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One Technology Executive on How to Bring Amazon-Style Digital Innovation to Healthcare

June 14, 2018
by Heather Landi
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Health systems across the country are focused on digital transformation with an eye toward lowering costs and improving access to and quality of care. At Seattle-based Providence St. Joseph Health, technology leaders are making significant advances in the health system’s digital journey, offering robust capabilities that empower patients to become more active participants in their own health.

Aaron Martin, executive vice president and chief digital officer of Providence St. Joseph Health (PSJH), is a key player in driving digital innovation across the health system. Martin is responsible for the digital, web, mobile and online marketing channels for PSJH, and he also serves as managing general partner of Providence Ventures, a $150-million-dollar healthcare IT venture fund.  A former Amazon executive for 10 years, Martin also previously worked at McKinsey & Company, and he was an executive/founder of two early-stage technology companies funded by New Enterprise Associates and Mayfield.

PSJH is a health system that includes Providence Health & Services and St. Joseph Health, with facilities in Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. PSJH has 119,000 caregivers who serve 50 hospitals, 829 clinics, and hundreds of programs and services.

Martin joined PSJH four years ago, and since that time, the health system’s digital team has been keenly focused on leveraging technology to provide patients and consumers better access, convenience and personalization. Martin brings his unique experience and expertise in consumer-facing digital technology to healthcare. “Traditionally healthcare, on the provider side, has been a B2B (business-to-business) industry, so traditionally not focused on consumers. For 10 years I worked at Amazon and now I’m bringing in that focus on the consumer and looking at it from the perspective of, how do we engage with patients, especially in a digital context? It’s about setting a high bar for customer service to our patients and to our consumers who are working with us,” he says.

Aaron Martin

One of the significant hurdles facing patient care organizations in this ongoing digital transformation journey is meeting consumers’ expectations, and at a time when the healthcare industry is generally behind the digital curve.

“Consumer expectations are such that consumers, and particularly Millennials, are not going to put up with this notion that I have to make a phone call to do anything. They want self-service wherever they can possibly get it; the expectation of the consumer is that you should be able to find and schedule a physician or a clinician appointment just as easily as you can make a restaurant reservation on OpenTable. There’s just a higher bar of expectations out there, which I think is great,” Martin says.

Technology leaders at PSJH are addressing these challenges, with a focus on building digital capabilities that ensure the health system continues to own and drive patient experiences and relationships, while also addressing the broader set of strategic problems for different patient populations.

Driving Digital Engagement

Foundational to PSJH’s digital strategy, Martin says, is delivering a ‘10x better experience’ online to entice healthcare consumers to work with the health system online, as opposed to offline. Once the health system has interacted with patients online, the second aim is to engage on an ongoing basis through a personalized health platform.

“Your digital experience has to be 10 times better than your offline experience to cause consumers to change behavior. Think about technologies such as Netflix, Amazon and Lyft, those are an order magnitude better experiences than what they replaced, and that’s what is needed to cause consumers to change their behavior.”

With this in mind, the health system’s digital team built PSJH’s Express Care suite of services for non-emergency, low-acuity care. As part of this suite of services, PSJH offers 33 Express Care Retail clinics to provide same-day visits as well as the Express Care Virtual platform enabling patients to see a nurse practitioner from their smartphone, tablet or desktop computer. Also, the health system launched Express Care at Home, a service that enables patients in the Seattle market to summon a provider, through an online platform, to come to their home or office to provide healthcare services.

According to PSJH, Express Care is projected to have well over a hundred thousand visits in 2017 with over 10,000 coming in digitally through Virtual Visits and At Home Visits. Net promoter scores, an indicator of customer satisfaction, for Express Care range from ~65 to ~85, on par with major technology companies like Apple and Amazon, Martin says.

The next challenge that Martin and the digital team tackled was finding ways to engage consumers an ongoing basis. “Healthcare is challenging because unlike other industries and services we use as consumers, there isn’t a natural engagement model that is frequent. Healthcare consumers and patients often only interact with the system episodically if ‘something is wrong’. How do you create that engagement between episodes of care?”

Martin continues, “Some industries and some companies have naturally occurring engagement models that are better than healthcare. We’re based in Seattle, so just down the street is Starbucks, and I use their product every single day. So, when they are transitioning me to an online state, by using their app, they have an engagement model that is just naturally occurring, because it’s daily for me.

PSJH has developed two digital platforms—Circle and Xealth—to promote more frequent consumer engagement. Circle by Providence is a personalized platform which delivers content, products, and services for women to help them manage their health and the health of their families. The Circle app is targeted to the female head of household, who Martin refers to as the “chief medical officer of the home.” “She controls about 90 percent of the healthcare spend, not only for her family but also extended family,” Martin says.

The key to this platform is personalization, he notes. Personalization is driven either through a connection to the patient’s electronic medical record (EMR) or by the woman providing information about herself and her family. The resources Circle offers continue to grow with new, relevant information continually being added. The platform drives digital engagement in much the same way as the Amazon Prime platform.

“If you look at Netflix, Amazon and all these other e-commerce platforms, they have a personalized engine riding on top of them that basically says, ‘We’ve noticed you like this product, this movie, can we be helpful to suggest this other content for you?’ That’s exactly what this platform does.”

Another way PSJH is driving digital engagement is through Xealth, a digital prescribing service. One challenge facing clinicians is they can’t prescribe digital apps, services or products to their patients in the same way that they prescribe medications right from the EMR. “How do offer your patients the vast array of different applications, content, products and services that are out there, without having to build it all yourself? We can’t out-innovate the marketplace,” Martin says. As an example, a clinician may want to prescribe a digital diabetes prevention program, such as Omada, to a patient. In most cases, clinicians must do this outside of the EMR and outside of their existing workflow.

