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Ikispiration: Why Apple, Amazon, JP Morgan Chase and Berkshire Hathaway Can Easily Fail in Healthcare

February 27, 2018
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What awaits Jeff Bezos, Warren Buffet and Jamie Diamond on their most excellent adventure to introduce transformative technology to healthcare?

Years ago, I read an article in Smithsonian Magazine about Dr. Yoshiro Nakamatsu, a.k.a. "Sir Dr. NakaMats," who claimed to have more than 3,300 patents—including the original floppy disk. He had some interesting things to say about successful innovation:

That early floppy, he says, is perhaps the purest embodiment of Ikispiration, the Dr. NakaMats system of creativity. It has three essential elements: suji (“theory”), pika (“inspiration”) and iki (“practicality”). “To be a successful invention, all three are needed,” says Dr. NakaMats. “Many inventors have pika, but not the iki to realize their dreams.”

I was reminded of Ikispiration recently when Apple rolled out a patient-facing personal health application and Amazon, JP Morgan Chase and Berkshire Hathaway announced they were launching a new company to innovate healthcare:

"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."

These announcements have garnered a lot of attention and a mix of enthusiasm and skepticism. One well-seasoned healthcare IT colleague responded to the above quote with a sarcastic, “Gee, why didn’t we think of that!” Echoing a famous healthcare newbie, another said, “Who knew healthcare was so complicated?” and then added, “Pretty much everyone who has worked in healthcare or dealt with serious illness!”

Decades of experience have taught me that we must seek ideas from outside healthcare if we are serious about transformation. There is a lot to learn about efficiency, safety, quality and satisfaction from other industries. There is also much to gain by studying marketing, behavioral economics, human factors design, organizational culture and many other fields. So, I strive (and sometimes fail) to be an open-minded skeptic, to maintain equipoise between unbridled enthusiasm and rank cynicism.

However, it’s not a biased conceit to say that healthcare really is different from other industries. That’s because healthcare is:

  • Very personal and touches much that is sacred about us as human beings. Patients are not exactly like consumers, but they are more alike than we have previously recognized.
  • Pervasive and spans the continuum of care from home to school to work and everything in between.
  • Very simple or exceedingly complex or both.
  • Diverse, encompassing everything from wellness and prevention to chronic disease to palliative care and hospice.
  • Mostly focused on “sick care” and only deals with a small part of what actually drives health outcomes.
  • Culturally complex and highly stratified with distinct tribes and clans who must collaborate and have different knowledge, power, biases and motivations.
  • Hobbled by economic and business models that don’t align well and affect 1/5 of U.S. GDP.
  • Highly regulated.

For all these reasons, Ikispiration makes me skeptical about these new entrants in the race to fix healthcare. They are likely long on pika (“inspiration”), short on suji (“theory”) and shorter still on iki (“practicality”). It’s a pattern I see all the time. A very cool, even inspired idea is put forth, but those suggesting it don’t know much about the theory that drives healthcare delivery and reimbursement. Frequently, they lack meaningful practical knowledge of how things actually work in healthcare (as opposed to the theory) and how to effect change in culturally complex environments.

They also tend to overlook the iron triad of “people, process and technology” that determines the success of most improvement efforts in healthcare. Deploying technology solutions is pretty worthless if you don’t address underlying processes (typically workflow) and people’s needs, motivations and culture through substantial change management efforts.

Consider Apple’s new personal health app. It “checks the boxes” on inspiration and theory. A mobile personal health record (PHR) could be a big win. Apple’s ability to deploy simple, elegant solutions could make it a formidable competitor in this arena. But dig a bit deeper and you will find that the data exchange is limited and hangs by a single, narrow thread: FHIR (Fast Healthcare Interoperability Resources). Sorry, but that’s only practical for getting a very limited subset of data out of EMRs (electronic medical records). Worse yet, FHIR implementations vary from EMR vendor-to-vendor compromising its ability to be a consistent standard.

