing client organizations as well as an increase in new client conversations, because of our history of managing back-office and front-office services for our clients.
HL: The company is known first and foremost for scribe work. How important a service is scribe work these days?
Gupta: For us, scribe work is a meaningful component that addresses the much larger problem of physician documentation and coding. Virtual scribes, like Scribble, are important because they provide different value to different shareholders: patients gain intimacy, attention and quality of care; providers benefit from the "joy of practice" and increased compensation; for organizations it’s about access, revenue and engagement; for providers and self-ensured employers it’s about access, quality and cost of care.
With Scribble, we partner with clients to create accurate and comprehensive clinical notes for each patient visit, which enables a physician to interact with a patient anywhere, whether through telehealth, in the home or in the exam room. Digitizing this data has enabled digital health platforms to create pre-visit summaries for patients and further individualize the patient experience.
HL: Is this a difficult environment for provider systems to scale in? Can you share specific challenges that arise from scaling RCM and managing cost optimization?
Gupta: For a period of time, we may see fewer organizations with the ability to scale. However, we anticipate that organizations that have weathered the last 18 months well will want to scale and perhaps scale more aggressively than pre-COVID given that there will be many organizations looking to sell.
The biggest challenges for organizations looking to scale, outside of culture, come from standardizing technology, sharing data and standardizing processes. (Forward-thinking companies like IKS) are technology-agnostic, meaning our platform can scale as our clients improve operational and financial performance. Our technology seamlessly and securely integrates with existing platforms, and in many instances take the disparate systems within organizations and creates a standard data repository that serves as a single source for advanced analytics and insights. One of the many ways that we support our clients’ growth is through onboarding and inculcating new acquisitions into a standardized way of working.
By training and retaining back- and front-office teams, (we can help) to ensure that payment is collected at the time of service and that key data is captured correctly and timely. This important work relieves leadership from being burdened with identifying and rectifying these inefficiencies.
HL: Healthcare is experiencing unprecedented burnout. What is IKS’ answer to tackling burnout across physicians and staff?
Gupta: Pre-pandemic, burnout was already a looming threat in healthcare. Now, it’s more endemic than ever. Not only are staffs dealing with the most severe health crises of our time, but they are also navigating the looming pressures of day-to-day administrative work. Relieving healthcare workers’ administrative burdens and workflow bottlenecks offloads administrative work that leads to burnout and turnover, while also providing healthcare professionals with insight and expertise to enhance preventative care.
We believe the answer to burnout in healthcare is giving clinicians the time back in their day to care for patients, and the time back at night to be with their families, rather than writing their medical notes. Across our client organizations, rates of burnout are down, employee retention is up, patients are more satisfied, and clinical outcomes are improving.
HL: How does IKS work with clients to cut costs and improve quality of care?
Gupta: (Companies like) IKS enable provider enterprises to achieve clinical, financial, and operational excellence at scale by improving how our clients capture, collect, and protect revenue, while enabling optimal clinical and operational outcomes. (These companies help) clients grow revenue by accelerating patient collection and optimizing payer reimbursement; reducing operating expenses with virtual expertise and technology enabled workflows for greater efficiencies and patient access; and building enterprise value through an enablement platform that scales as our clients grow. By removing administrative bottlenecks, we can help restore the joy of practicing medicine – which improves patient satisfaction and enables value-based care.
HL: Interoperability, particularly in context of the 21st Century Cures Act, remains a big topic. How does IKS enable patient information to flow to and from the deliverers of healthcare?
Gupta: Unified data platforms can map to disparate EHRs, practice management systems, population health apps, clearinghouses, payer feeds and a host of other applications, allowing organizations to have a central place for clinical and financial data which can be used for reporting, analysis and other data-driven insights delivered via computational analysis or human BI experts. In addition, (these) platforms have features such as our Stacks solution, which converts unstructured data (e.g., consult notes, communications between practices) into structured data in the proper field of the EHR, allowing for more complete patient records and easier access for the practicing physician. Finally, for practices centralizing to a single EHR platform, the movement of existing clinical data is often an incomplete and time-consuming journey. Solutions like IKS combine field mapping technology with scalable, clinical, discernment, and expertise to safely migrate clinical data into the new EHR to make for a more complete medical record and safer healthcare.
HL: What is the health IT/health service industry not intensely focused on right now, that should get more attention?
Gupta: Right now, everyone is trying to develop technology that will help the industry take a giant leap forward. However, all these solutions rely on a healthcare environment that is standardized with consistent data quality and operating simplicity. That environment simply does not exist, and so unfortunately, what the industry is being sold is impossible to deliver. Resulting in being led back to the paradigm of healthcare tech that fails to deliver the promise on which it was sold, leading to further cynicism within the industry.
Additionally, much attention has been focused on advanced technology and AI promises, but the immediate wins that can be gained by eliminating inefficiencies and standardizing processes can bring immediate financial, clinical and emotional gains to our overburdened systems.
