Q&A With Jay Srini
Healthcare Technology: From the research we’re seeing, it seems that the technologies you’re focused on are becoming the rule rather than the exception. Are all of the initial promises of these technologies coming to pass?
Jay Srini: There are several areas of emerging technology in healthcare with different rates of adoption, and although each category faces its own unique challenges, some common underlying barriers are encountered when adopting these technologies. Focusing first on the fundamental technology needs in our industry – electronic health records, CPOE [computerized physician order entry] and BPOC [bar-coded point of care] solutions – we find they have not been adopted as quickly as one would expect. This is due to the lack of market economics, immature standards and the complexity of integration and interoperability, which are all essential prerequisites for the solutions to be successful. In recent months however, considerable attention has been focused on this problem by three individuals: Dr. David J. Brailer, the first director of the Office of the [Health] National Coordinator for Information Technology, Dr. Mark McClellan from CMS and Mike Leavitt, the Health and Human Services Secretary.
Their focus is to address the gridlock in HIT [healthcare information technology] adoption. The key building blocks for the new strategy to stimulate adoption have been the national contracts awarded to address EHR [electronic health records] certification, interoperability standards, addressing variations in privacy and security practices and developing prototypes for NHIN [Nationwide Health Information Network] architecture. Additionally, the formation of the AHIC [American Health Information Committee] work groups to provide breakthrough solutions in the areas of electronic health records, chronic care improvement, consumer empowerment and bio-surveillance are expected to stimulate the deployment of such technologies while improving patient safety and the quality of healthcare provided. The intent of these initiatives is also to allow the patient to take an active hand in their health, both from a clinical and financial perspective. A critical step in this direction is transparency in healthcare, which leads to availability of cost and quality data to the consumer along with a personal healthcare record [PHR] where the patient may have access to their own health record.
An evolving area of healthcare technology pertaining to consumer-enabling and patient-enabling technologies is sometimes referred to as “pervasive healthcare” or “unbound healthcare.” The fundamental premise is that healthcare has to follow the patient and not vice versa. In other words, care is provided in a distributed healthcare ecosystem whether the patient is at home, at the workplace or at a longterm care facility. Pervasive healthcare is made feasible by technology. Hospitals and healthcare facilities should be used for healthcare delivery only when necessary. Seamless, effective and efficient healthcare delivery across these various settings is the goal of unbound healthcare. Additionally, the focus of such technologies is geared toward prevention, continuous monitoring and allowing for intervention at the earliest possible stage to prevent complications that can nip the problem in the bud. An aging population with increasing numbers of chronic diseases and co-morbidities, coupled with diminishing clinical resources and increasing healthcare costs, is dictating the use and growth of such proactive health technologies. Efficiency and effectiveness are critical to slow the pace of healthcare costs, which are becoming insurmountable for both the government and for private enterprises providing healthcare for their employees.
When I look at the entire gamut of unbound healthcare technologies, starting with something as basic as patient/physician messaging, all the way through to the remote patient monitoring for chronic disease management or telemedicine, I find that in many cases the technology is slowly maturing and becoming more reliable but the supporting elements are not ready yet for them to provide positive outcomes. There are some basic requirements for these technologies to be successful. First, it has to be integrated into the work flow of the clinician. Second, there has to be a viable reimbursement model that is optimal and effective. Third, it goes without saying that the solution should be affordable, effective and be capable of deriving the needed outcomes.
Additionally, if we plan to use it both for preventive care/wellness and healthcare delivery/treatment, with changing health insurance models where the consumer is increasingly bearing more of the cost of healthcare, we want to ensure it can be mass-produced cost-effectively with an easy-to-use form factor. The technologies involved could be very similar to how an iPod or an MP3 player works. Last but not least, we need changes in legislation to allow for healthcare delivery across state borders, eliminating the onerous barriers that exist today.
HCT: Have any of the technologies in particular fallen short of expectations?
JS: One finds that patient/physician electronic communication, as basic as it sounds, has not achieved the results that we might have anticipated. For messaging to be effective, we need the electronic health record. Otherwise, what you achieve is a paper record juxtaposed with electronic messaging. However, we know that the adoption of EHR is just at 15 to 20 percent nationally, so in many cases messaging is deployed without an EHR. It is critical to remember that technology that does not integrate into the daily clinician work flow slows the rate of adoption and will in fact be abandoned over time by the clinicians.
