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Top Ten Tech Trends 2018: In the Fight Against the Opioid Crisis, Providers are Turning to Technology

August 30, 2018
by Heather Landi, Associate Editor
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More than 40 percent of all U.S. opioid overdose deaths in 2016 involved a prescription opioid, according to the CDC
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Editor’s Note: Throughout the next week, in our annual Top Ten Tech Trends package, we will share with you, our readers, stories on how we gauge the U.S. healthcare system’s forward evolution into the future.

Opioid abuse and addiction continues to be a national crisis, but it is being felt at a very local level. Patient care organizations across the country are seeing the impact of the opioid crisis on the health of their patient populations.

From 1999-2016, more than 350,000 people died from an overdose involving any opioid, including prescription and illicit opioids, according to data from the U.S. Centers for Disease Control and Prevention (CDC). Overdose deaths from opioids, including prescription opioids and heroin, have increased by more than five times since 1999. More than 40 percent of all U.S. opioid overdose deaths in 2016 involved a prescription opioid, with more than 46 people dying every day from overdoses involving prescription opioids, according
to CDC data.

Many industry leaders say technology can help address two key challenges of the opioid epidemic: drug diversion, including the illegal use of prescription opioids, and clinical appropriateness, including effective uses of opioids for patients with legitimate needs. Technology tools such as e-prescribing, prescription drug monitoring programs (PDMPs), and clinical data exchange, all aid healthcare professionals, by informing their care decisions with more actionable intelligence at the point of care.

Surescripts, the Arlington, Va.-based operator of a nationwide electronic network for prescription-related data and information, has been at the forefront of this area as its platform connects electronic health record (EHR) vendors, pharmacy benefit managers, pharmacies and clinicians, as well as health plans and long-term and post-acute care organizations. In 2017, 13.7 billion secure health transactions took place via the Surescripts network—a 26-percent increase from 2016—including 1.74 billion e-prescriptions. What’s more, the network connected 1.47 million healthcare professionals—13 percent more than in 2016—with secure patient data for 233 million Americans, or 71 percent of the population. Also, in 2017, more than 1.46 billion medication history transactions were made available to providers at the point of care.

There is a burgeoning health IT solutions market targeting opioid use disorder and addiction, with many of these solutions leveraging data and analytics to help providers see prescription drug usage patterns.

Jackson Tate, a research manager with Orem, Utah-based KLAS Research, who has been researching this technology market for an upcoming KLAS report, notes that there is significant innovation occurring, but this health IT sector is still in nascent stages. “There are certain technologies that we’re seeing pop up and become more popular that help doctors and care managers engage with their patients who are at high risk for opioid dependency or currently have an opioid use disorder. We still classify this market, as a whole, as being in early stages, with a few vendors that are out there in the field.”

Jackson Tate

The Louisville, Ky.-based Appriss Health is a leader in the field of PDMP analytics and tools, as its platform, PMP Aware, is now live in 30 states and provides access to mandatory pharmacy reporting. Appriss Health’s PMP Gateway platform integrates state PDMP data into EHRs and into physician and pharmacist workflows to provide real-time data at the point-of-care. Appriss Health also operates the PMP InterConnect, an interstate prescription drug data sharing platform that now includes 45 states.

One promising strategy to address the prescription opioid epidemic is optimizing PDMPs through integration with the IT systems of patient care organizations. Maryland is one state that has made inroads in this area, as CRISP (Chesapeake Regional Information System for our Patients), a regional HIE, provides access to PDMP data and has successfully integrated with a number of EHR vendors. Providers also can access PDMP data directly in their workflow through CRISP’s SMART on FHIR (Fast Healthcare Interoperability Resources app, which is accessed 100,000 times a day, according to CRISP.

As Healthcare Informatics Managing Editor Rajiv Leventhal noted in a recent article, Michigan state leaders utilized Appriss Health’s technologies in its ongoing fight against opioid abuse. Michigan state officials conducted an assessment utilizing Appriss Health’s artificial intelligence (AI) and machine learning technologies, including its “overdose risk score” that predicts the likelihood of a drug-related death to enable more advanced interventions and responses.