Where technology should focus is at the confluence of opportunity, practicality, and the connecting points within a patient's journey. So many health IT solutions are all clamoring for the same exam room space, or are otherwise so tied to a niche, that the responsibility for capturing value from those products relies strictly on the provider and their organization. Healthcare IT should take a less flashy, more holistic view of where to eliminate tasks within a provider’s workflow, decrease the tasks that the technology itself creates and increase the accountability that the solution assumes.
Indiana's largest health system is now using a FHIR app developed by the Indiana Health Information Exchange, providing emergency physicians with one-button data gathering for common symptoms.
As the oldest health information exchange in the United States, founded in 2004, the Indiana Health Information Exchange (IHIE) has provided a road map for other HIEs to follow. And as pandemics rage and physician burnout threatens to spiral out of control, the IHIE is more than just a pipeline in which for medical records to flow.
It operates the Indiana Network for Patient Care (INPC), the nation's largest interorganizational clinical data repository, with participation from more than 120 hospitals, 18,000 practices, and 50,000 providers. All told, it includes data on more than 17 million patients, at a time when interoperability remains a challenge nationwide.
The IHIE is also a member of the Strategic Health Information Exchange Collaborative, a national collaborative of more than 80 HIEs, which collectively serve 95% of the U.S. population.
Now, the IHIE has stepped up its game, with initiatives reaching into emergency departments and across states. IHIE president and CEO John Kansky recently spoke with HealthLeaders about its newest initiatives, and the resources that HIEs are bringing to bear during a time of pandemic. This transcript has been edited for clarity and brevity.
HealthLeaders: In the past, we got to see each state compete to build the best-looking HIE model, and then maybe others emulated it. To what extent has that actually come to pass?
John Kansky: We've moved on from the “let a bunch of flowers bloom,” and some states are going to figure out the best way to do an HIE and then we'll copy them, to a way for the successful models to be adopted and employed by the states whose models weren't as successful. We just had a pandemic, and states that had good health data utilities had good access to high quality information across their state regarding testing and hospitalizations, and states that didn't, didn't.
For any number of reasons, every state should have one of these things. That's where the discussion begins about the Consortium for State and Regional Interoperability (CSRI), which we joined earlier this year. The CSRI is six large, robust HIE organizations that started collaborating around the pandemic response, because the ONC and CDC were saying you need to have a lot of good data(and) it's too bad you can't make a national COVID dashboard. And we said that's true, we can't make a national COVID dashboard, but in three weeks we showed them a six-state COVID dashboard.
HL: What else does the CSRI do?
Kansky: One area is advocacy. We believe that the statewide health data utility model - and we believe every state should have one of these – (is) never going to happen if we don't work together to communicate and advocate for policy change.
HL: What about having a national HIE?
Kansky: That ship has sailed and it's not going to happen. The TEFCA (Trusted Exchange Framework and Common Agreement) is the federal government's answer to that question, a framework that will unify all of the existing efforts.
HL: Are efforts by vendors to replace HIEs going to take away the need for HIEs?
Kansky: HIEs have value, and as I stated earlier, I passionately believe that every state needs to have one and one that works well. Part of the challenge of the belief in the value of health information exchange is that we don't have good health information exchanges in every market and every state in the country, and no one would argue that point.
We're going to achieve national interoperability in this country the way we do a lot of things in America. We're going to try 14 things all at once, and we're going to create massive chaos. And we're going to end up with a system that turns out it works pretty darn well, even if it's more complicated than it needed to be.
HL: People like to compare it unfavorably to how smoothly the banking system works as one system.
Kansky: The financial system works. But if you really start peeling that onion, you will find that it took over 20 years for these complex networks and subnetworks to evolve. Whether people like that answer or not, I think if you let the market figure it out, as EHRs (electronic health records) are getting better at interoperability capabilities of their products, and the federal government is focusing more policy on advancing interoperability, and the HIEs are figuring out how to be more capable and more sustainable serving state governments as well as the healthcare system, I think we're on a decent path.
HL: So where in the 20-year curve are we?
Kansky (laughing): Year 22. Don't take me too literally on banking taking 20 years. Even in countries where they have nationalized healthcare, they have healthcare information exchange problems. So we will never be without challenges. it's so much better than it was even, I'll say, seven years ago, because before, we didn't have CareQuality, we didn't have Commonwell, we didn't have the eHealthExchange. There's a whole bunch of things that have matured and advanced.
HL: We still haven't run into many doctors' offices that have retired the fax machine.
Kansky: It's really hard to get people off of fax. Part of the reason is because EHR vendors have - I'm air quoting - solved the problem. I'm not criticizing them; I would have done the same thing. But a lot of faxing isn't via fax machine. It's faxed into their EHR platform, but not structured data. So where they've taken the pain out of it is the problem.
