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In Catalonia, Health IT Governance Rises Above the Political

June 6, 2018
by Mark Hagland
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The chief executive of Catalonia’s healthcare IT agency shares insights on the progress he and his colleagues have been making in HIT development in that region of Spain

Those who have been following the political scene in Spain lately know that the politics around the independence movement in Catalonia, that country’s wealthy northeast region, has become very intense of late. Certainly, the debate around the future of Catalonia remains heightened and controversial.

But beyond the news headlines, Catalonia (in Spanish, Cataluña; in Catalan, Catalunya)—whose land mass of 12,400 square miles is about the size of the state of Maryland, but whose population of 7.5 million is closer to that of Virginia—is a region noted for its economic and cultural vitality and ingenuity.

What’s more, because of the governmental landscape in Spain and Catalonia, healthcare information technology is in some ways very well-situated in terms of its overall governance. As in nearly all of the western European nations, healthcare is largely government-run in Spain. What’s more, Spain is governed through an architecture of autonomous regions, including Catalonia, which is governed by its own Parliament and regional government, the Generalitat de Catalunya.

Under the governmental architecture of the Generalitat is the Ministry of Health of Catalonia, and, managing the healthcare information technology resources of the Ministry of health, is the TICSalut Foundation. As the TICSalut Foundation’s website explains, “The TicSalut Foundation is an agency within the Ministry of Health that works to promote the development and use of ICT and networking in the field of health, acts as an observatory for new trends, innovation and monitoring of emerging initiatives and provides services for the standardization and accreditation of products. The implementation of ICT in the health sector is now unstoppable and is seen as one of the most transformative elements in the health sector of the future. The fact that the health sector in Catalonia covers 100 percent of citizens within a framework of universal and public coverage, together with the involvement of a variety of agents, organizations, suppliers and subsidiary industries, puts the health sector in an excellent position to act as an economic innovator and energizing influence in the use of new technologies.”

Late last year, Healthcare Informatics Editor-in-Chief Mark Hagland met with Francesc Garcia-Cuyàs, director of the TICSalut Foundation in Barcelona, to discuss some of the innovations taking place in Catalonia, and his perspectives on the Catalan, Spanish, and European healthcare IT development issues, and the comparisons between the Spanish and American situations, with regard to interoperability, health IT investment, and systems integration. Below are excerpts from that interview.

Mr. Garcia-Cuyàs, please tell me a bit about the governance and management aspects of the healthcare system in Catalonia, with regard to healthcare IT development and management?

In the Catalan healthcare system, each hospital has its own information system. But over the course of time, we have been creating full interoperability among all the hospitals in the region. We began an intensive IT harmonization initiative in 2006, and have been evolving it forward ever since.

We have developed a regional plan for digital health, a strategy for healthcare delivery, and for informatics. Our philosophy is that the technology must serve to support specific projects, as well as supporting digital transformation, and the patient experience, among other priorities. Our overall system encompasses both primary care information systems and medical specialty-based systems. And every hospital and outpatient center is able to share electronic health record-related data in our repository; all our hospitals, primary care clinics, and specialty medical practices, are connected. We have a national healthcare system that provides complete integration of EHRs, and allows for nationwide data-sharing, as appropriate. What’s more, all our local and patient care organization repositories are connected. Also, we’ll be moving everything to the cloud soon.

Meanwhile, in Catalonia, we’ve got 7.4 million patients in our regional system, with 18 percent of them over the age of 65, and 2 percent living with at least one chronic illness.


Francesc Garcia-Cuyàs
 

Tell me about some of the more advanced capabilities in your system?

Yes, we’ve got electronic prescribing, and pharmacy automation, including an integrated electronic prescription system across the entire nationwide healthcare system. What’s more, patients can check their personal electronic health records from their smartphones. We have all test results stored in our EHR. One of our goals is to be as people-centered as possible. We believe that by giving patients relevant information, they will participate in working to improve their health status.