However, Tate notes that PDMP integration with health IT systems is not yet widely adopted. Case in point, more than a year ago, Michigan state officials announced an upgrade to the state’s aging opioid-tracking system and efforts to integrate it with EHR systems, at a cost of $2.8 million. A year later, only 42 percent of the state’s prescribers and dispensers have automatic access to the PDMP, according to an article in Crain’s Detroit Business.

Leveraging Data and Analytics

Many hospitals and health systems have moved forward to leverage their own IT systems, such as their EHR systems and population health tools, to collect and analyze data in order to address opioid abuse and addiction, and to prevent overdose deaths.

At the Danville, Pa.-based Geisinger Health System, clinical leaders are grappling with the fact that Pennsylvania’s opioid overdose death rate was the fourth highest in the country, and many of the counties with the highest death rates in 2016 were served by Geisinger Health System.

As detailed in a Healthcare Informatics article, Geisinger’s clinical IT leaders developed a strategy to address this by utilizing data and health IT tools to change providers’ prescribing practices. As a result of this effort, the health system has slashed opioid prescriptions in half, from a monthly average of 60,000 opioid prescriptions to 31,000 prescriptions per month.

John Kravitz

John Kravitz, CIO at Geisinger Health System, notes that data and IT were foundational to these efforts, as physician leadership developed a provider dashboard linked to the EHR to identify current practice patterns among providers. “Having the dashboard linked into the EHR has been critical to success,” he says. The health system’s IT leaders also leverage the state’s PDMP and is currently working to build APIs (application programming interfaces) to connect to providers’ workflow. 

“There are organizations that are further along down the path and they see the vision of where technology could take them and how it could be leveraged,” Tate says. “Those who are advanced and deep into this are looking to use big data and social determinants of health to further engage and understand their patient populations, and then also looking for those tools that are going to be disruptive. There’s a growing appetite for these new, smaller, innovative technologies.”

Emerging Technologies

There are a number of startups working on digital opioid solutions. Princeton, New Jersey-based Braeburn Pharmaceuticals developed a prescription implant that provides those who are addicted with a steady low dose of buprenorphine rather than opioids. RxAssurance, a healthcare startup based in Denver, built an app that can be used by patients to fill out a survey about family and personal health histories, and the platform then gives doctors assessments to determine a patient’s risk for opioid abuse.

At Brigham and Women’s Hospital in Boston, the emergency department piloted the use of capsules embedded with ingestible wireless sensors to measure patients’ prescription opioid use. The hospital partnered with eTectRx, a Newberry, Fla.-based technology company that develops the digital pills, to test the use of the pills on patients admitted to the ED for bone fractures and who were prescribed oxycodone.

When swallowed, the capsules are dissolved by digestive acids in the stomach and emit a radio signal that is picked up by a reader worn around the patient’s neck. That wearable device then forwards the message, via Bluetooth technology, to a smartphone app, where a clinician or pharmacist can view the patient’s medication adherence. Peter Chai, M.D., an emergency medicine physician and a medical toxicologist at Brigham and Women’s Hospital, says the technology can help to detect a pattern in how patients are taking pills and can help physicians to intervene if there’s a change in that pattern.

“Prescription opioids are the only medication where the onus of how you use it is placed on the patient. Patients are told, ‘take it as needed for your pain,’ but there is a huge gap between what patients think ‘as needed’ means, and what physicians think,” Chai says. “The cool part about the technology is that now that we can detect changes in digestion patterns or dangerous escalations, so we can then develop intervention and outreach.”

Chai and his colleagues plan to test the digital pills on post-operative spinal fusion surgery patients to track digestion patterns several months after surgery.

Peter Chai, M.D.