You have to make the alternative either more economical or more attractive. We used to think that if we just had all of the data on every patient from every source, and we put it in a giant repository, and every time a patient presented for care we made all of that information available to the clinician, that that would be HIE nirvana. And that was wrong. Because physicians do not want to know every darn thing about their patient. They need to know the things they need to know when they need to know them.
So we have created this app. It uses FHIR (Fast Healthcare Interoperability Resources). We have added a button for the top primary complaints of patients that the emergency physicians told us they encounter. The first one they asked us to do was chest pain. We work with the emergency physicians to say, when you have a chest pain patient, what information do you always pull together? "I always need to know what meds they're taking. I need to know their latest labs, I want to see their last EKG." And they just rattled off seven things that they wanted. So we built a button in their EHR that says chest pain. They get a patient that says they have chest pain, they push that button, and within like four clicks, and then five seconds, they have all the things on that list pulled from the health information exchange. Then they said, that's great, can you do more? Because we have these other six common primary complaints. So we built that.
HL: How widely deployed has that become?
Kansky: It's used by the largest health system in the state at all of their emergency departments statewide. We haven't deployed it yet beyond that first large customer. Now we need to implement it on another EHR platform.
New management targets social determinants of health integration.
The Idaho Health Data Exchange (IHDE) overcame an existential crisis by modernizing its patient matching technology and reducing data duplication to less than 1%.
In this process, IHDE matched more than 5.1 million messages while reducing patient data duplication rates by 94%, going from 18% to 1% on identity resolution, yielding more than 2.8 million searchable patient records, and improving care across the state.
The 10-year-old data exchange began its turnaround two years ago, when it asked Capital Health Associates to modernize the exchange, says Hans Kastensmith, the contracted executive director of IHDE and a managing partner at Capital Health Associates.
Building upon a base stack of technology from Orion Health, Capital Health Associates adopted 4medica's Big Data MPI [master-patient index] and 4medica's “1% as a Service“ to provide a real-time, transaction cloud-based service to quickly assess, normalize and cleanse mismatched patient identity data as a foundation for patient safety, data integrity, and interoperability.
IHDE had acquired grant money, including from Medicaid sources, as well as funding from the HITECH Act of 2009, which sunsets this year, to fund the transition, Kastensmith says.
"We came in, and I've had over 30 years’ experience in healthcare, especially in pioneering things like population health management and accountable care," he says. "We put in what we call a super stack of technologies that stretch all the way from social determinants of health to a brand new FHIR-based warehouse."
Many of the unclean data situations were more a product of misbehaving electronic health record software than of the clinics and practices using them, Kastensmith adds.
"You end up having to have a very spirited data quality program, where you conduct hand-to-hand conduct with some of the EMR vendors to get cleaner data out of them," he says.
Initial work on the enterprise master-patient index required having four or five people going through the duplicated records, trying to manually merge them, Kastensmith says.
Work accelerated when Laura Nixon, another consultant retained by IHDE as a product manager and a health IT consultant with the company Briljent, introduced Capital Health Associates to 4medica, Kastensmith says.
"When somebody steps up like that, I like to give the folks the authority to do it," he says.
4medica guaranteed that the cleaned data would reduce bad records to less than half a percent, and sustains that guarantee as the exchange continues to connect to more medical records, Kastensmith says.
"To us, for a relatively inexpensive service, we actually could let that program, and improvement of that particular set of data, go over to another company, which allowed us to turn our attention to building the stack and creating a much stronger company," he says.
4medica culls out the duplicate records through a set of scoring mechanisms, followed by machine learning that continues to get smarter about ferreting out duplicates over time, says Gregg Church, president of 4medica.
Church's company started out 23 years ago as one of the first data interoperability technologies on the internet to let physicians order labs and get test results back easily, Church says. Previous clients included health information exchanges in Michigan and New Jersey, he adds.
The data cleanup saved IHDE from possible insolvency and prepared it for the new challenges it faced, Kastensmith says.
"The business model that we came into, when we picked this company up, was not sustainable," he says. "Only 40 percent of its income came from its customers. And with the waning support that was coming from the HITECH Act, which is closing out this year, we lost 65 percent of our revenue. If we did not change our ways and be able to offer more goods and services and quality data to people like our insurers and ACOs, there was no way that we were going to bring revenue generation up to have a sustainable model for the company."
Kastensmith says the 4medica technology has paid for itself already.
"That doesn't include the rest of the stack that we've wrapped around it, which is quite an expensive proposition," he says. And more providers are now joining the HIE, which has 2,800 active participants, and the 501(c)3 corporation foresees breaking even by the end of 2022, he adds.
The focus now is on expanding the type of data IHDE is collecting. Toward that end, IHDE recently became the first HIE in the United States to sign a statewide license with Findhelp.org, formerly known as Aunt Bertha, which provides a free online tool to help the public find food assistance, help paying bills, and other free or reduced cost programs that factor into social determinants of health.