Would you say that the overall regional health information system in Catalonia is one of the most advanced in Spain?

Yes, it really is; Catalonia has advanced faster than some of the other regions here; in fact, other regions are busy copying what we’ve been doing here.

What have been and continue to be, the biggest challenges for you and your team, in managing this very large regional health information system?

There are two. The first is helping our providers to manage the care processes of our citizens who are living with chronic illnesses. The other is moving forward into leveraging artificial intelligence-based tools, particularly to participate in robust data analytics.

But you have been moving forward in that area?

Yes, we have; we’ve been moving forward into predictive analytics, for example. Predictive analytics will be very helpful in a number of areas. We have an office of artificial intelligence, and we’re moving into the use of both machine learning and deep learning. One of our goals is to help to facilitate the success of a number of specific projects in our healthcare system, and to help individuals working on those projects to integrate their use of AI tools into their work. For example, we’re currently working on a report on our progress as healthcare system around care management. AI would be very helpful in that work.

What are something the projects you and your team have been working on recently?

We’re making progress in areas such as the expansion of the use of electronic signatures, and we’ve got three pilot projects moving forward in that area and others.

Have you achieved barcoded medication administration yet?

Yes, that exists. One element that is helpful in that regard is that the dispensing of prescription pharmaceuticals is highly regulated in Catalonia. Only official pharmacies are allowed to dispense medications; it’s not like in the United States, where commercial drugstores have pharmacies. Our pharmacies are state-controlled. Those kinds of commercial drugstores are allowed only to sell over-the-counter medications.

What might happen in the next few years?

We hope to be able to articulate a strategy to introduce more technology into the social sector. In fact, we have an office dedicated to research in that area. Things like some kind of digital café, and other resources that would create greater patient/healthcare consumer engagement around educating patients about their medications, and so on.

What have been some of the learnings on the journey forward so far?

One has been that, in developing new technologies, we need to work closely with physicians and nurses, in order to develop optimal solutions. Digital care is complex, and clinicians need to be part of determining what works and what doesn’t.

Sidebar: Digital Transparency in Catalonia

In one section of its website, the healthcare administration of the regional government of Catalonia, the Generalitat, includes this information about digital data transparency and access in Catalonia:

“The Government of the Generalitat de Catalunya has committed itself to the opening of public data, with the aim to make them transparent to the public, in addition to promote the use and re-use of the information generated by the Administration. The data are grouped in a common portal according to the standards promoted by the International World Wide Web Consortium (W3C). The “Open Data Gencat” project follows international trends around open data and navigation, according to the appropriate boundaries around privacy, security, and property that apply in each case, according to the Government Agreement of November 2010.

The Department of Health of the Generalitat is working for many of the data collected from the Observatory and other health interests to continue the process of opening in a coordinated manner with the Gencat portal, where you can see all the files available related to health issues. The files released allow, in addition, for the development of data visualization tools, and for the ongoing monitoring of the ongoing progress of DiagnostiCat, a portal of the Catalan Institute of Health that shows almost in real-time data for diagnostics of diseases that are presenting in a large majority of primary care centers in Catalonia.”

 

 


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Survey: Who Will Shake Up Healthcare? C-Suite Leaders Weigh In

August 20, 2018
by Heather Landi, Associate Editor
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With new, disruptive entrants coming into the healthcare market, which company is poised to have the biggest impact on healthcare? The majority of C-suite leaders have their eyes on Amazon to shake up healthcare, according to a recent survey of healthcare C-level executive leaders.

Reaction Data, a market research firm focused on the healthcare and life sciences industries, surveyed about 100 healthcare organization leaders on which companies will have the biggest impact on healthcare, and why for its recently published report on healthcare disruption and the future of the healthcare market. The report also looks at emerging technologies and healthcare organizations’ future technology plans.

