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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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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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Should Apple Join the Amazon/Berkshire/JPMorgan Joint Healthcare Venture?

January 10, 2019
by Rajiv Leventhal, Managing Editor
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Apple should get involved with the Amazon, Berkshire Hathaway, and JPMorgan Chase & Co joint healthcare venture that the companies announced last year, said Jim Cramer, television personality and former hedge fund manager.

According to a CNBC report this week, Cramer—the host of CNBC's Mad Money and whose charitable trust also owns shares of Apple—said that J.P. Morgan CEO Jamie Dimon would have to be the one to bring Apple involved in the venture, since Warren Buffett's Berkshire Hathaway owns a huge stake in the tech stock that could appear "self-serving.” Said Cramer, “It is really time for, I think, that ecosystem to embrace the Apple ecosystem."

As Healthcare Informatics noted in a news report published last January, “With an ambitious-sounding, if vaguely worded, announcement, three corporate giants—Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. announced Jan. 30 that they were launching an initiative to improve satisfaction and reduce costs for their companies’ employees...The three companies, which bring their scale and complementary expertise to this long-term effort, will pursue this objective through an independent company that is free from profit-making incentives and constraints. The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost.’”

Although not many details are known about this collaboration, the organizations named Atul Gawande, M.D., as CEO of the initiative, back in June.

Meanwhile, in August, 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 initiative, Amazon will be 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.

Over the past year, industry observers have had their eye on non-traditional healthcare players such as Amazon and what they can bring to the table from an innovation and cost-cutting perspective. One recent survey of 100 healthcare organization leaders found that most C-suite executives do have their eyes on Amazon to shake up healthcare.

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.

In a recent interview with Cramer that aired this week, Apple CEO Tim Cook attested, “I believe, if you zoom out into the future, and you look back, and you ask the question, 'What was Apple's greatest contribution to mankind?' It will be about health.”

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