The Great Re-Bundling of Healthcare

This post was originally featured on HIStalk.

Computers break assumptions. By breaking assumptions, computers are re-bundling industries. No industry will be left untouched as computers eat the world.

Computers do everything that humans do, but computers can perform each at effectively infinite scale. Performing each of these functions at infinite scale breaks fundamental business assumptions:

1) Store data. Computers can store historical records of every business interaction or transaction. In an analog world, the overhead of storage and retrieval outweighed the cost, if it was even possible at all. Computers deliver perfect memory. 
2) Process data. Computers can process data — historical, in real time, and cross-referencing each — to deliver new business insights. 
3) Share data. Computers can share data and insights across geographies instantly.

The media industries — newspapers, magazines, music, videos, and movies — were disrupted by computing because none of these businesses were actually the businesses they claimed to be. They were distribution businesses that called themselves media businesses. Once computers dismantled their distribution channels, they crumbled, and a new wave of technology-centric distribution businesses emerged in their wakes (blogs, Apple, Netflix, PirateBay / torrents, etc.) These technology businesses re-bundled the respective media industries by breaking analog business assumptions.

Healthcare is being re-bundled. All players in the healthcare sector — patients, providers, payers, regulators, and vendors — are realizing that their roles will change in a digital future. That future will be one in which:

1) Store data. There will be human-perfect (as perfectly as humans can record) data for all patients all the time. 
2) Process data. Computers will analyze everything that they can based on all available data, both current, historical, and for every patient there ever was. 
3) Share data. Information flows between all parties in the healthcare system — patients, providers, and payers — seamlessly across geographies.

In healthcare, these endpoints are currently hamstrung primarily by regulation and interoperability challenges, and to a lesser extent by technical device limitations (primarily at-home diagnostics and treatments). In the next 5-10 years, most of the political and regulatory issues that are obstructing these endpoints will resolve themselves.

When healthcare delivery systems reach these endpoints, how will the re-bundled healthcare system function, and how will providers be controlled and organized?

Store / process data. Computers will use vast volumes of data to diagnose and treat (genomics, years of history, etc. -> Watson). Each patient will help improve outcomes for every patient.

Store / process data. Providers will be presented with contextual data and information on demand.

Process / share data. Providers will be able to communicate whenever and however necessary.

Process / share data. Geography will become almost entirely irrelevant except in high-acuity cases. Telemedicine will be standard, not the exception. Patients will be able to capture data for diagnostics and treat most simple conditions at home. Amazon drones will deliver devices and treatments to patients on demand.

Although technology advocates claim that technology levels the playing field among competitors within a given market, in many cases, technology markets tend towards winner-take-all markets. This has been especially true in markets in which a single technology vendor disrupted a analog legacy players such as Google, Microsoft, and Apple (music).

If geography is irrelevant, data can be seamlessly shared and providers and patients are on an equal playing field in terms of diagnostics and treatments relative to their peers. Provider entities should tend towards one of two extremes: nationwide monopoly* or highly fragmented and distributed. We’re witnessing the former as the prominent clinics, the Cleveland Clinics and Mayo Clinics of the world, open virtual and remote clinics all over the country. Technology is enabling them to extend their reach, promote their brand, and drive high-acuity, high-revenue cases back to the mother ship. They’re using technology to feed the proverbial beast.

The ACA sparked this trend, but that doesn’t mean that the pendulum can’t swing back in the other direction.

If the pendulum were to swing back to support a highly fragmented delivery system, what would cause and support it? Seamless data transferability and abstraction of administrative functions. No one can unseat Google or FaceBook in their respective markets because no one can access their databases. If doctors can access patient data from all other providers on demand and if providers don’t need to rely on a larger administrative entity (perhaps RCM providers such as athenahealth could take over all administrative functions?) then patients would only be bounded by the providers they enjoy interacting with. Nothing would bound patients, providers, or payers to larger provider entities.

One for all, or all for one?

* It’s worth noting that although systemic pressures may tend towards national monopoly, the system would result in an oligopoly given how large many of the established players already are.

Stay Home

This post was originally featured on HIStalk.