About 80 percent of the healthcare leaders surveyed are C-level executive leaders—27 percent CEOs, 17 percent CIOs, 17 percent chief nursing officer (CNOs), 17 percent CFOs and 7 percent revenue cycle management directors. Almost half of the respondents were from hospitals.

According to the survey, 59 percent of provider organization leaders think Amazon will be the most disruptive, with 75 percent of CEO respondents choosing Amazon as having the most potential for real disruption. Fourteen percent of respondents cited Apple, 8 percent selected Google, 7 percent chose Microsoft, 4 percent said IBM, 3 percent cited Walmart and less than 3 percent said Salesforce.

The report cites one CEO’s comment: “[Amazon has] visionary leadership and the ability to make the change happen.”

The report also breaks down the number of comments each vendor received per attribute, with 14 attributes such as “name recognition,” “ability to commodify,” “progressive/innovative,” “predictive analytics,” and “affordable.” Amazon received the most comments and, based on those comments, appears to have the most diverse attributes, according to the report, as respondents cited the company for all 14 attributes.

Amazon has made several moves into the healthcare space, including its acquisition of PillPack, an online pharmacy startup, back in June. Earlier this year, Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. announced that they were launching an initiative to improve satisfaction and reduce costs for their companies’ employees. Details of that joint venture have been vague, but experts have pointed to reducing healthcare fraud and administrative costs as key areas that the companies will focus on.

The report also summarizes the work underway at Apple, Google and Microsoft, including Apple and Google’s ongoing efforts to develop their devices and apps and continued development of artificial intelligence (AI); Microsoft’s work with St. Jude Children’s Research on genomics and advancing cloud and AI and IBM’s work in cloud, encryption and data mining. Salesforce allows providers to utilize its cloud CRM tool to manage patients and store data.

Reaction Data also surveyed respondents on emerging technologies, and 29 percent cited telemedicine as a technology that will have the biggest impact, although telemedicine has been around for decades. Twenty percent of respondents cited AI. Only 2 percent cited blockchain, despite all the buzz that technology has been generating. Combined, virtual services/telehealth and AI accounted for almost half of the responses. What’s more, 15 percent cited interoperability, 13 percent selected data analytics, 11 percent cited mobile data and 7 percent said information security. Cloud was cited by 3 percent of respondents.

The number one use case for telemedicine is reaching patients who live in rural areas, according to a quarter of respondents, with the same percentage citing “follow up care” and “managing specific patient populations.”

With regard to AI and machine learning, the vast majorty, 65 percent, of respondents said the technology was “important” and 16 percent said it was not important; 19 percent were neutral. However, while providers clearly see the technology as important, more than half of respondents (53 percent) are at least a year away from adopting it, and many are three years away from adoption. Twenty-eight percent said they plan to adopt AI in one to two years, while 25 percent said they are 3-plus years away from adopting the technology. What’s more, 15 percent have no plans to utilize AI. Fourteen percent of respondents said their organization has been using AI for a while, 11 percent plan to adopt the technology in the next year and 7 percent have adopted some AI.

Breast imaging is by far the main use case for AI, according to the report, with three-quarters of respondents citing this area for AI adoption. The report also breaks down what providers are looking for in AI technology—convenience (33 percent); interoperability (27 percent); technology (18 percent); predictive analytics (11 percent); affordability (5 percent) and progressive/innovative (2 percent).

The report also looks at business trends in healthcare, noting that there have been dozens of mergers and acquisitions recently. These include provider/provider, vendor/vendor, and payer/payer relationships. Now the lines are being blurred as entities are crisscrossing into new spaces. “Examples include CVS acquiring Aetna, Optum purchasing Advisory Board, PinnacleHealth getting picked up by UPMC, Walgreens partnering with NewYork-Presbyterian, Apollo buying LifePoint Health and merging it with RCCH HealthCare Partners, and many others,” the report states.

The survey also gauged healthcare provider organizations’ acquisition plans. While 61 percent said they plan to remain independent, the survey found that 39 percent of provider organizations are currently planning to either acquire other organization, execute a merger, or sell to a larger organization, which points to a dynamic market becoming even more in flux.

