The U.S. healthcare industry is in the process of major transformation and during a health innovation conference at the Massachusetts Institute of Technology (MIT) on Oct. 21, faculty, researchers, clinicians and practitioners addressed the challenges confronting the industry and the tools being brought to bear to address those challenges.
MIT’s Sloan School of Management’s Initiative for Health Systems Innovation (HSI) sponsored the “Technology, Analytics and Systems” conference at the Cambridge, Mass.-based campus with a specific focus on three major challenges—the management of chronic illness, the role of telemedicine and intra-system payment and reward plans for providers.
To kick off the day-long conference, Jay Levine, retired principal of ECG Management Consultants, drew parallels between the ongoing transformation in healthcare to transitions in other industries in which there were dramatic federal realignment of regulations, such as the banking and airlines industries. “There was dramatic disruption in those industries, characterized by new entrants into the industry, low cost entrants, and consolidation among players to attain scale and market. This transition is now happening and it’s ripe for the innovation and application of technology and analytics and other tools that are bringing to bear in the healthcare industry,” Levine said.
MIT Sloan Professor Retsef Levi, Ph.D., co-chair of the conference and the HSI, said, “The health system is under significant pressure to change, to transform itself, and to articulate what this transformation is about, the current health system is designed to provide discrete, reactive care for sick patients, in specified locations, and it’s physician-focused with providers paid based on the volume of activities performed.”
He continued, “What it needs to transform to is very different. The idea of health is going to be broader, more comprehensive—what do patients eat, do they smoke, where do they live? It’s going to require us to think deeply about what we do for every patient, and how we think about the welfare of the population. It’s going to be team-based, patient-centric, and data-driven personalized care. And providers will be paid based on risk managed, health outcomes and efficiency.”
Retsef also said market incentives and payment schemes will not be enough to drive the transformation. “There is a lot of evidence in the last 50 years that tweaking market incentives is not enough,” he said, noting the development of accountable care organizations (ACOs). “There is growing concern that just merely changing the incentives is not sufficient as some organizations are seriously struggling and it’s an ambitious task.”
“We really need to fundamentally rethink how health systems are structured and what organizational capabilities they should have in terms of analytics, technology, workforce, processes and resource allocation. We need to think deeply about behavioral and cultural considerations—the humans that are patients and the humans that are providing the care. And, of course, we need to continue to leverage advancements in clinical innovation and how use that to create effective systems with better outcomes at sustainable cost.”
Retsef also said MIT’s Sloan School of Management’s HSI program is working to bridge different stakeholders across disciplines to address these healthcare challenges. “Most health systems, even the pioneering systems, struggle with the stream of ideas and technologies and how to take these ideas and technologies and do something that is sustainable economically. There is very little infrastructure to allow these systems to think and experiment rigorously to learn what works. We can be facilitators with data-driven experimentation and system cost-benefits analysis,” he said.
The Role of Telemedicine
During a panel discussion, healthcare industry leaders and an economist discussed the current and future state of telemedicine and the challenges to more widespread use of telemedicine technologies.
On the panel were Kevin Galpin, M.D., acting chief consultant of Veterans Health Administration (VHA) Telehealth Services; Michael Hodgkins, M.D., vice president, chief medical information officer at the American Medical Association (AMA); Mary Modahl, chief marketing officer and senior vice president, American Well Corporation and Joseph Doyle, Erwin H. Schell professor of management and a professor of applied economics, MIT Sloan School of Management.
Looking at the current state of telehealth and what it encompasses, Galpin, whose agency, the VHA, has been progressive in this space with two million telehealth visits in 2014, said, “We break it down into three things. There’s accessibility to the system, so a patient has an appointment over at this location and how do I make it easier for the patient to get access to care, whether that’s bringing something from a main medical center to a local clinic, or even to their home. Second, there’s the capability to increase capacity, so in underserved areas, in rural areas where it’s hard to recruit, we go to areas that I can recruit and deliver services through digital technology. And then quality and looking at areas where we want to improve outcomes. In our ICUs, we added telemedicine as an additional layer of providers and systems on top of what we already have and we get better outcomes. Those three things can blur and great programs will improve all three, but you can focus on one and you can have different goals for different programs.”
Modahl with telehealth vendor American Well, said, from a technology point of view, telemedicine is moving rapidly forward. “You hear about technology such as remote monitoring, two-way video visits and those technologies, and we have individual silos of innovations, but when they come together, the applications become truly exciting.”
She continued, “We’re working on how to bring data from remote monitoring systems in, so the data is in front of clinicians and healthcare providers can see how they need to do interventions. I’m not saying we’re there yet, but that’s at the forefront of innovation. Is it video, or is it store and forward technology? I think it’s all of those things and it’s evolving from individual silos to a digital delivery system with a range of capabilities, and it needs to integrate back into systems of records such as electronic health records (EHRs) from companies like Epic, Cerner and Allscripts. Another area of research is developing APIs [application program interfaces] to make sure integrations happen, because if we make telemedicine a little thing on the side, it’ll just be a little thing on the side. We believe that every clinical relationship will have some element of telemedicine and some element of in-person care.”
