The Barriers to Military Healthcare Technology Innovation and What We Can Do to Remove Them


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This briefing was presented at the Military Electronic Healthcare Records Symposium in Washington DC. It answers the following questions:
* Is disruptive innovation in military healthcare technology possible?
* What does innovation in military healthcare mean?
* Where are the major areas in military healthcare where innovation is required?

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The Barriers to Military Healthcare Technology Innovation and What We Can Do to Remove Them

  1. 1. The Barriers to Military Healthcare Technological Innovation and What We Can Do to Remove Them DoD & VA Electronic Health Records Symposium Washington, DC Shahid N. Shah, Chairman - OSEHRA Strategic Advisory Board
  2. 2. NETSPECTIVE Who is Shahid? • • • • • • Serial healthcare IT entrepreneur, advisor to numerous startups, blogger, healthcare technology futurist Chairman, OSEHRA Strategic Advisory Board 23+ years of software engineering and multi-site healthcare system deployment experience in Fortune 50 and Government sectors. 15+ years of healthcare IT and medical devices experience (blog at 15+ years of technology management experience (government, non-profit, commercial) 10+ years as architect, engineer, and implementation manager on various EMR and EHR initiatives (commercial and non-profit) Author of Chapter 13, “You’re the CIO of your Own Office” 2
  3. 3. NETSPECTIVE What’s this talk about? Questions answered Key takeaways • Is disruptive innovation in military healthcare technology possible? • What does innovation in military healthcare mean? • Where are the major areas in military healthcare where innovation is required? • Go narrow, specialize, dive deep • Understand PBU: Payer vs. Benefiter vs. User • Understand why military healthcare agencies buy stuff so you can build the right thing 3
  4. 4. NETSPECTIVE What does “disrupting healthcare” mean? This is $1 Trillion and the Healthcare Market is about $3 Trillion MHS is about $50 billion ~10 million beneficiaries This is $1 Billion 4
  5. 5. No, your innovation will not disrupt military healthcare. I promise. The good news is that doesn’t have to. 5
  6. 6. No, your big data or mobile ideas will not disrupt military healthcare. But if you can use them to add or extract value from the existing system, you’ll do just fine. 6
  7. 7. No, your EHR/PHR or app will not be used by enough MHS doctors or patients to disrupt healthcare. But if you can get even a fraction of them to use your software, you’ll do just fine. 7
  8. 8. No, your innovation will not be easily accepted by permissionsoriented institutions. Find customers with a problem-solving culture willing to accept risks and reward failures. 8
  9. 9. No, your innovation will not be easily integrated into regulated device-focused clinical workflows. Incumbent vendors will not entertain the potential of new legal liabilities without someone to share it with or new competition without direct compensation. 9
  10. 10. NETSPECTIVE What I mean by “actionable innovation” You have made the job of identifying, diagnosing, treating, or curing diseases faster, better, or cheaper for clinicians through the use of information technology (IT) or business models. You have made the job of self-diagnosing, selftreating, or preventing diseases and improving overall wellness of patients through the use of new incentives, business models, or IT. 10
  11. 11. NETSPECTIVE How innovation in military healthcare is different As described by Dr. Paul Tibbits at the conference this morning Health IT Experience Single Payer System Information Sharing “Improve tech and you save money, improve information sharing and you save lives” Data Interoperability Strong Program Management Significant Systems Engineering Capabilities 11
  12. 12. NETSPECTIVE Infectious diseases used to kill us… …but what’s left seem only to be “manageable” not easily “curable” Top killers in 1900 Pneumonia and influenza TB Diarrhea and enteritis Top killers today Heart disease Cancer Chronic lower respiratory diseases Per 100k population, Historical Statistics of the United States, Millennial Edition 12
  13. 13. NETSPECTIVE From cures to management… …young people don’t dye of diseases often now Death by age group, 1900 Death by age group, Today 13
  14. 14. NETSPECTIVE What Is the business of military health care? What business are you in? The Emergence of Health as the Business of Health Care • It's always better to define an organization by what beneficiaries want than by what you can produce or build – For example, whereas doctors and hospitals focus on producing health care, what people really want is health – What makes military health innovation different from non-military health? • In the future, successful doctors, hospitals, and health systems will shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health. Source: 14
  15. 15. NETSPECTIVE PBU: Payer vs. Benefiter vs. User If you don’t understand the exact interplay between PBU your product will fail The person or group that actually uses the product. User The person or group that benefits most from the use of the product. Benefiter Payer The payer is the person/entity that writes the check for your product. 15