The new FHIR-based data warehouse will be able to ingest even more data as health insurers are required in 2022 by the Department of Health and Human Services to share data among themselves in the FHIR format, Kastensmith says.
"That opens up an opportunity for IHDE within our state and regionally to exchange that insurance data in a native FHIR format," he says.
The recently enacted HHS rules forbidding information blocking also play a role in this expansion of HIEs, he says, but hurdles remain.
"If there's no regulation around how much you can charge to get to that data, then we'll still have somewhat of a problem," he says.
Also on tap are stronger ties between HIEs on a regional basis, Kastensmith says.
"We formed a company called Beyond HIE recently with the Utah Health Information Network and Comagine Health, a quality improvement organization in about 15 states across the nation, as well as Orion Health," he says. "We're starting to set up regional and nationwide relationships with other HIEs to try to relieve some of the financial burden and regulatory burden for being able to deliver validated data sets. There is going to be an interesting dynamic over the next four or five years in how HIEs look in the future."
Fairmarkit helps drive more competitive supply chain bids to Blue Cross Blue Shield of Kansas City and helps out during PPE shortage.
Technology is being utilized to better exploit supply chains in healthcare at a time when the challenges of navigating supply chains has never been more stressed.
At Blue Cross Blue Shield Kansas City (Blue KC), technology that optimizes tail spend—generally defined as the amount of money that an organization spends on purchases that make up approximately 80% of transactions, but only 20% of total spend volume—saw a return on its original investment in less than three months and average savings of about $2,000 per RFQ (request for quotation). All without hiring any additional employees.
The supply chain platform provided by Fairmarkit draws upon Fairmarkit's data set of supplier catalogs to automate supply change sourcing and to also help organizations such as Blue KC achieve greater use of diverse suppliers, such as minority-owned businesses, helping the organization with diversity compliance requirements, as well as risk mitigation through diversification of suppliers.
"Companies just don't throw resource and technology at tail spend, because it's not a leading tip of the spear," says Greg Tennyson, senior vice president of strategy and procurement at Fairmarkit. "What Blue KC recognized right away is there's an opportunity to drive value out of that 20% of the spend, to de-risk it, enhance supplier diversity, to scale their operations."
The Fairmarkit platform uses machine learning to interpret freeform text about suppliers and data drawn from its own customers to help purchasers obtain more competitive bids on tail spend, while diversifying their mix of suppliers, Tennyson says.
"We're still leaving the decision with the human element to decide how they want to eventually award the business," Tennyson says. "They're only deciding how to award the business based on criteria. But we are partnering with customers to create additional work streams, weighting criteria."
"In 2020, we issued 89 RFQs via the platform," says Jason Buck, Blue KC's director of strategic sourcing, procurement, and vendor management. "This volume was approximately $3.5 million in spend. Of that spend, Blue KC garnered 7.54% savings. Blue KC ended the 2020 year with the Fairmarkit platform ROI of over 500%."
This high ROI has allowed Blue KC's procurement team to scale, while continuing to bring cost savings, Buck adds.
"During the early stages of the pandemic, in March and April of 2020, we leveraged Fairmarkit to identify PPE [personal protective equipment]," Buck says. "Fairmarkit’s solution allowed us to quickly scan and source items that were of high demand—all while ensuring that we were obtaining market parity pricing."
Later in 2020, Blue KC also leveraged Fairmarkit to source required materials as the organization planned for re-entry back into its headquarters. Finding items such as hand sanitizer and disinfectant wipes were another high-demand product.
Jason Buck, Blue KC's director of strategic sourcing, procurement, and vendor management
Improving supplier diversity
So far, Fairmarkit's platform has impacted about $2 million in annual Blue KC spend. The platform is also being integrated this year into Blue KC's Workday procure-to-pay system to drive these results and reduce the amount of manual rekeying requirement by the procurement team, Buck says.
As for supplier diversity, "Blue KC is in the process of maturing its supplier diversity program and was intentional about improving Blue KC’s diversity in the tail spend category," Buck says. "Fairmarkit has enabled Blue KC to quickly enrich our Blue KC’s supplier profile data, as well as other prospective suppliers in their marketplace. Fairmarkit has also implemented features to assist Blue KC in including a diverse supplier in RFQs. The focus and features that Fairmarkit is implementing enable Blue KC to improve its supplier diversity program and ongoing oversight/reporting."
Now, Blue KC is investigating expanding use of the Fairmarkit platform beyond its core use procuring IT software, hardware, and subscription-related expenses outside of SG&A (selling, general and administrative) expenses, Buck adds.
Fairmarkit has proven its platform in a variety of non-healthcare industries, with customers such as British Petroleum in the U.K., as well as telecom and high-tech companies, Tennyson says.
Fairmarkit currently has no direct competition, filling a niche not currently filled by large enterprise resource planning (ERP) suppliers such as Coupa, SAP, and Oracle, Tennyson says.