Doyle, a professor of management and applied economics at the MIT Sloan School of Management, outlined his current research on telehealth comprised of two randomized, control trials. One telehealth trial is focused on a suicide prevention program. “It starts with a predictive model and uses a lot of variables, big data, and machine learning type tools to identify which patients might be at risk of attempting suicide.” As part of the program, physicians at some clinics receive notifications that their patients are scoring high in the risk assessment tool. For large organizations, researchers are sending hundreds of thousands of text messages to patients asking them how they are feeling and supplemented with phone outreach. “We’re hoping to move the needle on this, with big data tools coupled with casual analysis through randomized control trials,” Doyle said.
The second project involves a community paramedic program through a large healthcare provider in New York, he said. “They use data tools to identify super utilizers, and then provide home visits with a paramedic and a virtual visit with a critical care physician there on-site to help prevent this revolving door with emergency room visits with this population. This a way to improve the quality of the care these patients are getting, as it’s more timely, at their home so they don’t have to make a trip to the ED and it saves money at the same time.”
The Technical Challenges
When discussing current technical challenges to using telemedicine technologies, such as video conferencing, Galpin made a plea to digital technology developers and engineers to make improvements to the patient experience by focusing on what he called “low-hanging fruit.”
“With video conferencing, for example, with the person you’re talking to, their eyes are here toward the top of the screen, and the camera is here at the bottom of your screen. I think the technology exists to correct that so I can look at my patient’s eyes and they look at my eyes. We’re doing care from a distance and being able to look somebody in the eyes is a critical piece.”
Galpin noted that there is the opportunity to improve quality and access to care, but the "tools are missing."
“I’ll use the stethoscope as an example," he said. "When I was training, we used written records, I’d listen to the patient with a stethoscope and then translate that information into a visual picture of heart sounds. And now with EHRs, I have to describe the sound. So we’re now digitizing but I’m still describing the sound. Why can’t we see a visual of the heart sounds? If I could digitize that and put it into a picture, I could do better care through a stethoscope remotely than I do in person without a digital stethoscope.”
Modahl agreed with Galpin about the need for better tools for clinicians. “We’re training clinicians to deliver healthcare over telemedicine systems and they are learning to look into the camera a certain percentage of the time so the patient feels that they are being looked at. There are challenges of reimbursement and human factors and both are critical on the patient side and the clinician side. We need to figure out protocols, what is the evidence for how we treat various conditions remotely? Clinicians have a different relationship with patients in that the patient has to assist with the examination, it’s 'feel here, do this,' so it’s a different kind of examination emerging, and it’s not defined yet.”
Hodgkins sees the management of healthcare data as one of the biggest challenges to harnessing the potential of telemedicine. “I think we’re in a challenging stage in the use of technology to enhance care. Some of you may be familiar with the Gartner hype curve and some people think we’re heading into the trough in this space. That’s not a bad thing. It means we have a challenge figuring out how all this works at a system level. The big challenge is the data we created With EHRs, we’ve moved analog to technical stores of information that don’t talk to each other, or don’t talk to each other very well, for the most part, even though that was the promise. And with the introduction of digital technologies, apps, we’ve created more data. The biggest challenge is how do you create a system that makes sense to deliver the best care at the best time for each individual?”
Evaluating Telemedicine’s Effectiveness and Reimbursement Challenges
According to the panelists, a significant challenge facing the healthcare industry in the use of telemedicine is a lack of peer-reviewed, academic studies focusing on the efficacy of telemedicine to improve care and the potential for cost savings.
The panelists cited a report from The Agency for Healthcare Research and Quality (AHRQ) released in July. In that report, AHRQ concluded that the use of telehealth is vast and varied, yet there is evidence to support its effectiveness for specific uses, such as remote patient monitoring for patients with chronic conditions and psychotherapy as part of behavioral health.
“One thing the report focused on was the need to focus on the practice,” Hodgkins said. “There is very little literature on how best to execute digital health in clinical practices and how to integrate it into workflow, and they also said there isn’t enough metric data to see the financial impact of digital health.”
While Modahl agreed that there is a lack of research, she noted that American Well works with 45 major health plans. “With the health plans, the actuary teams do their estimates, and the fact is that we are moving from 50 million covered lives to 75 million covered lives. The actuaries have concluded it’s beneficial in terms of payment and that it’s saving money. I think the studies will come out over time. Observationally, we see the people who estimate cost, the commercial insurers, are fast to cover it.”
Galpin with VHA said, “We certainly study this and have our own data and have seen fantastic outcomes, with a 50 percent reduction in admissions or readmissions. I think this is a challenging area for telemedicine, what do you study? Am I testing the providers’ ability, the patients’ adherence, or the technology? We know the technology works. We need to design studies to measure the type of outcome we are trying to achieve.”
Hodgkins said an AMA survey of 1,300 physicians indicated that physicians are ready to embrace telemedicine. “The good news is, the vast majority, 75 to 80 percent, are excited about the possibilities and opportunities created by virtual health. The expectation is that these tools have to integrate with their work. To get to the state of disruption, you have to accept technology, and it must fit into the work life of physicians and staff. Physicians want to know it won’t disrupt their work, or disrupt their relationship with patients.”
“If you make it easy to use, people will use it,” Galpin said. “We have a far way to go to make it fully integrated.”
The discussion among the panelists turned to current payment models and reimbursement for telemedicine services. “It’s a challenge, and we have to live within those [limitations] right now,” Modahl said. “With regard to reimbursement, there’s also integration with EMRs, which are these old systems, so there are huge technology challenges for sure. Ultimately, telemedicine will be for payers who are in it for the long haul and make the commitment and there might be a five to 10 year period of doing integration.”