Healthcare is an industry unlike any other in the U.S. I, like many others, have struggled to explain why that is to the conventionally-minded business world.
Some say that factors such as the pressures of caring for people, the magnitude of consequences associated with poor performance, the cost of products and services, medical legal vulnerability, and a host of other factors, including the expectations of consumers, are the cause. After all, it has been said, that the American consumer of healthcare expects the very best care, right now, and someone else to pay for it.
I have spent a great deal of time trying to explain to new and highly successful businesses trying to enter the healthcare market that it is not business as usual– sometimes successfully, it's often not. Unfortunately, the roadside is littered with the carcasses of very business-savvy companies that tried to enter healthcare with the same conventional business strategies that brought them success in other industries. With 40 years as a practicing clinician, healthcare consultant, healthcare corporate executive, strategist and business development strategist under my belt, my own views are on the uniqueness of this industry that are beginning to gel.
A friend and sage fellow consultant, much loved by all who have ever known him, Harvey Price, once made a statement that has resonated in my consciousness for many years. “Healthcare,” Harvey declared, “is an industry that goes thorough phases without going through them.”
In and of itself, this comment says a lot. Adding a historical perspective adds to the incisive wisdom contained in these words.
For the first 60 years of the 20th century, healthcare experienced monumental advances - with Joseph Lister’s decades-long call for asepsis finally being put into practice, and with the discovery of penicillin and insulin. Science steadily expanded and improved upon such discoveries, clinicians moved into specialties, oversight was light, and practitioners kept paper notes - clearly not the most efficient of processes by today’s standards. Although it can be argued that we take better care of patients now, I think it can be equally argued that we have replaced one set of inefficiencies with another, high tech set of inefficiencies. Who among us, practicing in the1970s, could have conceived of the technologies available to us today? At least in those years we knew what we were dealing with, and felt that we could count on things to stay the same long enough for us to establish our own approaches to practice and make financial investments in the tools of our craft.
The introduction of Medicare by Lyndon Johnson brought the availability of affordable care to millions of our citizens, but it also began the process of pulling the rug out from under the independent decision-making of the industry. Suddenly reimbursements were uniform, determined by the government and based upon a continuously changing set of complex formulas and concepts which few practitioners even understood. Suddenly office managers were taking courses trying to keep up and understand as they absorbed the responsibility of keeping their physician employers in the black. Suddenly hospitals were hiring Chief Financial Officers to put their financial operations in place and to be attentive to such concepts as Return on Investment (ROI) and careful cost containment. If nothing else, the government can be counted on to continuously change the rules, and as a result healthcare was transformed from a rather static industry concentrating of taking advantage of advancing science, to a dodge-the-bullet, float-like a butterfly, keep one’s head above water, “What’s coming after what’s coming next?”, knock my competing hospital out of business industry.
Harvey had a corollary: “The challenge has been to distinguish trends from fads.”
In the late 1990s, handheld devices began to appear. Remember Palm Pilots? At first they provided a means of keeping contact information and schedules and required docking stations. Then they became wireless. Competing products offered more and more computing capabilities and began to interact with simultaneously evolving EHRs – first via docking stations and hard-wire – then wirelessly. Then came smartphones, and the cloud. At every stage, millions were invested, innovative startup companies appeared and disappeared, clever feature-functionality captured our interest, and then disappeared. We went through fads without going through them simply because they couldn’t stick around long enough for the industry to absorb and apply them.
And just as the products appear and disappear, so does the language of the industry – a phenomenon that is even more costly. The hot topic of the day becomes the buzzword of the “informed”. This initiates the fad of the day, stimulates billions of dollars of investment and costs as providers and hospitals dodge and weave to maintain viability and currency of “quality” - and then fades without a foothold or lasting impact to be replaced by yet another fad. Consider Regional Healthcare Information Organizations, Health Information Exchanges, and Accountable Care Organizations. All great ideas - all rarely financially sustainable - and all potential fads. Who will put their life savings into any of these entities?
To me, the trend is clear: the need for open interoperability of systems and availability of standardized data.
A term appears (e.g. the Patient Centered Home”), the “informed” propagate the term, consultants materialize, information systems add feature functionality, innovators introduce products, payers manipulate reimbursement schedules, and hospitals dodge and weave. All until the next disruptive concept or reimbursement, or coding regulation, or fad comes along.
Those who invest in the trend survive. Those who invest in the fad either make a quick fortune or lose heavily.