This reminds me of the early days of personal finance programs that only let you download transactions for a few banks and none for credit cards. Only the most obsessed users were willing to do all that data entry. Personal finance took off when banking achieved meaningful interoperability. PHRs will be the same. 

In short, Apple may design a “killer app” but still faces the same interoperability problem as any innovator in healthcare. Google and Microsoft faced the same challenges in their PHR efforts, which they ultimately abandoned. In each case, these companies had pika and suju, but not iki! As I have written before, the “iki solution” for interoperability will be robust APIs (application program interfaces).

What awaits Jeff Bezos, Warren Buffet and Jamie Diamond on their most excellent adventure to introduce transformative technology to healthcare? Recently, I was working on a project to leverage real-time EMR integration for patient satisfaction surveys. There was plenty of pika and suju in those discussions as we explored theories and ideas about detecting and heading off or remediating negative patient experiences. Excitement grew as we discussed how automating the administration of these surveys could reduce the cost while improving the yield and accuracy and would position healthcare providers to respond in a timelier fashion.

Then we ran smack into the iki of Centers for Medicare and Medicaid Services (CMS) regulatory requirements. There may be many good reasons to survey patient satisfaction, but the most compelling for a health system is the impact the CMS HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey has on reimbursement. CMS places significant restrictions on when and how these surveys are administered. As we experienced firsthand, this iki significantly complicates efforts to innovate and automate.

So, let’s welcome Apple, Amazon, JP Morgan Chase and Berkshire Hathaway and all they can bring to improve healthcare. We definitely need their help and that of many others, because real transformation can only result from a synthesis of old and new. Both old-timers and newcomers alike should strive to be open-minded skeptics and engage constructively in this opportunity to learn together. We would also be wise to remember Dr. NakaMats and his prescription for successful innovation: Ikispiration.

Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email DaveLevinMD@gmail.com.


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New Blockchain Project Sets to Tackle Provider Credentialing

November 12, 2018
by Rajiv Leventhal, Managing Editor
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A group of five healthcare enterprises—National Government Services, Spectrum Health, WellCare Health Plans, Inc., Accenture, and The Hardenbergh Group—are linking up to participate in a distributed ledger program aimed at resolving administrative inefficiencies related to professional credentialing.

The project, Professional Credentials Exchange, is being developed by ProCredEx and Hashed Health, a blockchain innovation consortium. The exchange leverages “advanced data science, artificial intelligence, and blockchain technologies to greatly simplify the acquisition and verification of information related to professional credentialing and identity,” according to officials.

In an announcement, officials noted that credentialing healthcare professionals “is a universally problematic process for any industry member that delivers or pays for patient care.  The process often requires four to six months to complete and directly impedes the ability for a healthcare professional to deliver care and be reimbursed for their work.”

They added, “Hospitals alone forfeit an average of $7,500 in daily net revenues waiting for credentialing and payer enrollment processes to complete.  Further, nearly every organization required to perform this work does so independently—creating a significant administrative burden for practitioners.”

As such, the groups, via the exchange, will aim to address the time, cost, and complexity associated with these processes by facilitating the secure, trusted exchange of verified credentials information between exchange members.

Included in the collaboration are WellCare Health Plans, which serves about 5.5 million members, and Spectrum Health, a 12-hospital health system in western Michigan. National Government Services is a Medicare contractor for the Centers for Medicare & Medicaid Services (CMS), and processes more than 230 million Medicare claims annually.

"A fundamental component of developing the exchange lays in building a network of members that bring significant verified credential datasets to the marketplace," Anthony Begando, ProCredEx's co-founder and CEO, said in a statement.  "These are the leading participants in a growing group of collaborators who bring data and implementation capabilities to accelerate the deployment and scaling of the exchange."