Over time, Tennyson adds, the Fairmarkit platform is approaching the ability to perform fully autonomous sourcing, which will further optimize the savings and flexibility of the platform.
Editor's note: This story was updated on November 17, 2021.
At the Wright Center for Community Health, the Keystone Health Information Exchange (KeyHIE) immunization registry paved the way for strong COVID-19 vaccination stats.
KeyHIE, the Keystone Health Information Exchange, is saving lives and money in Pennsylvania.
A cornerstone of KeyHIE's work is a strong statewide immunization registry, put in place in time for the COVID-19 pandemic, according to Linda Thomas-Hemak, MD, president and CEO at The Wright Center for Community Health, which serves northeast Pennsylvania through eight patient-centered medical home primary care practices, as well as a mobile medical unit.
"KeyHIE made the highway between the providers and the state registry," Thomas-Hemak says. The registry allowed The Wright Center, headquartered in the rural town of Jermyn, to see patients' immunizations from many locations in the state where they had received them, she says.
Linda Thomas-Hemak, MD, is the president and CEO of The Wright Center for Community Health. Photo courtesy of The Wright Center for Community Health.
The Wright Center is also now an opioid center of excellence, offering recovery services to outpatients to respond to the opioid epidemic that preceded the COVID-19 pandemic. KeyHIE was an instrumental part of battling both epidemics, Thomas-Hemak says.
"The infrastructure was crucial in the way that our organization embraced the COVID vaccination initiative," she says.
The Wright Center for Community Health's Opioid Use Disorder Center of Excellence (COE) saw its first patient in February 2017. Since then, the COE has seen about 1,700 patients. Of those patients, 20 have died from what the COE terms a known overdose. An additional nine have died from unknown causes. The Wright Center is one of 50 such COEs in the state.
For each patient in The Wright Center's medical home, KeyHIE provided valuable information from elsewhere in the state about emergency department visits and other key medical events that happened away from the clinic.
"How many lives has KeyHIE saved? More than the number of people who have died from an opiate overdose," Thomas-Hemak says.
During the opioid crisis, The Wright Center established the Healthy Maternal Opiate Medical Support program, or Healthy MOMS for short, to assist a particularly vulnerable population: women who are pregnant and have a substance use disorder. KeyHIE was instrumental in tracking that population, Thomas-Hemak says.
During the COVID-19 pandemic, KeyHIE has also helped The Wright Center analyze its population of vaccine-hesitant and late-adopting vaccination patients.
"I want to know where they are, and why they are disengaging," Thomas-Hemak says. "Are there things I can see in our data that tells me that this is a determinant of engagement or not? I want to better understand that."
As integrations between agencies progress, The Wright Center will be able to expand its use of KeyHIE for even more population health effectiveness.
"Ultimately, we want to use that [KeyHIE] highway again, to connect to the opiate command center in the Pennsylvania Department of Health," Thomas-Hemak says.
Among other things, such integration will eventually allow the integration of coroner's records, including causes of death, into statewide health information.
The Wright Center discovered the causes of death of some of those nine people, not through the HIE, but through social media postings. "As the CEO, I was devastated," Thomas-Hemak says. "We still don't have electronic death record certification processes reliably across this country."
Just prior to the COVID-19 outbreak, "things were looking a little better" on the opioid front, she says. "It was a really beautiful exercise with the data and outcomes that I want more visible in my workflow."
Thomas-Hemak will "continue to polish, develop, and deeply invest in KeyHIE, and how it appears in my electronic medical record," she says.
Dollar savings and freeing up FTEs
Health information exchanges relieve physicians such as Thomas-Hemak from hours of drudgery, chasing down and entering (or re-entering) data they need to tell their patients' stories more completely.
A multi-location family practice center elsewhere in Pennsylvania realized a return on investment of $110,000 by automating the injection of patient data into EHRs through connection to KeyHIE, says Kim Chaundy, senior director of operations at Geisinger Health System, which runs KeyHIE. The KeyHIE subscription costs the family practice $23,000 annually, which, when deducted from an overall $133,000 savings, yields an annual ROI of $110,000.
"They used to have eight full-time equivalents (FTE) that would sit in a 'tanker station' area," Chaundy says. "They were responsible for capturing this information that came into a fax server. It took them roughly one minute per document to match the document to the patient and upload it."
Kim Chaundy, senior director of operations at Geisinger Health System, which runs KeyHIE. Photo courtesy of KeyHIE.
That equated to 743 man-hours, or 93 man-days over a year. Thanks to KeyHIE, only half of an FTE now needs to be dedicated to managing such data entry, checking for potential mismatches, Chaundy says.
As for the remaining FTEs, they were reassigned to higher-priority tasks, such as being more proactive in the care of patients, she says.