“The impacts to the vendors who sell to these organizations, to the payers who negotiate with them, to the care providers who work for them, and to the patients who are treated by them, could be significant. It isn’t an overstatement to say that it is critical to keep a very close watch on this market dynamic,” the report states.

With a significant percentage of organizations planning to change their ownership structure and make-up in the next few years, along with organizations adopting new technologies, and with new entrants moving in, it appears that there will numerous forces at work to shake up healthcare soon.

 

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Will IBM Watson Repeat History?

August 15, 2018
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Recently, there have been some articles about IBM Watson and healthcare.  In particular, a blog by John Lynn speculates on the “health” of IBM Watson in healthcare.

I’ve had my own personal experiences with IBM in healthcare.  While with GE, we did a joint venture with IBM in the early days of PACS and RIS, and I was an original IBM MedSpeak/Radiology reseller in the early days of speech recognition.  In both cases, IBM did not have the financial wherewithal to play the long game in terms of the technology and exited both.

Interestingly enough, MedSpeak/Radiology was not the first foray into digital dictation for IBM, so they exited that business multiple times.  I also have to say, MedSpeak/Radiology was a pioneering technology that was very competitive.  It just wasn’t the business case the IBM management was looking for.  Similarly, IBM’s effort with GE toward RIS and PACS was naively predicated on employing IBM’s RIS product, and not on interoperability with other RIS vendors.

There are countless business examples of companies launching products based on great expectations, only to have them fail to achieve those expectations.  There are also countless examples of companies getting into products that have no relevance to existing businesses because the think they have a “better mousetrap.”  One that comes to mind is GE.  Years ago, GE developed in their research center an electric garden tractor which was very innovative for the 1970’s.  Unfortunately, when GE attempted to bring the product to market, they discovered they did not have a single market channel that addressed lawn-care equipment!  GE ended up selling it to Bolens for a fraction of the development cost.  And, in retrospect, it was premature given the current fascination with electric vehicles!

I am not implying that IBM hasn’t done its homework on IBM Watson.  I suspect it may be more of two other factors at play.  One, it’s a question of chicken and egg.  Is the advancement of Artificial Intelligence more about the application or the platform?  Secondly, does IBM have the infrastructure to succeed?  In the case of the first factor, IBM is more about the platform than the application.  In the second case, the same could be said for the platform versus the application, as IBM does not have a significantly parallel channel that would address AI applications.

I think this is why IBM initially acquired Merge Technologies, as they saw it as both a “sandbox” to learn imaging, but they may have also seen it as a potential distribution channel.  With further understanding, they were quick to learn that attempting to develop and market applications through Merge would make them a competitor to other viable players such as GE, Philips, and Siemens.  That resulted in a move to create “consortiums” that could develop applications on the IBM Watson platform, thus broadening the appeal of IBM Watson across a broader distribution channel.

The question going forward is – has IBM learned from its history of past healthcare ventures?  If IBM can make a business case for addressing Watson as the platform for AI, it might be a stronger case than trying to be the end point for AI.  This would be consistent with its strength in computational platforms in business, which have classically been a better business model than applications (OS2 or Lotus vs. Microsoft Windows and Office anybody?!). 

I recall the OS2 days versus Microsoft Windows.  As a fan of OS2, I had hoped it would succeed.  Unfortunately, as I learned, there were very few applications for OS2, which is ultimately why people purchased personal computers in the first place.  If IBM had been smart, they would have given OS2 software licenses away in an attempt to build consumer demand for the development of applications.  Unfortunately, that didn’t happen, and I doubt there are any OS2 users out there today.