Consider the term “Big Data” – and allow me to throw some gasoline on the fire
The technically gifted can apply definition to the term “Big Data” but to most of us it simply means that there is an awful lot of data being generated out there for us to deal with. This data must be standardized, verified, formatted for interoperability, and delivered to clinicians and decision-makers in a useful, reliable manner.
Yet I see the concept of “Big Data” as nothing more than a fad – a naïve application of term to a concept that seems to have a boundary - something comprehensible.
The reality is that we don’t have “Big Data”. We have endless data and that endless stream is about to explode exponentially. What we do have is a Big Problem and it is looking us right in the eye. What we have, and are about to get, beyond the level of comprehension, is “Incessant Data” – never ending, endlessly expanding, 24/7, unstandardized, unformatted, non-uniform, and often unavailable. “Big Data” is nothing more than the subatomic core of the Big Bang in the universe of data.
We are about to get water-boarded with data !!
The other industry that parallels healthcare in the sense of change is the micro and nano technology industry – an industry that has targeted healthcare and is introducing us to previously incomprehensible capabilities. Sensors and wearable, implantable and ingestible devices will revolutionize the way we diagnose disease and deliver care over the next few years. Like healthcare fads however, this industry presents us with the same challenge of knowing where to hang one’s hat. The micro and nano technology industry is presenting us with technologies that one could never have imagined just six months previously – constantly changing even while trying to get a foothold.
Watches that generate a full six-lead EKG with one point of contact on the skin, wearable devices that generate blood glucose levels, oxygen saturation and other blood constituent levels without an actual sample of blood, clothing that measures and transmits parameters for monitoring cardiac disease, intelligent pill bottles that indicate if medications were taken on time or at all, vital signs transmitted from a host of wearable devices, ultrasound and even x-ray images obtained on one’s smart phone ……. – the list goes on and on. Millions of apps and devices generating data at a level beyond comprehension.
But let’s go a step further. Millions of people who are healthy and health-conscious are grabbing up such devices to monitor their own healthy lifestyles. Dietary patterns and caloric intake are being monitored, and exercise and vital sign patterns etc. reside on the servers of companies selling apps and micro-devices for the healthy. Certainly this would be valuable information for population management. Currently most of this data is not available because it sits on private company servers inaccessible to the general healthcare system.
This incessant data is largely unformatted, not applied to standards, not verified, and insecure. Privacy issues are monumental. What happens when my EKG shows up on Facebook?
Even more data will be generated as we continue to mine previously unobtainable unstructured data. Maturing software can now extract structured data from pdf documents and even handwritten notes.
How do we get effective information for analytics when this constant stream of incessant data flows into the pot? How is it run through algorithms and knowledge engines so that it is delivered to clinician decision makers in a concise, actionable format?
24/7 unfiltered data is invaluable to an analyst and a nightmare for a practitioner.
This is where the concept I have been talking about for more than a decade comes into play. I have long maintained that vendors have mistakenly pursued the path of supporting mechanical, text-book workflows that have nothing to do with the way clinicians actually practice. Hence the dismal failure to clinicians to embrace EHRs. What needs to be supported is clinician “Thoughtflow" – which asks how we access, assess, prioritize and act on data according to our specialties and thought processes. This concept, in the context of incessant data, takes on a whole new challenge. Vendors have not managed to handle it in the current environment and state-of-art (?) EHR systems. (I apologize for the question mark but somehow I cannot comfortably apply the term “art” to the EHR world). How will they manage to do so with the seemingly infinite deluge of data coming our way? More data will challenge the capabilities of vocabulary standards, language processing and clinical decision support systems – all essential to supporting Thoughtflow.
This to me is the challenge: Supporting Thoughtflow in an age of Incessant Data
The fads are many: Ever changing devices, means to deal with the data, the data-sharing entity of the day. These are not to be latched on to – they will change and be replaced by new and disruptive products and services at a rapid rate
The trend is imposing and we must prepare ourselves. The tidal wave of data is about to hit and we don’t want to find ourselves running inland, looking for high ground and then deciding what to do with all of that water. The data isn’t going to recede – it’s going to keep coming and coming and in inconceivable amounts. This is no fad.
And yet – I suspect that we will all be on the high ground together trying to decide what to do as the data streams ashore unabated. Such is the nature of our industry.
Sam Bierstock, MD, BSEE is a physician and the Founder and President of Champions in Healthcare, providing Business Development Strategic Services for innovative healthcare technology companies
The term Thoughtflow is a registered trademark and may not be used in any commercial fashion in healthcare without the permission of the owner of the trademark