Providing a heat map of the pandemic
KeyHIE includes 42 hospitals, numerous clinics, and some local pharmacies in its service area. "We were able to capture and leverage existing infrastructure to track and process a heat map of where the epidemic was going in the state of Pennsylvania," Chaundy says.
These heat maps were updated every five months. "It was amazing to see how it developed, how you could see the pandemic over time move across Pennsylvania," she says. Some KeyHIE members used the heat map as a mechanism to identify hotspots and determine where they were going to pop up tents, she adds.
Patients in long-term care facilities who tested positive for COVID-19 were able to have their medical status follow them via KeyHIE when being transferred to an emergency department, so that ED staff could be appropriately notified, Chaundy says.
HIEs fulfill the health interoperability promise
As a physician, Thomas-Hemak is concerned that substituting state HIEs with software vendor-provided alternatives might run afoul of the current push to eliminate information blocking and promote ubiquitous health data interoperability.
"Billions of dollars went into the meaningful use campaign, and we paid an awful lot of attention to the dissenters who didn't even want to move out of paper-based records," she says. "The pandemic has established a proximity between the federal agencies of Health and Human Services of the United States, and the people and providers in the trenches taking care of the American public.
"IT tech companies, EMR vendors, statewide exchanges, and the regional exchanges need to feel the pressure of the federal government meaning business" on information blocking, Thomas-Hemak says. "You're either going to fix this and police yourselves and get the information flowing, so that America gets healthier, and healthcare gets more affordable, or maybe it doesn't belong in your hands, in terms of interoperability."
Thomas-Hemak presented testimony about the benefit of healthcare data interoperability, including reversing physician burnout, to the U.S. Office of the National Coordinator for Health Information Technology’s Health Information Technology Advisory Committee during a virtual hearing in May.
"Part of the reason that primary care has a crisis in this country is because the primary care doctors are absolutely exhausted from chasing data," she says.
Ribbon Health AI tech powers Health Karma patient-friendly provider navigation and telehealth service.
At a time when the digitization of healthcare is turning parts of it into commodities, but out-of-date provider directories continue to thwart successful patient-provider connections, some providers are stacking technologies like double-decker sandwiches to improve patient experience and navigation, aiming to reduce visits to emergency rooms and urgent care centers.
One such example is the recent collaboration of patient navigation and telehealth service Health Karma with the AI-powered application program interfaces (API) created by Ribbon Health. Health Karma says its new service offers patients more accurate and reliable provider directories, coupled with navigation that zeroes in on the precise provider specialties that patients seek.
Ribbon Health's technology tackles the problem of provider directories differently than traditional approaches, which often ends up laced with errors or plagued by being out of date.
"Ribbon is aggregating over 1,000 different data sources on providers at any given time," says Nate Maslak, chief executive officer and company founder of Ribbon Health. "We have data partnerships and licenses, and scrape the open web, open government data sets, whatever is out there, to make sure that hits our system."
Nate Maslak is the CEO and company founder of Ribbon Health. Photo courtesy of Ribbon Health.
The gathered data is filled with duplicates and contradictory information. "We see over 50 phone numbers per doctor," Maslak says. "And that's just phone numbers." Physical addresses and insurance plans accepted can also return their own set of contradictory results.
Ribbon Health then applies machine learning to these data sets to predict which information about each provider is currently accurate. "If 800 sources say that Dr. Smith is at 123 Main Street, and 200 sources say she's at 400 University, what's the probability that either or both of those locations are right at this moment in time?" Maslak says. "Our algorithms assign a confidence score to that, and that's what we deliver to our customers."
Ribbon Health customers, such as Health Karma, receive their own copy of Ribbon Health data through Ribbon Health's API, and can modify or edit that data as they see fit, Maslak says.
Other Ribbon Health customers include care navigators and insurance brokers. "There are many referral management workflows that we power and sit behind the scenes of," Maslak says. "Our goal is to make it possible to integrate with anybody everywhere."
In many cases, Ribbon Health automation has replaced physical binders of outdated referral information at healthcare providers that required vast human patient navigator resources to utilize and maintain, leading to too many unnecessary patient visits to emergency departments and urgent care, Maslak says.
For digital-first Health Karma, the Ribbon Health data powers a patient experience aimed at simplifying healthcare navigation, not only for the uninsured, but for patients who find the websites of typical small employer-provided or individual insurance plans to be too complex, error-riddled, or out of date to be useful, says Michael Swartz, president and co-founder of Health Karma.
In addition, Health Karma provides low-cost monthly telehealth and behavioral health services, Swartz says. "For a lot of people, the most value lies in our virtual primary care and behavioral health programs," he says. Discount prescription medications are also available through the Health Karma site.
Michael Swartz is the president and co-founder of Health Karma. Photo courtesy of Health Karma.
In the future, Health Karma plans to offer online booking of appointments, but for now, its provider directory directs consumers to the provider's phone number.