If IBM can take stock of its history, there is a fighting chance for IBM Watson to be a significant factor in healthcare.  But, the company will need to learn how best to foster the development of AI applications.  In his blog, John Lynn relates the experience of Lukas Wartman of the McDonnell Genome Institute at the Washington University School of Medicine in St. Louis, who laments on how much faith one can put in the results (of using Watson).  As with past technologies, we are at the tip of the iceberg in terms of applying the technology.  Here’s hoping that IBM can figure this one out, be in it for the long game, and live up to the hype of IBM Watson!

 

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Analyzing Blockchain’s Evolution in Healthcare: Two Experts Dive into the Details

August 15, 2018
by Rajiv Leventhal, Managing Editor
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Two healthcare leaders at KPMG believe that blockchain activity in healthcare will ramp up in the next 12 to 24 months

Earlier this year, five prominent healthcare organizations—Humana, MultiPlan, Quest Diagnostics, and UnitedHealth Group’s Optum and UnitedHealthcare—announced they would be launching a blockchain-based pilot program with the aim to improve healthcare data quality and reduce administrative costs. The organizations said they would be specifically examining how the technology could help ensure that the most current healthcare provider information is available in health plan provider directories.

While many more details of this initiative are not yet known, this announcement has opened the eyes of other healthcare IT leaders who have become increasingly curious about this emerging technology. For instance, at the Nashville Health IT Summit earlier this summer, a senior executive from MultiPlan, which is part of this pilot project, was asked about his perspectives on the research and development work done on blockchain in healthcare in the past few years.

To this point, two leaders at KPMG—Arun Ghosh, the firm's U.S. blockchain leader; and Michael B. Yetter, director, healthcare management consulting—recently spoke with Healthcare Informatics about the impact of this new initiative, what the greatest use cases are for blockchain in healthcare today, and how quickly providers and payers might start moving into full-scale projects. Below are excerpts from that discussion.

What are you hearing about blockchain right now as it relates to its greatest use cases in healthcare? What are people most bullish about?

Yetter: From a client perspective, things are a bit on the early side. But [we often see that] as many emerging technologies gain momentum in some other sectors, you will see the pathway through pharma and then into healthcare with payers and providers. We are seeing that same pattern here. On the ground in the healthcare space, especially amongst payers and providers, we’re starting to see more interest in meaningful pilots. We have had some earlier adopters doing proof of concepts and pilots—many around claims or aspects of claims management, and some around the regulatory impacts of the supply chain.

Michael B. Yetter

We are starting to see the nature of conversations around what those use cases could be become increasingly sophisticated around things such as consortiums on provider data, and making sure the historical challenges around getting provider data to agree across multiple entities—who are either submitting or processing claims—that those specific data elements or attributes or shared or reconciled in a better way. So that’s one good example for where you are starting to see collaboration.

Ghosh: The additional capability that blockchain provides, versus traditional EHR (electronic health record) systems, and other enterprise technology that exists today, is that from the time of an encounter to the time of discharge, we see blockchain being piloted around records and interactions with the patient, but also interactions with the pharmaceutical ecosystem—from drug provisioning or procurement to drug administration. Even with the Obama administration saying that we need EHRs across the board, it’s still nascent in terms of who has access to what kind of record and what kind of electronification exists.

Arun Ghosh

So blockchain is coming as the next level of granularity: if we can provide immutable records that are now at the time of pre-diagnosis all the way to wellness, we can track getting better, but also not returning to the hospital. Now, we have a story. Between payers, providers, pharmaceuticals, and distributors, we are seeing varying levels of interest and adoption. They are saying, “let’s pilot a certain part of this,” but there is still no end-to-end view yet, from what we have seen.

What are your thoughts on the MultiPlan/Humana/Optum/Quest/United initiative? Would you classify this as a meaningful pilot?

Yetter: From an outside view, and we haven’t been directly involved, it’s my understanding that this collaboration is focused on provider data sharing. I would classify that as more meaningful because they are bringing multiple parties together to solve for a specific use case and problem. So it goes beyond the earliest conversations, going back a year or more, that were more about learning and understanding the technology. Now they are saying that they get the technology, so let me apply this to a problem we have and something that we can enhance in the industry. And seeing multiple big players involved is encouraging.