There are also startups developing innovative tools, from wearables to therapy apps, on the consumer-facing side to aid people battling opioid addiction. Trigger, based in Chicago, developed an app that monitors phone use to determine when someone recovering from addiction is most at risk. Chrono Therapeutics is developing a wearable patch to help patients overcome nicotine addiction and has plans to make a similar patch for opioid addiction.

Many healthcare leaders say that while innovative digital tools can help address some aspects of the problem, the technology needs to seamlessly integrate into the health system to be scalable and to make a significant impact. “You can prescribe a digital oxycodone pill in a research study, but I think the real gold is to develop this as something that a primary care physician could prescribe and a pharmacy would know how to interact with it,” Chai says.

Chai also notes that technology alone will not combat the growing opioid abuse and overdose problem, and that patient engagement is still a key part of the solution.

“There are many innovative devices out there, a dime a dozen, but none of it is going to work unless you deliver a message about appropriate medication use correctly to the patient,” he says.


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Moving Forward with Digital Transformation, with Cybersecurity in Mind

January 22, 2019
by Heather Landi. Associate Editor
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The forces of disruption and innovation—whether in the form of new business combinations such as CVS-Aetna or big technology companies like Amazon coming into healthcare—are undoubtedly impacting the healthcare industry and likely herald some seismic shifts in the industry landscape. Just in the past year, the industry has seen CVS’s acquisition of Aetna, the announcement from Amazon, Berkshire Hathaway and JPMorgan Chase & Co. of a new healthcare venture, Cigna’s acquisition of pharmacy benefit manager company Express Scripts and Amazon’s acquisition of online pharmacy company PillPack.

According to a new survey from BDO USA, a Delaware-based accounting and advisory firm, and NEJM Catalyst, 87 percent of healthcare leaders at patient care organizations predict Amazon, of all the new entrants in healthcare, will be have the most significant impact on the industry by 2020. It is against this backdrop that many healthcare organizations are focused on digital transformation initiatives, driven by a need to increase revenue and profitability, improve the patient experience and boost operational efficiency.

According to BDO’s Middle Market Digital Transformation Survey, which polls C-level executives at companies with annual revenues between $250 million and $3 billion, 94 percent of mid-market organizations have either developed a digital transformation strategy or are in the midst of developing one. Among healthcare organizations, 37 percent are currently developing a digital transformation strategy, 28 percent have developed a strategy but haven’t yet implemented it and 24 percent are implementing a strategy, according to that survey, which polled executives in the healthcare industry well as the natural resources, financial services and retail industries.

At the same time, healthcare is the most stressed of all industries when it comes to cyberattacks and data privacy breaches, with 43 percent citing it as their biggest concern, according to the BDO survey. While these two issues—digital transformation and cybersecurity—may seem largely unrelated, two technology thought leaders, Gregory Garrett and Malcolm “Chip” Cohron, say the two issues are intertwined, particularly as healthcare organizations face evolving and increasingly sophisticated cyber threats.

In an interview with Healthcare Informatics Associate Editor Heather Landi, Garrett, head of U.S. and International Cybersecurity for BDO USA, and Cohron, national Digital Transformation Services leader for BDO USA, share their perspectives on the current cybersecurity landscape in healthcare, the role that digital transformation plays in a threat-based cybersecurity strategy, and the key considerations for healthcare executive leaders as they move forward with digital transformation.  

With regard to the healthcare sector, what are some of the high-level takeaways from BDO’s Middle Market Digital Transformation Survey?

Cohron: We found that, compared to their counterparts in financial services, natural resources and retail, mid-market healthcare companies place the greatest emphasis on developing a digital transformation strategy. More than half (53 percent) cite it as a top digital priority. Healthcare is also most worried about cyberattacks and data privacy breaches. We think the two go hand in hand. Healthcare organizations have a target on their back because of all the highly valuable personally identifiable consumer information they possess. They are also, generally speaking, much further behind in digitizing analog information and manual processes, and their outdated IT infrastructure wasn’t built with security in mind. Because of that, they face greater urgency in digital initiatives like replacing or upgrading legacy IT systems. If they don’t, their cyber defenses are left vulnerable and they’ll have a higher price to pay.