  16. 16. NETSPECTIVE What kinds of military users are you targeting? Go narrow and deep not wide and shallow Prevention • Education • Health Promotions • Healthy Lifestyle Choices • Health Risk Assessment 26% of Population 4% of Costs • • Obesity Management Wellness Management • • • • • • • Assessment – HRA Stratification Dietary Physical Activity Physician Coordination Social Network Behavior Modification 35% of Population 22% of Costs Management • • • Diabetes COPD CHF • • • • • Stratification & Enrollment Disease Management Care Coordination MD Pay-for-Performance Patient Coaching 35% of Population 37% of Costs • • • • Physicians Office Hospital Other sites Pharmacology • Catastrophic Case Management Utilization Management Care Coordination Co-morbidities • • • 4% of Population 36% of Costs Source: Amir Jafri, PrescribeWell 16
  17. 17. NETSPECTIVE Defining your military PBU participants is really hard Don’t focus on market segmentation, but do try to figure out who your customer is Target military health sector? Number of staff or participants? Annual agency spend? Geography? Number of hospital beds? Number of patients? Type of patients? The list goes on and on…be specific! 17
  18. 18. NETSPECTIVE How will your customer pay for your innovation? If you haven’t figured it out for them, customers will not figure it out for themselves Direct Payment • Your best option • Very few truly disruptive technologies can be directly paid for by providers within the USA • Limited adoption of ‘traditional’ pay for service reimbursement for next generation technology Direct Reimbursement Indirect Reimbursement • Second best option • Improvements in technology are outpacing payer adoption • Reimbursement will come but its time consuming and difficult • Emerging option • Payer requirements for improved quality and efficiency are creating indirect incentives to adopt innovative solutions • Solutions targeting new value-based reimbursement incentives are highly useful to medical providers 18
  19. 19. NETSPECTIVE Where does your innovation fit? Target the right market so you understand the regulatory impacts Be aware of regulations, don’t fear them, use them as a competitive advantage Patient Education Least Regulation Patient Administration Diagnostic Tools Therapeutic Tools Therapies Most Regulation 19
  20. 20. NETSPECTIVE What problem will you be solving? Focus on jobs that need to be done, not what you want to build Improve medical science? Improve access to care? Reduce costs? Improve therapies? Improve diagnostics? Improve drug design? Improve drug delivery? Create better payment models? 20
  21. 21. Identifying opportunities in military health ecosystem Data for health or cost reductions
  22. 22. When does data matter? Only when we use it. 22
  23. 23. When will we use the data? When we can trust it. When we can access it. 23
  24. 24. When will we trust the data? When it doesn’t “suck”.  24
  25. 25. How do we know data doesn’t “suck”? When it’s “actionable” – or probably when we can use it to make decisions based on it (e.g. for jobs to be done, workflow, etc.). 25
  26. 26. Unused data never gets better. Fix broken windows. Iterate your way to better data by forcing its use. 26
  27. 27. NETSPECTIVE Application focus is biggest mistake Application-focused IT instead of Data-focused IT is causing business problems. Silos of information exist across groups (duplication, little sharing) Clinical Apps Billing Apps Lab Apps Other Apps Healthcare Provider Systems Patient Apps Partner Systems Poor data integration across application bases 27
  28. 28. NETSPECTIVE NEJM believes doctors are trapped It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life. New England Journal of Medicine “Escaping the EHR Trap - The Future of Health IT”, June 2012 28
  29. 29. NETSPECTIVE Real world requirement: Reduce heart failure readmissions Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study “This study provides preliminary evidence that technology platforms that allow for automated EMR data extraction, case identification and risk stratification may help potentiate the effect of known readmission reduction strategies, in particular those that emphasize intensive and early post-discharge outpatient contact.” 29
  30. 30. NETSPECTIVE The Strategy: Modernize Integration Need to get existing applications to share data through modern integration techniques including minimal meta data. Clinical Apps NCI App Billing Apps Lab Other Apps Apps NEI App Healthcare Provider Systems Patient Apps NHLBI App Partner Systems Master Data Management, Entity Resolution, and Data Integration Improved integration by services that can communicate between applications 30
  31. 31. NETSPECTIVE Common approach, low data interop Feature X Feature X Feature Y Feature Y Feature Z Presentation Functionality Data Presentation Functionality Data Application A Application B Copy features and enhance (everything is separate) Feature X Feature X Feature Y Feature Z Feature Z Presentation Functionality Data Application A Presentation Functionality Data Application B Connect to directly to existing data, but copy features and enhance 31