AliveCor just announced AliveInsights, an integrated telemedicine solution that lives on top of AliveCor’s smartphone ECG. AliveCor is advertising that a cardiologist will read one’s ECG within 30 minutes.

Everyone is fighting to reduce costs through telemedicine. Beyond regulatory issues, the greatest challenge has been delivering medical devices and equipment to patients’ homes so that doctors can receive that data. AliveCor is making interesting moves in this space by providing an integrated telemedicine service with their ECG hardware.

How and when will all basic medical services be delivered remotely? I see two distinct models emerging.

HealthSpot has been making waves recently for setting up a private "health station" or "health kiosk" that costs less than $15,000 to install. Right now, they’re piloting the kiosks in ERs and a few retail clinics. I suspect their vision is to install the kiosk in every retail clinic and school throughout the country. The kiosk only consumes about 44 square feet and can be operated by a medical attendant for just $30,000 – $40,000 / year. The kiosk includes a stethoscope, otoscope, dermascope, thermometer, BP cuff, scale, and pulse ox reader. It can support most simple PCP visits.

HealthSpot isn’t employing physicians, but selling these kiosks to provider organizations so that the providers can extend their reach virtually through HealthSpot. This is interesting because there could be HealthSpot kiosks in Maine with Mayo Clinic branding. Although this makes sense for prestigious provider organizations in the short term, I can’t help but think that this practice will ultimately lead to a dilution of brand and prestige in the medium to long term. It will become increasingly more difficult for patients to recognize brand value when most provider interaction is virtual.

American Well, Teladoc, Ringadoc, and others are taking the more extreme view that patients shouldn’t leave their homes at all. They are also employing or contracting with physicians directly as opposed to selling into existing provider organizations. This model presents the challenge of getting equipment to patients in their homes. I suspect this problem will solve itself in the next 2-3 years. Amazon, Google, and others are investing an enormous amount of capital and resources in bringing same-day delivery to the masses.

I can foresee a future in which the tele-mid-level providers will see patients virtually, determine what additional equipment is needed, and rent the necessary equipment to patients for a follow-up visit later that day, or at worst, the next day. Amazon and Google would gladly support this model to drive enormous volumes of shipping traffic. If the at-home diagnostics suggest more serious complications, the mid level would loop in a higher level provider or specialist.

I’ve spoke to HealthSpot’s CEO Steve Cashman about this threat. For now, HealthSpot is taking baby steps, but recognizes what may become an existential threat. I’m sure they’re planning for this future. It will be interesting to see how things play out in the "stay out of the hospital" telemedicine space.

Who's Eating Healthcare?

This post was originally featured on HIStalk.

As Robert Cringley recently noted, computers empower unparalleled discrimination. Before insurance companies could calculate rates on an individualized basis, they calculated rates based on population pools. They simply didn’t have the computing power or prowess to discriminate at the individual level. As a result, the healthy financially supported the unhealthy by average premiums across population pools.

In the 1990s, the cost of computing fell to a point that payers could discriminate. So they did. Payers could easily identify patients that would incur high costs based on a relatively simple set of questions about one’s health. For many patients, payers were so concerned that healthcare costs would be so high that they’d prefer not to take on any risk at all and simply refuse to insure the patient. This has been the controversial norm for the better part of the last 15 years.

One of the most important clauses of the Affordable Care Act is that which mandates that payers cannot deny coverage for any reason. Payers must price that risk. In many cases, they expect that the costs of care will be so large that they are distributing those costs across their entire insured populations. Paul Levy recently noted that this is happening to such a degree that many healthy individuals are seeing their premiums increase under the Affordable Care Act.

This is direly ironic. Computers, the ultimate discriminatory tool, can no longer discriminate. Over the 15-20 years of the discriminatory cycle, healthcare costs have systematically outgrown the GDP as obesity has risen to become the #1 killer in the US. Coupled with the fact that no one is allowed to be uninsured (most of whom weren’t healthy to begin with), premiums are, on average, increasing for a substantial percentage of society.

Is this a classic case in which computers are eating healthcare, or are we as a society eating ourselves?