What are some key digital transformation success factors?

Cohron: According to BDO’s Middle Market Digital Transformation Survey, for mid-market health organizations, the biggest barriers to successfully implanting a new digital initiative are 1) interoperability with legacy technology and processes (cited by 60 percent); 2) lack of skills or insufficient training (47 percent); and 3) underinvestment (41 percent). The first barrier is one of technology and the latter two of people, but the challenges are interconnected.

Interoperability initiatives are typically focused on process standardization and data integration. The goal is to make sure data is available, accessible and secure throughout the doctor-to-patient lifecycle, thereby streamlining information sharing and enhancing transparency.

But adopting new standards and embracing information sharing comes down to people. We’re talking about fundamentally changing the way people work. The type of behavioral change needed to make these goals a reality starts with tone at the top. The senior-most leaders of the organization not only need to be bought into digital transformation, but also need to convincingly evangelize the vision. You need your employees to understand why they need to leave the status quo behind, believe in the strategy and engage in the process. Most importantly, they need to understand what’s expected of them.

While an injection of new talent can help improve your overall digital competency, you will also need to provide current employees with the resources, training and development they need to be effective as their roles evolve.

In that survey, 43 percent healthcare respondents identified cyber attacks or privacy breaches as top digital transformation challenges, the most of any industry in the survey. What role does digital transformation play in healthcare organizations’ cybersecurity strategy?

Cohron: To sustainably innovate patient care, health organizations must be able to safely store and analyze patient data—the most valuable resource to the consumer, the business of health and, we believe, the security of a nation. At the same time, with the infiltration of technology into healthcare, consumers expect care to be available at their fingertips, personalized to their individual needs and preferences. They want digital health solutions. If health organizations are to keep up with these demands, not only do they need to digitize their core business processes, they need to reimagine the business of health altogether. We imagine a future where doctors will be able to tailor therapies to patients’ DNA and customize drug regimens, aided by cognitive diagnostic solutions, heralding a new era of precision medicine. Both digital transformation and cybersecurity are key.

Garrett: Digital transformation and threat-based cybersecurity go hand in hand.  Security is the backbone to digital transformation—and in fact, it can even serve as an innovation catalyst. Taking on digital transformation initiatives like upgrading or replacing legacy IT systems are key to not only increasing operational efficiencies, but also bolstering cybersecurity, as both security and privacy should be embedded into the initiative’s design and architecture. When an organization overhauls their IT infrastructure, their security risks undergo an overhaul, too. Old vulnerabilities may be mitigated or even eliminated, while new ones are introduced. The process of implementation will require a fresh look at how data is accessed and used and can help health companies shift their security resources accordingly, in conjunction with an external threat monitoring system. 

How would you describe the current state of healthcare cybersecurity, with regards to the threats healthcare organizations are facing and the healthcare industry’s defense posture?

Garrett: Technology has brought healthcare to consumers’ fingertips and put them at the center of their care for the first time. Now, traditional tech companies are building health apps, wearables and other devices, and consumers are using those to track their health progress and feed data back to their doctor, insurance provider or both. Underlining this new level of capitalization of data in healthcare is the Amazon, J.P. Morgan and Berkshire Hathaway health initiative. While this level of data-sharing is of course net positive for personalized care, it widens the target for cyber attackers.

To manage this growing cyber risk without constraining patient care innovation, a threat-based approach to cybersecurity is key for health organizations.

What is a threat-based cybersecurity strategy?

Garrett: Threat-based cybersecurity is a forward-looking, predictive approach. Rather than—or in addition to— focusing just on protecting critical data assets or following the basic script of a generic cyber program, threat-based cybersecurity concentrates investments in the most likely risks and attack vectors based on a company’s unique threat profile and the external threat environment. The problem with any cyber framework is that it’s relatively static, and typically updated based on historical breach data and lessons learned instead of forward-looking information. Security controls are meant to address specific risks posed by specific threats, which are constantly changing.