If a consumer visiting Health Karma already has insurance and registers with the site, the site can make sure the consumer goes to an in-network doctor, or they can use the Health Karma virtual primary care until they need to go to that in-network doctor, he says.
In addition, Health Karma is arranging for small employers to enroll their employees into a personalized Health Karma navigation service, using Health Karma's more up-to-date provider directory, Swartz adds.
"We realized most people just do not have the knowledge to be a healthcare consumer," Swartz says. "That lack of knowledge was making people hesitate to interact with our marketplace, or healthcare as a whole. So, two and a half years ago, we took a step back and said we need to bridge the gap of confidence."
One way Health Karma differentiates its virtual offerings from others is by letting patients choose and retain their providers, creating ongoing patient-provider relationships, instead of being helped by different providers from visit to visit, Swartz says.
And unlike pure-play telehealth offerings, Health Karma can navigate consumers to brick-and-mortar physician and therapist locations, based on the insurance they carry, he adds.
"We don't offer insurance plans," he says. "We're able to integrate into over 2,000 different insurance plans. We do work with a lot of brokers, and there is potential going down that road of making it easy for you to decide if plan A or plan B is better for you, potentially."
Swartz likens Health Karma to some of easy-to-use fintech startups, such as Nerd Wallet, which helps financial consumers select from a mix of credit cards, investing, insurance, loans, and banking, among other things.
But to build that service, Health Karma had to have "top of the line" data about insurers, which is what Ribbon Health provides.
To further pinpoint the expertise of providers, Ribbon Health acquired claims data from multiple private proprietary sources, the company says. This data lets Health Karma visitors select providers based on a sophisticated set of search terms.
"Let's say you want a mental health therapist that focuses on ADHD, [and] has experience treating female adolescents 13 to 21 years old," Swartz says.
Using such criteria, consumers can sift through hundreds of potential providers to reach a handful that precisely meet their needs, he says.
"That's what we're trying to do, not only with mental health, but with all different types of search," Swartz says.
The Health Karma site also draws upon provider ratings generated by Healthgrades.com, although the Ribbon Health approach gives consumers much better search results than they would get by just visiting Healthgrades, he adds.
Planning health system growth now involves modeling growth both with and without the 2020 pandemic effect, says analytics firm.
Healthcare providers experienced significant disruptions in 2020 as the COVID-19 pandemic began, challenging their operations in many ways. In response, many rapidly deployed telehealth solutions both to fill revenue gaps and support ongoing patient care. However, at the same time, a flood of fresh venture capital investment flowed into new telehealth vendors, while entrenched retail companies eyed the telehealth opportunity as well. As a result, healthcare providers are now facing competition from a different direction in a post-COVID healthcare economy.
The convergence of these issues—and many more—have made health IT analytics a central part of health system success, which is especially true for those wanting to fuel future growth in a highly competitive landscape. For companies like Trilliant Health, which provides advanced analytics to some of the top health systems, that means building out capabilities that analyze troves of data, enabling providers to understand macro and micro market-level dynamics. Most recently, the company announced a new application, Demand Forecast, to help health systems plan their growth strategies. Trilliant Health also published a report that unpacked many of the big trends occurring in the post-COVID-19 healthcare economy.
HealthLeaders connected with Trilliant Health President and CEO Hal Andrews to discuss the challenges currently facing healthcare providers, and to understand how Trilliant Health is evolving to serve its health system partners.
HealthLeaders: Many health systems took big revenue hits during the pandemic because of the disruptions to preventive care, elective procedures, and other in-person services. Are these disruptions longer-term problems and/or permanent?
Hal Andrews: From a long-term and/or permanent perspective, I would distinguish between revenue and volume. Based on the most recent financial reports, most large health systems were able to recover from revenue losses through relief from the CARES Act and other governmental initiatives. In addition, the rapid recovery in financial markets has generated unexpected investment income that has also softened the damage attributable to volume declines. However, the volumes that disappeared between March 15 and June 2020 appears to have been largely lost, not postponed.
HealthLeaders: In response to COVID-19, a lot of health systems stood up virtual care operations, but now some are walking that back, due to declining demand. What do you think will happen in the virtual care market, how does that affect health systems, and should they be investing or divesting?
Andrews: There are three key issues to consider. First, the massive percentage increase in telehealth utilization is primarily attributable to the law of small numbers, i.e., health systems have historically delivered very little care via telemedicine as a percentage of their total volumes. Second, telehealth is very efficient and effective for certain clinical services, especially behavioral health, but consumers are clearly choosing in-person care over telehealth in the aftermath of the pandemic. Third, and most importantly from a strategy component, health systems are incapable of providing a commodity service —which telehealth is—at a competitive price against Amazon or Walmart, among others. Health systems would be better served to invest in clinical services that Amazon and Walmart cannot, or will not, provide, as opposed to trying to compete to deliver a commodity service that fewer than 20% of Americans utilized during the pandemic.