Anesthesiologists are Moving up the Value Chain

Dr Leng is right. The future of anesthesia isn't about competing with CRNAs and computers. Cost pressures dictate that eventually, mid levels and computers will win. Instead, anesthesiologists should look for what else that can be done - and that only they can do - given that more junior staff can do what anesthesiologists once had to do.

Anesthesiologists must move up the value chain. That will likely manifest pre, intra, and post op:

Pre-op: Devote more time and energy to the pre-op processes. That may even mean working with surgeons (if they can), planning and communication with the patient before they arrive for the procedure, work with OR staff and pre-op nurses in the prep processes, and ensure that all pre-op checklists are being adhered through (even endoscopic scope cleaning checklists).

Intra-op: Support the most complex intra-operative anesthesia cases.

Post-op: Monitor patients more closely in the PACU and help with discharge planning to ensure the fastest, safest recovery.

In a nutshell, anesthesiologists will move up the value chain into a more managerial role. Most providers are by definition doers, not managers. As mid levels continue to proliferate throughout every avenue of care, doctors, particularly anesthesiologists, are poised to become the grand overseer of the entire peri-operative flow.

Assuming a managerial role will introduce a new set of challenges, primarily around communication and collaboration between anesthesiologists and their mid levels. Pristine EyeSight helps solve that exact problem.

Pristine EyeSight is Pristine's HIPAA compliant, secure, 1st person audio / video streaming solution built for Google Glass. Pristine Glass wearers can share what they're seeing, hearing, and saying securely to any authorized device - iPhone, iPad, Android phone, Android tablet, Mac, or PC. EyeSight is the ultimate communications tool.

Anesthesiologists and their mid levels have felt tension as they compete over the same cases. The problem hasn't been the mid levels, but the fact that the anesthesiologists didn't have the tools to assume a more managerial role. Pristine EyeSight is the ultimate communications tool that will connect CRNAs and anesthesiologists so that anesthesiologists can move up the value chain. As anesthesiologists move between the PACU, the outpatient clinic, and pre-op staging areas, they'll use EyeSight to beam into ORs through their mid levels.

The future of anesthesia looks brighter than ever before.

Tackling the Top Safety Issues of 2014 Through Pristine Glass

This post was originally featured on The Pristine Blog.

The ECRI Institute just released a list outlining the top 10 safety issues facing hospitals in 2014. The Joint Commission will be looking at these issues with particular focus over the coming year as they audit hospitals.  This list helps us understand the problems that are currently plaguing hospitals and how we can leverage our solutions to address them.

Eyeware computers, including Glass, present incredible new opportunities to improve patient safety at lower costs, thus driving value. Our solutions on Glass solve several of these acute problems by enabling new abilities which can transform existing procedures. In short, we help deliver lower overall costs and safer medical care.

6) Inadequate Reprocessing of Endoscopes and Surgical Instruments - This has been an acute challenge because scope processing staff can't use their hands to interact with digital or paper checklists. This problem is particularly difficult to deal with because the cleaning process for many of these scopes involves 40-50 steps that can take over one hour. Each scope per manufacturer and model has to be cleaned according to a unique set of instructions. With just a few models of scopes, the system is highly prone to mistakes; it's very easy to miss a single step. Using Pristine CheckLists, scope processing staff are able to utilize checklists per manufacturer and model with their voices. Additionally, because Pristine CheckLists support images and videos, staff can take pictures and videos at each step along the way without using their hands.

10) Retained Devices and Unretrieved Fragments - Everyone has heard of horror stories in which a sponge, towel, or other item was left inside of the patient during the surgery. Many vendors are developing solutions that attempt to tackle this problem. Given that there are literally dozens of opportunities for error per surgery, the ultimate solution will probably be multi-pronged. Using Pristine EyeSight, we're helping provider organizations understand what causes mistakes. And using Pristine CheckLists, we can help nursing staff maintain an accurate count as they place items inside and remove items from the body cavity.

Glass and other wearable computers will leverage context to drive value. The practice of medicine is defined by specific actions of hospital personnel in particular contexts, often in conjunction with other providers and workers. Pristine's apps on Glass will support a future of medicine in which both computers will assist humans as contextually necessary.