Articles by Matthew Donahue, James Fitzgerald
Happy New Year 2016 to our readers and customers. We are glad you are with us. Jacob Wheeler, Associate Product Manager sat down with Matt Donahue, VP of Technology Development and CTO, and Jim Fitzgerald, EVP to discuss the year gone past and the year ahead in Healthcare IT. Here is the discussion:
1. Transition to Cloud
JW: Healthcare is continuing its transition to cloud services for IT; what are the obstacles hospitals face in this move, and what are the most important considerations for hospitals looking to go to the cloud?
MD: The transition to cloud is a necessary one. Despite this, healthcare is not really an industry that is setup to easily and rapidly adopt new IT technologies. For reasons of funding, hospitals are challenged to maintain a pool of industry leading talent in their IT department which makes adopting the latest and greatest technologies difficult. It’s important, though, as the cloud will free up capital funds for clinical assets and will free up IT resources for solving problems rather than maintenance.
The primary challenges hospitals face in the transition to cloud are challenges of perception. There is no real technical hurdle. It shifts the IT budget from a capital expense to an operating one. There is a certain fear of losing control of your environment, of the unknown. For the transition to cloud, it’s important to view IT resources as a consumable good.
JF: To add some color to Matt’s view of cloud being necessary, let me add “inevitable”. If we zoom way out, macroeconomic theory suggests that free markets move inexorably towards efficiency. The scale, professional management, and rock-solid facilities typically offered by cloud services providers afford a level of quality IT as a utility service that many hospitals could not duplicate in-house, and maybe with technology where it is now, they should not even try to. As a patient and as the father and husband of several patients, I am far more interested that my local hospital has adopted the latest patient safety workflows and is investing in more advanced diagnostic and treatment tools. As a patient, the new all-flash array in the basement or the disaster recovery appliances in the wiring closet don’t mean very much to me if I am not pleased with the level of care. I think the emerging breed of Healthcare CIO is going to become a sort of systems and partnerships architect to source the best IT services for his or her hospital, and the IT team is going to become a healthcare user empowerment and enablement team. In fact if I could digress a little, I would hope in 2016 that we see doctors who have been legally and financially leveraged into 100% EHR and EMR compliance and IT professionals in healthcare come together to beat down the issues that leave many doctors feeling they are worse off than they were 5 years ago. That should not be the case. Done right, cloud frees up hospitals to focus on what is important about healthcare.
I like sharing with people the reality that not a single one of our healthcare hosting and disaster recovery has laid off staff because they have adopted our cloud services. Many report greater user and IT employee satisfaction as the transition unfolds. That last guy with a pocket protector and a pack of unfiltered cigarettes who used to change the disk packs on the minicomputers may have left the building.
Finally there is “cloud” and then there is “cloud”. Confusing, isn’t it? Cloudy, even. When our technical people at PPI say “cloud” it is an abstract term for a large scale set of highly virtualized and liquid compute, storage, security, and network resources that is molded into custom architectures for each customer. When The Boston Globe, or the-guy-in-the-coffee-shop in the campaign primary ad, says “Cloud” they usually mean a place where you keep your digital audio and video content, do your banking, manage personal or corporate email, or buy things. Lots of things. The former can support complex multi-tier applications tracing their client-server architecture to the 1990’s, which, by the way is an accurate description of almost every market-leading healthcare application today. The latter cannot and will not run anything more than simple data collection from personal devices or interaction with portals until all kazillion apps and databases are standardized on a common web platform and a common database.
JW: We’ve seen a lot of consolidation lately, both in the technology vendors and the hospitals themselves; what impact do you think this will have?
MD: Honestly, it may be too early to tell. Consolidation will reduce your options as a consumer, but on the other hand, may result in more interoperability and better care. The large hospitals can afford to attract some of the best clinicians, and when large hospitals buy up smaller community hospitals, it allows those doctors and nurses to practice outside of the large cities. On the other hand, with fewer independent options, there will be less price competition. A direct parallel can be drawn to the technology vendor consolidation: fewer options means less competition but also greater simplicity of interoperability.