The first step to employing this strategy is to assess and take ownership of your organizational DNA, or the data assets and other intellectual property that make you unique—and an attractive target. During this process, health companies must keep in mind that the data assets they value most may not be the prime target for a would-be hacker. Most hackers seek the path of least resistance, more interested in making a quick buck than going after an organization’s “crown jewels.” For example, their data on performance outcomes, which they might value most, is not as valuable to a hacker because it’s more difficult to monetize on the dark web.

Taking patient needs into account, a health organization must determine what digital initiatives are needed to be competitive in the future—while also employing a threat-based cyber approach to anticipate what type of cyber risks could hinder or even arise from those initiatives.

What do the most frequent types of large-scale breaches from 2018 indicate about how health organizations should evaluate their threat environment in 2019?

Garrett: The most frequent types and locations of large-scale healthcare breaches in 2018 were unauthorized access or disclosure and email, respectively. We think this means that to effectively detect and respond to risks, health organizations need to prioritize the following actions. First, bolster access controls like technical policies and procedures to ensure only authorized employees have access to protected health information (PHI) via electronic health records (EHRs) and personally identifiable information (PII). Second, implement stronger audit controls to track and identify internal and external access to and exploration of information systems that contain PHI and PII. Also, organizations need to strengthen intrusion detection systems to more accurately monitor traffic moving throughout their email, network and information system endpoints to identify suspicious activity and clear threats in real time.

 


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Walgreens, Microsoft Ink Strategic Deal to “Transform Healthcare Delivery”

January 15, 2019
by Rajiv Leventhal, Managing Editor
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Observers are pointing to the agreement as a clear sign that the two companies are looking to fend off Amazon’s increasing push into healthcare

Walgreens Boots Alliance Inc. and Microsoft Corp. are joining forces on a major seven-year healthcare partnership that will aim to “deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.”

The companies announced today that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI (artificial intelligence) platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.

While innovation in healthcare has occurred in pockets, officials of the two companies believe that “there is both a need and an opportunity to fully integrate the system, ultimately making healthcare more convenient to people through data-driven insights.”

As part of the strategic partnership, the companies have committed to a multiyear research and development (R&D) investment to build healthcare solutions, improve health outcomes and lower the cost of care. This investment will include funding, subject-matter experts, technology and tools, officials noted in the announcement. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, this year, WBA will pilot up to 12 store-in-store “digital health corners” aimed at the merchandising and sale of select healthcare-related hardware and devices.

Executives noted that the companies will focus on connecting WBA stores and health information systems to people wherever they are through their digital devices. What’s more, the integration of information will enable valuable insights based on data science and AI that can allow for improvements such as supporting the transition of healthcare data into more community-based locations and sustainable transformation in healthcare delivery.

And by working with patients’ healthcare providers, the companies will look to proactively engage their patients to improve medication adherence, reduce emergency room visits and decrease hospital readmissions. Core to this model is data privacy, security and consent, which will be key design principles, officials stated.

Just last month, Walgreens Boots Alliance announced that it would work with Verily, an Alphabet company, to develop a medication adherence pilot project. Industry observers are already attesting that the Walgreens-Microsoft collaboration is an obvious sign that the two companies are trying to counter Amazon's growing healthcare footprint.

“Improving health outcomes while lowering the cost of care is a complex challenge that requires broad collaboration and strong partnership between the healthcare and tech industries,” Satya Nadella, CEO, Microsoft, said in a statement today. “Together with Walgreens Boots Alliance, we aim to deliver on this promise by putting people at the center of their health and wellness, combining the power of the Azure cloud and AI technology and Microsoft 365 with Walgreens Boots Alliance’s deep expertise and commitment to helping communities around the world lead healthier and happier lives.”