Using the Xealth platform, clinicians can prescribe digital care just as they would a pharmaceutical, directly from their EMR, Martin says. The platform provides a simple, continuous connection back to the health system ecosystem and existing portal. The clinician also can see if the patient has taken action on what was prescribed right in the EMR workflow. “The patient is going to the virtual drug store to pick up whatever it is their physician has recommended, and then we have an opportunity as they are ‘walking’ through that virtual drug store through our portal app to show them other products and services that we just launched that may help them in their next episode of care,” he says.

Martin notes that foundational to this digital journey is establishing an accurate catalog of providers, or a “source of truth” for physician directories. To address this challenge, the health system implemented solutions from Boston-based startup Kyruus, which uses analytics to help hospitals match and schedule patients with appropriate providers.

“Having an accurate physician directory sounds like a small problem to solve, but it’s not, it’s a massively complicated problem. We have 20,000-something clinicians on the Kyruus platform, and I think, 10,000 or so of those we employ, and the balance of them are affiliated, so they might just have credentials in our hospitals. So, it’s about making sure the clinicians still work there, have credentials, and then what’s their scope of practice,” Martin says.

Kyruus offers an enterprise-wide platform that integrates patient access applications and the provider data management platform, which enables health systems to optimize patient access across points of entry, with the same provider data appearing in each channel. The result is consistent information across the enterprise, more precise patient-provider matches, and a better patient experience.

Improving Healthcare Access, Convenience

For patient care organizations, building better digital platforms can help to address larger healthcare challenges around patient access to care and convenience. While some healthcare leaders worry that increasing access will drive up utilization, Martin says he holds a contrary view.

“I think if you can lower the cost of care and make it more prevalent, you’re going to lower the overall cost to healthcare. I think there’s a lot of disfunction that happens due to lack of access,” he says. “A lot of the work that we’re now doing is around taking that convenience platform, with Express Care, and we’re starting to retool it and refocus it toward the Medicaid population.”

Martin notes that it’s common for Medicaid patients, due to issues with access to primary care, to utilize the ED for low-acuity, primary care visits. In some of its hospital emergency departments, the health system is experimenting with offering visitors to the ED the option of a video visit to address low-acuity health issues.

“We’re looking at these other technologies to improve access and drive down the economics of delivering care. We’re starting off with low acuity, and you’ll see us work more in primary care and parts of specialty care as well,” he says. “Our mission, fundamentally, is to serve the poor and vulnerable; inconvenience hurts lower income patients much worse than middle and upper income. If you’re asking someone who works an hourly job to take a day off work to go to a primary care clinic, that’s a day’s wages. If we can create an offering where he or she can pick up phone and allow us to triage whatever complaints he or she may have over a telehealth visit, then that helps those patients.”

More broadly, driving digital engagement also enhances population health efforts as well, Martin contends. “If you have great digital engagement with patients across different patient populations your ability to deliver population health is enhanced dramatically. Today, how population health happens is, typically, you have people intervening by calling people during dinner and doing case management. If you’re constantly engaged with them digitally, you can be a lot subtler in terms of encouraging them to try healthier habits and to access care in a different way,” he says.


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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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AHRQ Launches App Challenge for PRO Data Standardization

August 15, 2018
by Rajiv Leventhal, Managing Editor
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The Agency for Healthcare Research and Quality (AHRQ) has launched a competition to address the need for greater use of standardized patient-reported outcomes (PRO) data in clinical care and research.

The total prize pool for the challenge, called the AHRQ Step Up App Challenge, and which will be spread out over three phases, is $250,000. PRO data, according to AHRQ, are defined as any report on the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or other medical expert.

But a key challenge for providers and patients is that PRO data are not routinely collected and used in practice. One reason is that there is no standardized way to collect and integrate PRO data into health IT systems, thereby limiting the ability for clinicians to use the data or easily share these data across health systems for research or other purposes, including quality improvement, according to AHRQ officials.

As such, the AHRQ Step Up App Challenge seeks innovative technologists who can develop and present user-friendly apps capable of collecting standardized PRO data in various ambulatory settings, including primary and specialty care. The winning app will be tested in nine practice settings affiliated with MedStar Health in Washington, D.C., Maryland, and Virginia.

The challenge has three specific phases:

  • Phase 1: Participants will submit a five-page business proposal, demonstrating the originality and feasibility of their app idea.  Up to 10 winners will be selected with a prize of up to $12,000 each.
  • Phase 2: Phase one winners will develop and present an app capable of collecting standardized PRO data in various ambulatory care settings, including primary and specialty care.  First prize in this phase is up to $35,000, second prize is up to $30,000, and third prize is $25,000.
  • Phase 3: The grand prize winner in phase two will collaborate with MedStar Health to test the app in nine practices.  Upon completion of a successful pilot test, the grand prize winner will be awarded up to $40,000, bringing the winning prize to as much as $87,000.

The AHRQ Step Up App Challenge seeks innovative technologists who can develop and present user-friendly apps capable of collecting standardized PRO data in various ambulatory settings, including primary and specialty care. The winning app will be tested in nine practice settings affiliated with MedStar Health in Washington, D.C., Maryland, and Virginia.

“While some digital tools exist to collect these data, they are not in wide use due to problems with integrating them in practice workflow, as well as patients’ discomfort with using such tools,” AHRQ Director Gopal Khanna, said in a statement. “This competition will address this issue and result in a user-friendly app that can enhance healthcare data collection and thereby improve the quality of care for all Americans.”

In partnership with AHRQ, the Office of the Secretary is providing financial support from the Patient-Centered Outcomes Trust Fund, and the Office of the National Coordinator for Health IT (ONC) is leading stakeholder efforts to develop the technical specifications for the Step Up App Challenge.

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