Hal Andrews is the president and CEO of Trilliant Health. Photo courtesy of Trilliant Health.
HealthLeaders: Health IT analytics takes a backward-looking view of the market, to provide predictive insights into different trends and market vectors moving forward. However, 2020 was a volatile year that's hard to model, and it's looking like 2021 may not be much easier. How are these analytics evolving to better serve health systems in an uncertain time? How has Trilliant Health adjusted its platform?
Andrews: I would differentiate between reporting, which is the focus of the vast majority of health IT analytics, and predicting, which has only become possible at scale in the past five or six years. As you suggest, I am not aware of anyone who predicted 2020, which, in turn, creates challenges in developing demand models for the next 5–10 years. For us, there are several considerations. First, our Demand Forecast model is the aggregation of more than 3.5 million individual models, which dampens, if slightly, the impact of the "lost volume" in the second quarter of 2020. Second, our Demand Forecast model incorporates confidence intervals, which accounts for the volatility of 2020 through wider confidence bands. Third, we believe that our clients want and need to have the ability to compare the models "with" and "without" the volatility of 2020, and we will begin delivering that to our clients in the next few weeks.
HealthLeaders: Like politics, all healthcare is local. For large health systems that may have multiple locations nationwide—or even within the same city—how can they better serve these populations, who often have different trends or care needs from neighborhood to neighborhood? What are the opportunities and challenges that go beyond just data collection and analysis? How can they make sense and allocate resources appropriately?
Andrews: As you note, healthcare is local, but health systems have been poorly served by analytics companies in explaining how healthcare is local. The first step is recognizing that patients are consumers, and consumers have preferences that are based on psychology.
Every industry in the world, except healthcare providers, starts with the consumer: how many there are, where they are, what goods and services they want and need, and how they want to consume those goods and services. Despite lots of talk about healthcare consumerism, healthcare providers are prone to think about patients, which is why health systems often market EMR access as "patient engagement."
The reason that healthcare is local is, as you note, the fact that every market is comprised of different neighborhoods with different people who have different preferences. As in every other purchasing decision, consumer preferences influence patient decisions. As a result, there are patient cohorts that are identical from a clinical standpoint, and completely different with respect to their preferences; conversely, there are patient cohorts that are identical with respect to their preferences and completely different from a clinical standpoint.
Having differentiated between the clinical conditions and consumer preferences in a population, it is fairly straightforward to understand where they live and work and consume clinical services. It is then—and only then—that healthcare providers should bring to bear what they do—the services they can deliver efficiently and effectively and competitively.
HealthLeaders: In your recent report, "2021 Trends Shaping the Post-Pandemic Health Economy," you discuss how large healthcare market entrants like Walmart and Amazon are changing the market dynamics for health systems. What are the big takeaways for health system executives planning their growth strategies?
Andrews: Price is a critical lever for competition in a low-demand, high-supply economy. With more suppliers in the market chasing after consumer share of care, the competition is intensifying. While the competitive landscape affects all players in the health economy, the stakes are greater for health systems already playing a "negative sum game." There are always a few winners in a negative sum game, as HCA consistently demonstrates by winning market share of inpatient admissions in nearly all of their key markets.
Ultimately, winners in the post-pandemic health economy will be those that compete on price. Prices and reimbursement rates vary widely by market and payer type, except for Walmart, which has stayed true to its roots as a purveyor of goods and service with "low prices." Even though health systems have felt price pressures for years, the competition has never been greater as retail entrants like Walmart set the gold standard for engaging patients as consumers.
HealthLeaders: You recently announced the launch of a new application "Demand Forecast," which gives a 10-year view of market trends. Why is your solution different from the plethora of other health IT analytics options available to health systems?
Andrews: We think about analytics in two spheres: what just happened, which we call market analytics, and what is about to happen, which we call predictive analytics. In my 25 years in the healthcare services industry, I have seen a lot of the former and almost none of the latter, which is the reason we decided to develop our Demand Forecast model.
The challenge of delivering a Demand Forecast model at the county level for every county in America is twofold. The first, and arguably more difficult, challenge is an engineering problem. As noted previously, our Demand Forecast model is the aggregation of more than 3.5 million distinct models applied to more than 1 petabyte of data. Historically, the limits of computer processing made our approach unaffordable, if not impossible. With the advent of distributed computing in the past few years, delivering the model is now possible and affordable. The second challenge is to develop the millions of models required to create the forecast. If anyone else had created something similar, then I am pretty sure they would be talking about it—as they should.
HealthLeaders: If there was one thing that those responsible for growth at large health systems should know for planning 2022, what would that be?
Andrews: The hospital business is a negative sum game, with a growing number of suppliers pursuing a decreasing number of commercially insured consumers, who are the lifeblood of the system. Every health system overestimates their market share because no health system (or payer) understands how many suppliers are in the market. Understanding market share is essential to developing effective strategies to win a negative sum game.