Notably, the companies will also work on building an ecosystem of participating organizations to better connect consumers, providers—including Walgreens and Boots pharmacists—so that major healthcare delivery network participation will provide the opportunity for people to seamlessly engage in WBA healthcare solutions and acute care providers all within a single platform.

In an emailed statement reacting to today’s news, Forrester analyst Arielle Trzcinski noted, “The technology focus will enable Walgreens to put in place a critical backbone to enable a more connected experience for the customer/patient, as well as support broader interoperability.”

And speaking to the difference between retail pharmacies and traditional care providers, Trzcinski said that retail pharmacies offer an opportunity to engage with the patient much more frequently than at an office visit, giving an example of how chronic care patients see their pharmacist frequently, while some figures indicate that the average diabetic patient sees his or her provider once every six months.

“This gap creates an opportunity for the pharmacist to help monitor the patients’ health and prompt the patient to receive preventative care in the retail clinic or through a virtual care visit. Using an enterprise health cloud, like Azure, you create a more connected ecosystem so that we can share that data with the patient’s additional providers, track outcomes, and intervene earlier when an issue arises,” he said.

Trzcinski also pointed out that up to 20 percent of hospitals are at risk for closure in 2019—according to Morgan Stanley—with most of them located in rural areas. “Consumers will turn to retail locations like Walgreens, Walmart, and CVS for convenient care options as well as virtual care delivery to fill the gap,” he asserted.

Through this agreement, Microsoft becomes WBA’s strategic cloud provider, and WBA plans to migrate the majority of the company’s IT infrastructure onto Microsoft Azure, officials said. Microsoft also plans to roll out Microsoft 365 to more than 380,000 Walgreens employees and stores globally.

 “WBA will work with Microsoft to harness the information that exists between payors and healthcare providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world,” said Stefano Pessina, executive vice chairman and chief executive officer of WBA.


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“Revolutionizing” Healthcare: How Non-Traditional Players are Shaking Up the Sector

January 15, 2019
by Rajiv Leventhal, Managing Editor
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Traditional healthcare stakeholders will not be able to slow down new industry entrants such as Amazon, one leading consultant attests

In late November when Amazon announced that it was launching a machine learning service that will aim to mine data from electronic health records (EHRs), company officials, in a blog post, noted that the software, Amazon Comprehend Medical, is “a HIPAA-eligible machine learning service that allows developers to process unstructured medical text and identify information such as patient diagnosis, treatments, dosages, symptoms and signs, and more.”

Two of Amazon’s specialists—Matt Wood, Ph.D., a machine learning expert, and Taha Kass-Hout, M.D., a former FDA chief health informatics officer—noted that a core issue in healthcare and health IT today is that a large amount of critical data is stored as unstructured medical text, such as medical notes, prescriptions, audio interview transcripts, and pathology and radiology reports. “This means that being able to identify this information can be a manual and time-consuming process, which either requires data entry by high skilled medical experts, or teams of developers writing custom code and rules to try and extract the information automatically,” they outlined, adding that Comprehend Medical will instead aim to specifically allow developers “to identify the key common types of medical information automatically, with high accuracy, and without the need for large numbers of custom rules.”

Following the announcement, industry observers were quick to react to Amazon’s latest aggressive push into healthcare, with one consultant for Impact Advisors, Liam Bouchier, a principal with the firm, noting that this latest initiative is simply another example of Amazon “doing what it does best”—working to analyze large data sets as a means to gain meaningful insights into the consumer through a variety of different ways. “This concept does make some in the healthcare industry uncomfortable,” he added.

Another healthcare consultant—Michael Abrams, managing partner at the St. Louis-based Numerof & Associates—agrees that the initiative is exciting at the surface, and believes it speaks to a much larger issue in the health IT market: responding to a significant need to do something constructive with the voluminous amount of data that stakeholders already own.