JF: I personally consider it a living, breathing part of Park Place International’s mission to help community hospitals stay independent. If we can give them world-class IT services from our OpSus Cloud that are equivalent to those offered to satellites by large urban medical centers, we help them stay independent, competitive, and an organic resource which is interwoven into the community. On the technology side, I think the challenge for the vendor community is that the consolidation to cloud increases IT efficiency and reduces the number of customer targets simultaneously. For years, the hardware companies have been trumpeting cloud to sell virtualization, converged infrastructure, and the software-defined data center. Now that they are getting what they wanted, some of them don’t seem so sure they are happy to have it. The good news here is that there is a lot of pent-up money in venture funds and private equity and it is not all that hard for startup technology companies in healthcare and in the general market to get funded. This should at least ensure a steady supply of competitive innovation from the outside even as the industry consolidates. It would, I think, be a bad thing if the technology industry went the way of the automotive industry with a handful of huge, efficient companies cranking out mostly unimaginative products.
3. Internet of Things
JW: With Fit-bits and Apple Watches, we’ve seen the Internet of Things enter healthcare; how does this affect the industry’s IT requirements?
MD: The internet of things is the future of healthcare. It is creating an industry where the patients are more in control and responsible for their health. Instead of going to the doctor and being told what state your health is in, you can now go to the doctor with so much more data the doctor can analyze and use. It’s creating a more collaborative approach to a patient’s health.
On the back end, of which the doctor and patient are unaware, these devices are generating an explosion of data. The IT requirements are increasing just as fast. It’s not simply a matter of storing this data, but making it useful. It needs to be searchable, it needs to be interoperable, etc. The difficulty is synthesizing data that is stored in multiple different clouds and databases.
JF: Healthcare is at a turning point here. Practitioners and patients alike expect that health data should be liquid and exchangeable. The industry pays lip service at HIMSS plug-fests and connect-athons but the reality is starkly different. HL7 has been around forever but everyone had their own unique implementation. FHIR seems like a step in the right direction but it is limited by the framers perception of what actually should be in the interoperable patient record and what should not. Apple was criticized by some, as they always are, for trying to create a market-level standard with Healthkit that at least says “here is how data can be presented, found, formatted, and shared by mobile health applications running on IOS.” Proprietary, yes, but if it rolls out on a billion iPhones worldwide, it at least creates a benchmark which will force the industry to deploy complementary technologies and actually give 3rd parties some confidence to step in and contribute apps. What happens when that data goes from the IoT, to a datastore at a broker like Validic, to your EHR or EMR? How does it even map to a record that has one field for most things that are not a unique encounter? Does every upload become an encounter? Probably not. This kind of leverages Matt’s comments above on analytics. There is going to need to be an intelligent ingest engine that cleans, structures, and stores the PHRs and only forwards validated, meaningful information into the applicable clinical record. There is also going to have to be a lot better privacy protection. Too many places to consider it safe now have legally compliant copies of identified and de-identified patient health information. The economic incentives to leverage this are hugely compelling for the data holders. How do we protect the healthcare consumer?
4. EHR Market
JW: EPIC has been a market leader in EHRs for a while now; why do you think that is and will it continue?
MD: EPIC created a unique system, a system which was doctor-centric, that is attuned at some level to the clinical workflow. Other systems may have had superior modules for admissions and labs and billing, but EPIC designed an ambulatory workflow system and at the time was considered alone in the field. The other systems are catching up, quickly. With MEDITECH’s 6.15 Ambulatory release, they are a cost-efficient alternative that is gaining traction rapidly.
EPIC’s not sustainable for most healthcare providers. It’s an extremely expensive system which has been viable because of government subsidies and incentives. It’s great driving the Ferrari while your parents are paying for it, but as soon as they tell you to pick up the payments, you’re going to go look at the Prius.
JF: I have a lot of old friends running IT at hospitals that have switched, either by choice or by merger-driven corporate fiat to EPIC. There is real documented proof out there of the damage to credit ratings and people in the form of layoffs that follow these decisions at small and medium healthcare systems. There is also almost too high a price for the non-clinicians loss of functionality and efficiency for the modest or even just perceptual improvement to clinical practice that comes from adopting certain clinical apps. My Primary Care Physician is at Partners Healthcare, which recently transitioned from a homegrown web-based EHR loosely overlaid on Soarian to EPIC. At my first EPIC-driven physical with my doctor, he was forced to spend a lot more stick time on the PC to do the same documentation he had done with a few clicks in the old system. As a hospital employee he doesn’t really get a vote, and his pay is linked to his latency of documentation so he has “to learn to like it”. I asked him about it and he kind of shrugged his shoulders, sighed, and said “yeah I guess it’s great.” File that under “damned by faint praise.”