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Google Taps Geisinger CEO David Feinberg to Assume Healthcare Leadership Role

November 9, 2018
by Rajiv Leventhal, Managing Editor
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Top healthcare execs continue to leave the hospital and health system space to move into tech

Geisinger Health System CEO David Feinberg, M.D. has been tapped by Google to assume a leadership role over its healthcare initiatives.

According to a report from CNBC, “Feinberg's job will be figuring out how to organize Google's fragmented health initiatives, which overlap among many different business groups.” The report, from CNBC’s Christina Farr, added, “The search has been underway for months, according to several people familiar with the search process. Artificial intelligence head Jeff Dean has been deeply involved in the process and personally interviewing candidates.”

Earlier this year, it was rumored that Feinberg—the lead at the Danville, Pa.-based Geisinger for the last four years—could join the Amazon/Berkshire Hathaway/JP Morgan Chase  healthcare initiative, but that was put to bed when Feinberg released a statement in June, provided to CNBC’s Farr, in which he said, “I personally remain 100-percent committed to Geisinger and remain excited about the work we are doing and the opportunities ahead as we continue to deliver exceptional care to our patients, our members and our communities." Amazon, Berkshire Hathaway, and JPMorgan Chase ended up hiring Atul Gawande, M.D., as CEO of the initiative.

David Feinberg, M.D.Google has made several forays into the healthcare space over the years, and most recently tapped former Cleveland Clinic CEO Toby Cosgrove, M.D., to join the team has an executive advisor. Interestingly, the Cosgrove hiring was announced by Gregory Moore, M.D., Ph.D., vice president of Google Cloud’s healthcare division, who is also a former clinical IT executive at Geisinger.

As Healthcare Informatics reported on in its Top Ten Tech Trends package a few months ago, new business and technology combinations and ventures are heralding a new era of disruption in U.S. healthcare delivery. As Editor-in-Chief Mark Hagland wrote in his story, “Alphabet, Google’s parent company, is leveraging its extensive cloud platform and data analytics capabilities to hone in on trends in population health, [a] Business Insider report noted. The company plans to drive more strategic health system partnerships by identifying issues with electronic health record (EHR) interoperability and currently limited computing infrastructure.”

Indeed, these new “disruptors” are not only making major moves in the healthcare space, but also hiring some of the smartest minds from hospitals and health systems—a trend that some might see as troubling for the traditional healthcare player.

What’s more, the research firm Kalorama Intelligence recently reported that three companies—Google, Apple, and Microsoft—have filed more than 300 healthcare patents between 2013-2017—among them, Google’s 186 patents, mainly focused on investments for DeepMind, its artificial intelligence and Verily , its healthcare and disease research entity.

Feinberg also had some interesting comments about his vision for healthcare at the “HLTH: The Future of Healthcare Conference” this past May. Healthcare Informatics’ Hagland, who was at that event, reported this from Feinberg’s keynote: “For us, what really matters is so much about what’s happening outside the clinics or the hospitals,” he said. “We have 13 hospitals in our system. And I think my job is to close all of them. I know that out of 2,000 beds we have, if people ate right, used alcohol in moderation, didn’t use illegal drugs, wore seatbelts, ate healthily, had access to broccoli and blueberries, and didn’t shoot people with guns, 1,000 of those beds could be gone…”

As it relates to Google, Farr noted in her recent report, “Among the groups interested in healthcare are Google's core search team, its cloud business, the Google Brain artificial intelligence team (one of several groups at Alphabet working on AI), the Nest home automation group and the Google Fit wearables team.”

She added, “One particular area of interest is building out a health team within Nest to help manage users' health at home, as well as to monitor seniors who are choosing to live independently. Nest had been an independent company under Google holding company Alphabet, but was absorbed back into the Google Home team earlier this year.”

Meanwhile, at Geisinger, Feinberg—who will remain at the health system through the end of the year—will be replaced by Jaewon Ryu, M.D., as interim president and CEO.

