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Healthcare Outlook: How the Industry Will Trend and Transform in 2019

December 31, 2018
by By Timothy C. Peck, M.D., Industry Voice, co-founder and CEO, Call9
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This past year was a transformative one for healthcare. From big tech’s entrance into the field to the rise of virtual care to Congress warming to reimbursing innovative care delivery models, the healthcare industry has started to see some significant shifts in the space. The importance placed on value-based care has also been a major driver for industry change for patients, providers and payers. The opportunity to improve patient outcomes while decreasing cost will drive the industry forward and help reshape legacy practices.

In a speech at an Alliance for Connected Care telehealth policy forum in November, CMS (the Centers for Medicare & Medicaid Services) Administrator Seema Verma spoke about how “relentless innovation is a crucial driver in creating value across all industries.” With that sentiment in mind, here are five trends that will impact the health tech landscape in 2019:

Value-based care arrangements will provide opportunity for bipartisanship in 2019

In the current political landscape, the tendency toward partisanship is strong, but the American people want Congress to work together, particularly when it comes to healthcare. Republicans and Democrats should be able to find common ground with value-based care arrangements that incentivize providers to do what’s best for the patient rather than doing the most amount of “things” (i.e. tests, procedures, etc.) to the patient.

According to an NBC News and Wall Street Journal report, healthcare was the No. 1 issue for voters heading to the polls in 2018 – and voter turnout as a percentage of the voting age population was greater than any midterm election since 1914. Both parties will need to come together to get things done that address their constituents’ concerns about healthcare.

The good news is that CMS is asking Congress to enable them to make value-based arrangements accessible. Passage of the bipartisan Reducing Unnecessary Senior Hospitalizations Act (H.R. 6502), or RUSH Act, is an example of how Congressional leaders can work together on a value-based solution that saves the government billions of dollars while delivering better care to patients.

Providers and tech-related services will increase

Tech-enabled medical services are receiving a lot of attention right now; recent acquisitions and the other deals reportedly in the works point to a growing trend. In June, Anthem completed an acquisition of Aspire Health, the nation’s largest provider of non-hospice, community-based palliative care for people facing a serious illness. Landmark Health, a risk-based provider group that provides home-based medical care for patients with complex health needs, was rumored to be for sale early in the year, and Amazon paid nearly $1 billion for pharmacy startup PillPack.

The pace of innovation has traditionally been set by providers, who have more flexibility than payers in creating systemic change. However, this trend is shifting, and tech-enabled services are leading the way. More tech services, such as Aspire’s predictive clinical and claims-based patient algorithms, allows providers to take greater risks at lower cost, which pushes payers and other traditional services toward embracing—and funding—innovation.

Data will transform how providers make decisions

For a long time in healthcare there has been great hope that data will revolutionize healthcare. While it hasn’t quite happened yet, 2019 is when we will really start to see data used in ways that are transformative. The growing implementation of technology developed for healthcare is creating the opportunity to use clinical data in more sophisticated ways, allowing clinicians to make better decisions and deliver better care.

Payers will embrace technology innovation more than ever before

Companies like Bright Health, Devoted, Oscar and Clover are continuing to attract a lot of investment from the venture and private equity world because they’re seeking to offer a better user experience while also collecting and utilizing data in ways that will drive better outcomes—at lower costs. This will create competitive and creative pressures on entrenched payers to embrace new care solutions and otherwise be nimbler.

Private partnerships with healthcare providers will increase

Social determinants of health often prevent certain populations from accessing care in a timely and cost-effective manner. Take transportation, for example: millions of Americans miss or delay medical appointments because they don’t have a ride. However, the shift to value-based care, coupled with a willingness of companies across industries to integrate technologies into each others’ platforms, is creating new and interesting collaborations to address some of these disparities.

Timothy Peck, M.D., is the co-founder and CEO of Call9. He previously held a faculty position at Harvard Medical School and was the chief resident in the emergency department at Beth Israel Deaconess/Harvard.


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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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