Taking a step back, Abrams, in a recent interview, explains that one of the core issues that has arisen from healthcare’s digital shift is that having access to digitized data is different from being able to use that data to streamline decisions or improve quality. “Because hospitals rushed to digitization in response to extrinsic [financial] incentives [as part of ARRA/HITECH], they wanted to qualify for federal subsidies, but hadn’t really developed the internal capability to use the data. So, for the most part they are still very early on that learning curve, and the notion of aggregating data, data manipulation, and the insights you can draw from aggregating data, is still a new concept, Abrams says. He adds, “Now that [organizations] have these [EHR] systems and are saddled with substantial upkeep, it’s important to find a way to make it pay off.”

He contends that much of the healthcare delivery community is obsessed with “big data,” but the truth is that “they have hardly scratched the surface using the data they already own.” Abrams asserts, “Many of them don’t understand their own internal operations and don’t understand the cost of doing business— what it costs them to do a knee replacement, for example. All they know is at the end of the year, if they are profitable, it’s all good. Every corner convenience store has SKUs on everything they sell, and they know what the profitably is on every item. How many hospitals can say that? Not many,” he attests.

But according to what Amazon has said regarding its machine learning capabilities, this new software can re-digitize patient records and other clinical notes, analyze them, and pull out key data points, Abrams explains. “This is a very strategic move for Amazon because it already has advanced capabilities in natural language processing. Amazon Web Services has been selling this kind of text analysis software to markets outside of medicine for some time. They have a significant advantage,” he says.

A Vendor Community Satisfied with the Status Quo

An updated brief from the Office of the National Coordinator for Health IT (ONC) last summer revealed that health IT giants Epic and Cerner have continued to maintain the largest EHR market share (22 percent and 24 percent, respectively), based on the proportion of hospitals that reported using the developer's certified products.

These results, though unsurprising, signify to Abrams an oligopoly in that Epic and Cerner account for about half of the hospital market share, with the top-five vendors in this space accounting for roughly 85 percent of the market share. “When you have an oligopoly, you have a lot of large, slow-moving entities,” says Abrams, who also believes that as consolidation increases in the provider market, leading to fewer larger players among hospital systems, it makes it “almost incumbent upon vendors to also become fewer and larger, in order to have a balance of power.”

What’s more, Abrams attests that the EHR vendors with the largest market shares “regard their propriety code and the closed nature of their systems as a defense against encroachment by other, perhaps hungrier players who don’t have that market share. The status quo of a lack of interoperability suits the dominant players,” he says.

Can New Entrants Be Slowed Down?

With all this in mind, while health IT vendors have traditionally been content with incremental change, Abrams strongly believes that outsiders such as Amazon, Apple, and Google “bring the technology and commercial savviness to dramatically shake up what’s been generally a very complacent industry.” He adds, “Players like Amazon have their eye on the next big thing.”

Indeed, the traditional players and the healthcare delivery organizations are, on at least at some level, “terrorized about what these technology companies are going to come up with next,” he says. Consider that in just the last year alone:

  • Amazon, Berkshire Hathaway, and JPMorgan Chase & Co announced they were teaming up on an initiative to improve satisfaction and reduce costs for their companies’ employees.
  • Amazon said it would be part of another endeavor related to healthcare—to remove interoperability barriers and to make progress on adoption of health data standards. For this project, Amazon is teaming up with Microsoft, Google, IBM, and others to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project.
  • Apple, of course, also had a big announcement in early 2018: that it would be testing its new Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Since that time, more than 100 new organizations have joined the project,  according to Apple. The idea behind the feature is that consumers could see their medical records right on their iPhones.

As such, prior to the past year when non-traditional players began moving more and more into healthcare, providers were “reasonably comfortable with moving as slowly as they could because they thought they had a good fix on the level of pressure and the pace of change that they might expect from the government,” says Abrams.

Adding to this thought, he notes that providers—with the help of industry trade associations—could negotiate with the government on the speed at which certain regulations might come down the pike, depending on how ready stakeholders are. But, Abrams adds, “Nobody can say ‘slow down’ to Amazon; when they want to do something, they are going to do it, and if they have a better solution, it could very well revolutionize the industry.”


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