  32. 32. NETSPECTIVE Sophisticated, better data interop Feature X Feature X Feature Y Feature Y APIs Feature Z REST SOAP, RMI Presentation Functionality Data Presentation Functionality Data Application B Application A Create API between applications, integrate data, create new data Feature X Feature X Feature Z Feature Y SOA WOA Feature Z Presentation Functionality Data Application A Presentation Functionality Data Services Application B Create common services and have all applications use them 32
  33. 33. NETSPECTIVE What users want vs. what they’re offered Data visualization requires integration and aggregation and then homogenization What’s being offered to users What users really want 33
  34. 34. NETSPECTIVE The myth of mobility in healthcare Sexy but wrong: Device-centric closed systems Dull but right: Workflow-centric open solutions 34
  35. 35. NETSPECTIVE The myth of med device data interop Serial Converter Device USB Converter DDS MQTT Concentrator REST SOAP AMQP Local Network XMPP WCTP Gateway to EHR SNMP SMTP Cloud EHR MLLP 35
  36. 36. NETSPECTIVE Architecture transition opportunities Prevalent healthcare industry architectures Mainframes Client/Server EDI Data-driven Architecture (DDA) DDS Web 1.0 HL7 X.12 Event-driven Architecture (EDA) MQTT SOAP AMQP Service-oriented Architecture (SOA) MLLP Web-oriented Architecture (WOA) XMPP WCTP SNMP REST Web 2.0 & APIs SMTP MLLP 36
  37. 37. NETSPECTIVE How to identify the best opportunities From “Jobs to be Done” to the “Five Cs of Opportunity Identification” Circumstance • The specific problems a customer cares about • The way they assess solutions Context • Find a way to be with the customer when they encounter a problem and • Watch how they try to solve it Compensating behaviors Constraints • Develop an innovative means around a barrier constraining consumption • Determining whether a job is important enough to consider targeting • One clear sign is a customer spending money trying to solve a problem Criteria • Customers look at jobs through functional, emotional, and social lenses Source: 39
  38. 38. NETSPECTIVE Do you have ideas in payment design? Payment models going fee for service to outcomes-driven care The business needs The technology strategy • Quality and performance metrics • Patient stratification • Care coordination • Population management • Surveys and other directfrom-patient data collection • Evidence-based surveillance • • • • • • • • Aggregated patient registries Data warehouse / repository Rules engines Expert systems Reporting tools Dashboarding engines Remote monitoring Social engagement portal for patient/family 40
  39. 39. NETSPECTIVE Can you repurpose or enhance health data? Try to use existing data to create new diagnostics or therapeutic solutions Economics Administrative Phenotypics Behavioral Biochemical Genomics Proteomics IOT sensors 41
  40. 40. NETSPECTIVE Some stuff not to focus on Incremental tech innovation is easier, incremental workflow innovation is probably more useful • Don’t go for simple incremental technology innovation if you can be bold and incrementally improve workflow; but make it look like you fit into the existing ecosystem nicely • Don’t look at mHealth, look at mobility in healthcare • Don’t look at apps, look at entire systems 42
  41. 41. NETSPECTIVE Forget mobile apps, focus on health IOT • With all the attention being paid to mHealth there’s been an useless focus on mobile apps • For the mobile apps, instead focus on mobility in healthcare through “health internet of things (IOT)” and self-care technologies 43
  42. 42. NETSPECTIVE Healthcare Industry Fallacies • Healthcare folks are neither technically challenged nor simple techno-phobes (they’re busy saving lives) • Most product decisions are no longer made by clinical folks alone, CIOs are fully involved • Complex, full-featured, products are not easier to sell than simple, stand alone tools that have the capability of interoperating with other solutions are • Hospitals will not buy unless one proves value. • Selling into doctors offices is not easy. 44
  43. 43. NETSPECTIVE What makes your products successful • • • • • • • • • • • Easy to explain Defendable and differentiated Attractive partnership opportunities Word of mouth opportunity Potential for PR Scaleable staff and systems Scaleable product — build once, sell many times Uncomplicated Focused Sales model is scaleable and predictable Own relationship with and information about customers 45
  44. 44. NETSPECTIVE Why military healthcare organizations buy stuff Healthcare agencies have complex buying processes – figure out why and what they buy Increase revenue (topline) Maintain capabilities Reduce costs (bottomline) Attract new patients Increase staff productivity Find your reason 46
  45. 45. NETSPECTIVE The Customer Relationship If you can’t figure out why they buy, see if any of the things below make sense Customer Gives You Get • • • • • • • • Money Time Energy Commitment Referrals Past experience Expectations Knowledge You Give Customer Gets • • • • • • • • Product Price Value Convenience Selection Service Warranty Brand 47
  46. 46. NETSPECTIVE Health technology sector has many ups and downs Make sure you understand where your product fits in the hypecycle Source: Gartner; “Hype Cycle for Healthcare Provider Applications and Systems, 2010” 48
  47. 47. Visit E-mail Follow @ShahidNShah Call 202-713-5409 Thank You