Another great case in point is my recent personal experience bringing my youngest son into the Winchester (Massachusetts) Hospital emergency room in December with a pneumothorax. Winchester is running a prettified, highly-tuned-up and lovingly implemented version of MAGIC 5.67. (Many kudos, Gerald and team.) The triage desk had a wristband printed before we sat down to update our insurance info. 45 seconds after arrival my son was being hooked up to an EKG. Another minute later our new home address had been captured, his previous PCP from quite far away had been selected out of a pick list that appeared seemingly out of nowhere and scans of our driver’s license and insurance cards had been incorporated into his record. Staff used MAGIC with one hand and mostly without looking at the screen. I asked several staffers about their thoughts about the possibility of Winchester’s new partnership with Lahey meaning an implementation of EPIC. A few were indifferent. Most were negative. One of the Lahey-based ED specialty consulting docs who visited my son told me he liked MEDITECH better because he could find things more quickly. This level of efficiency is almost impossible to hit with a web page without a bevy of platinum-plated IT resources behind the scenes in the cloud.
It may sound heretical, but I think that the physicians influence in driving these decisions has reached its peak and the pendulum is slowly coming back into a healthy balance with financial considerations as well as the operating needs of the other departments in the hospitals.
5. Workflow Mobility
JW: Is healthcare successfully adopting a mobile workflow model? What implications will this have?
MD: Healthcare is adopting a mobile workflow model, but to optimize it will require a change in thinking. Healthcare has been adopting more and more mobile devices, but has yet to master the balance of mobile technologies in and of themselves. Our current approach has been to make the traditional workflow occur on a mobile device. This is an important step and certainly an improvement, but to optimize mobility, there will need to be workflow innovation to truly take advantage of the advances in mobile technology.
JF: We have become an app culture. I often liken my iPhone to a “swiss army knife for business travel”. I have an app for every stage of the travel workflow. As Matt implies, other than point IoT healthcare apps like Instant Heart Rate or My Fitness Pal, traditional HCIS tends to look at my iPhone as a really tiny PC. This approach will yield little efficiency gain in the long term. If you want everybody to use the tool, make it feel like a game. This is where MEDITECH is going with the rich HTML 5 experience in Web Ambulatory. Watch the people in an airport waiting lounge on Angry Birds, Bejeweled Blitz, and Boom Beach and you’ll get the picture.
6. Network and Data Security
JW: Network and data security are as important as ever; how have you seen hospitals tackling this challenge? Is it enough?
MD: Hospitals need outside help. Healthcare has really been the last industry where physical security was sufficient, where they could have all the computing and data occur in one building. This is no longer the case and healthcare cannot afford to make the same mistakes other industries have made in their transition to better data security. This is an area more than any other where healthcare needs to avail themselves of outside help, whether that be managed infrastructure hosting or consulting help to assess and remediate security postures.
JF: I’ve been at this a long time and the sad truth is that most hospital boards don’t spend IT capital until after the crisis. New servers are bought after the system slowdown. Disaster Recovery is contracted during the downtime the day after the hurricane. It is true for security also. The number of sites relying on firewalls, Active Directory, and access control lists (ACLs) as their entire security schema is chilling. This is probably one of the things driving Health IT to the cloud. To remain compliant, healthcare cloud services providers must implement physical, network, process, and technical security measures at a level of financial and legal compliance that few hospitals have considered or currently match.
7. What Else?
JW: What is the most salient development you’ve noticed in the industry that we haven’t talked about here?
MD: Analytics. We’ve seen recently a large push in business analytics for hospitals which has been helpful and is a trend we’ll continue to see. The real advances will happen when we apply analytics to clinical data itself to improve quality of treatment. Brittany Wenger, 17, won the google science fair by applying an analytics engine to de-identified patient information and could successfully predict 1 in 8 women who would go on to develop breast cancer. This was data solely at the University of Wisconsin and such a small subset, at that. Imagine what we could do if we could apply analytics to a much larger data set and with a greater scrutiny.
JF: Gene mapping and editing. Not my area of expertise, but it is going to drive stringent, diagnostic-quality compliance into EHRs and EMRs as this information becomes fully integrated. Accuracy of this data and proper maintenance of it will be crucial to patient outcomes over a birth to death timeline of the electronic health record.