Some have said that the greatest use of blockchain in healthcare could be improving on how HIEs (health information exchanges) operate today. Do you agree?

Yetter: I don’t think this is achievable in the short term, and there is the bigger picture of truly getting to a complete HIE—and when I say complete, I mean the truly clinical data that is shared between entities, and ideally something that is more accessible to the patient. The ingredients are there for blockchain to make that significantly more usable, and something that can be potentially controlled and accessed by the actual patient or member. And the patient or member can then have the ability to access the information, and also to permission through some of the mechanisms through blockchain, the sharing of that data or specific parts of the data to others who need it in the healthcare environment. There is a lot of good capabilities there that will evolve in this direction to have blockchain enabling more advanced HIEs, but it will be several steps along the pathway before we truly get to that transformation.

Ghosh: Part of this [potential] disruptive model is that it’s the true democratization of healthcare data—if my data is now being “streamed” into a blockchain, I have ownership of it. So the hypothesis of value here is that if the individual can control his or her data, and then can choose who to share it with—the plan, provider, or someone like Nike or Under Armour—the concept is that there are rewards, such as avoiding rehospitalizations.

How can healthcare organizations better prepare their infrastructures now to implement blockchain in the future?

Yetter: I think the blockchain [implementation] would be more of an add-on, especially in the near term. And I think you will see some of the major vendors out there, be it EHR or adjudication systems, start to consider and build in aspects of blockchain into their own platforms. So there will be a broader enablement that will naturally flow into the infrastructure as it moves forward. But in the near term, there is a good opportunity to add blockchain capabilities to what they already have, and then leverage it for specific cases of pilots or at-scale activities.

Ghosh: The big thing to recognize is that the way enterprise blockchain is evolving, from an infrastructure perspective, it is becoming augmentative rather than disruptive. So you can take an EHR and then you can augment the whole EHR workflow, from encounter to discharge, on the blockchain, [while maintaining] what the traditional EHR looks like. You don’t have to transmit all the data, like you would do in a data warehouse, into another ecosystem. You can leave it as source and hash parts of it on the blockchain as you build the blocks along the workflow. The enterprise blockchain vendors are making this easy to adopt.

There has been plenty of back-and-forth about just how much security blockchain can provide. What are your thoughts on this?

Ghosh: Anytime you encrypt data, it can always be decrypted. A blockchain is nothing but a distributed database at the end of the day. If you have access to that database that doesn’t have a consensus mechanism attached to it, then it is a little insecure. Looking at the T.J. Maxx breach a few years ago, people were swiping their credit cards and the transmission from the point of fail system to the storage system was being intercepted; that was the hack. In the same way, from the time that the traditional system would write to the blockchain, you can intercept that data, and that’s when the insecurity could come into play. And those standards are still evolving. There is no vendor out there that can not only encrypt the transmission protocols between source and blockchain, but also ensure that the blockchain itself is secure.  

What predictions could you offer for blockchain’s continued evolution in healthcare?

Yetter: In 12 to 24 months, you will see a lot of fast-moving activity, and with the changing nature of conversations and the work being done now, there is a clear signal that we are at a bit of an inflection point. But I think we will accelerate the meaningful work in this space and bring the technology in. Going back to the idea of acceptance and use of emerging technologies in other sectors first, we are seeing blockchain in place in financial institutions in meaningful ways. So in the next year or two, I think we will see the same thing in healthcare, whether it’s aspects around provider data, or getting into exposing things to the patient or member so they have greater control. We’ll see a lot of energy and investment in that space.

Ghosh: I think that beyond the pilots that you see today, the voice of the customer will be increasingly automated with enterprise blockchain. Within healthcare, the issue is, how do you provide greater autonomy, depending on who has the data and where? It’s not one or two companies that are trying to do something; it’s five or 10 that want to get together before someone else beats them to it.

 

 


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