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University Hospitals Applies Homegrown Discharge Planning Workflow Solution to Opioid Prescribing

November 1, 2018
by David Raths, Contributing Editor
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Seeks to commercialize logistics platform powering UH Care Continues
Eric Beck, president of UH Ventures

Cleveland-based University Hospitals is taking advantage of an internally developed technology platform to re-imagine the discharge process, including identifying patients at risk for opioid misuse and dependence.

Ohio has been described as “ground zero” for the opioid epidemic. According to the Ohio Department of Health, drug-related deaths eclipsed auto accidents as the state’s top cause of injury deaths in 2007 and that trend has continued ever since. Earlier this year the UH Care Continues discharge planning process was awarded $200,000 from the Ohio Opioid Technology Challenge for its technology solution to help health professionals in the fight against the opioid epidemic. 

In an interview with Healthcare Informatics, Eric Beck, D.O., M.P.H., an emergency medicine physician and president of UH Ventures, the business innovation arm of the UH system, explained the genesis of UH Care Continues and the health system’s intention to commercialize the solution.

“We began a journey earlier this year to re-imagine our care transitions process — how we get patients out of the hospital and thinking intentionally about where they go and what happens to them afterwards,” Beck said. “We were developing new roles, new processes, and new technology. One of our core tools is a logistics platform.”

Applying the platform systemwide to opioid prescribing, Beck said 18-hospital UH sought to put a reflective pause in the process to try to limit controlled substances, particularly opioids, to only the patients who really need them. There was a fair amount of inertia and “muscle memory” in terms of prescribing opioids for certain conditions, he added. In some cases, they are being prescribed as needed or prophylactically. “To the extent we can stem some of that, contain it, or add a little bit of conditionality, that was the opportunity we saw.”

The technology solution surveils patients as they are leaving the hospital, and as it identifies a patient with an opioid prescription, the pause asks if it is really necessary. Is the patient still having pain? Is it uncontrolled? To the extent that the answer is not an obvious yes, Beck said, are there alternative therapies available? “Or perhaps the patient only needs a couple of pills for an urgent issue and then they can call us for more active management of their pain.”

The platform manages both work flows and resources. “To the extent that the patient is leaving the hospital on opioids or may benefit from alternative resources, such as acupuncture or massage, how do we bring those resources to bear at the point of service?” Beck asked. “Part of the effort is trying to contain inappropriate prescriptions, but also marrying that with a set of alternative resources that the patient can be navigated to, based upon their needs and clinical condition.”

Besides triggering workflow and optionality around alternatives, the reflective pause also deploys an algorithm to risk-stratify whether the person is at high risk of becoming dependent.

“To the extent they need the opioid, let’s risk-stratify them,” Beck said, “and put them into a surveillance workflow and make sure that any excess opioids are disposed of properly. To the extent they don’t need it, let’s navigate them to something else.”

How will UH assess whether the platform is having a beneficial impact? By measuring follow-on behavior related to all opioid prescriptions, Beck explained. “Following them into post-acute space, did they take the opioid? Was it disposed of? When we look at patients offered alternatives, did they use those and was their pain controlled? We are engaging with resources within UH and the community to track the utilization of those services that we are navigating patients to.”

Although the opioid module meets a pressing need, Beck stressed that UH Care Continues has many other potential use cases, including driving care coordination between all the various actors in the hospital: the therapists, social workers, medical teams and nurses, as well as the off-site administrative support for getting patients out of the hospital and setting up resources, whether they are going to a facility or back home. “It also enables new choices like hospital at home – alternatives to hospitalization or getting patients home more quickly,” Beck said. “We think we have a winner here because it has a broader value proposition than just the opioid work flow. The opioid module is just one element that can be deployed. We are moving down the path of our commercialization milestones, and we will want to bring it to market.”

In fact, Beck said, UH Ventures has a queue of things it is looking to bring to market, some spun out as new companies.  “We are the innovation and commercialization engine for the system,” he said. “We are engaged with our digital health accelerator here in Cleveland and are working with early stage companies to provide them usability and validation support.”



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