Relatively speaking, e-prescription has been quite successful because it is able to provide value even when it is incrementally adopted and not fully integrated into the EHR.With many RHIOs [Regional Health Information Organizations], even though their full potential is attained only when integrated into the EHR and with full decision support capability, e-prescription is the first application to have been implemented as a communitywide initiative. Two such programs are the MA-Share Initiative and the Rhode Island initiative. To elaborate, a basic level of e-prescription just addresses the need for refills to be electronically provided to the patient. Irrespective of whether the original prescription was paper-based or not, this new feature provides significant value for the patient who can request and receive their refill online.
Similarly, we all know that having an electronic switch/hub, which allows for the e-prescription to reach the pharmacy and get filled electronically, provides the ultimate value. But even when the doctor basically prints out the e-prescription and faxes it to the pharmacy, it is a vast improvement over the paper-based system we’ve utilized for the past several decades. Technologies that show incremental benefit along the evolution chain have the benefit of being adopted more quickly because, as we all know, the “big bang” approach to incorporating new technology, all at once, without concern for work flow integration or usability, is destined to fail.
Please note, however, that even e-prescription has a long way to go before mass adoption by clinicians is reached. In short, health information technology adoption as a whole has been progressing at a disappointing rate.
HCT: Do you see an untapped benefit in adopting these technologies, a benefit that was not anticipated?
JS: With remote patient monitoring, initially the industry as a whole perhaps did not anticipate the ultimate potential it could achieve by focusing on its use solely to provide healthcare for sick people. The appropriate use for wellness, prevention and maintaining good health and continuous monitoring allows one to intervene early – before complications arise. That is where I believe the biggest bang for the buck lies.
We are acutely aware of the rapidly growing aging population in the U.S., which is compounded by diminishing healthcare resources that contributes to an everincreasing shortage of physicians and nurses (clinicians) in every specialty from radiologists right through [to] anesthesiologists and cardiologists. It is stated by many sources that the average age of a nurse today is 50 years old, and very few individuals are joining this challenging profession today. So a significant benefit in adopting these technologies is the potential to deliver care to patients, no matter their location and without transporting them to hospitals or clinical care settings. This allows for more effective use of our scarce resources and for simultaneously curtailing the spiraling costs, while still improving the quality of care. Additionally, aging baby boomers can be effective caregivers and provide support for their elderly, ailing relatives no matter where they may be.
HCT: How dramatically do the new technologies conflict with legacy procedures? Who in particular is dragging their heels?
JS: I think the greatest barrier to adoption has been reimbursement. As much as we have seen remote monitoring being able to deliver effective and appropriate care for the consumer, the corresponding optimal reimbursement model has yet to evolve either in the public or private sector. There are initial pilots for specific disease states and specific technologies, such as congestive heart failure, that have been sponsored by CMS and AHRQ, which will encourage the use of such technologies. However, we need to remember that these pilots are in their infancy and that a broad-based reimbursement model, which addresses the various disease states and the needed technologies, is lacking. Equally daunting has been the price tag of such technologies, though new innovative companies are finding disruptive technologies and cheaper ways of bringing cost-effective solutions to market.
The second barrier stems from the fact that healthcare is subject to state regulation; when cross-state healthcare needs to be delivered, not only have we not harmonized the different state laws but we are constrained by the credentialing and licensing requirements unique to each state. Last but not least, when you look at the adoption of these technologies, the value goes to the patient, the employer or the payer. Eleven cents on the dollar is all that is gained by the provider though they are expected to take the risk, make the investment and potentially increase competition in their market and lower their income through the adoption of these technologies.
HCT: What are the risks involved in totally adopting consumer-enabling and patient-enabling technologies?
JS: We cannot ignore security or privacy, especially with the knowledge of the losses of laptops containing VA health records, occurrences that have flooded the news channels recently. The loss of VA records was followed by a spate of similar incidents related to other healthcare institutions. As we get more digital and more information flows through the electronic highway, we need to be more cautious and find newer technologies to secure our information. However, in most cases it is not a matter of having just the right technology; it’s more a question of laying out policies and procedures and ensuring their adherence by all stakeholders. In short, a culture of security and privacy needs to be instilled at every level of the healthcare industry.
Interoperability is an issue confronting all aspects of healthcare. Even in traditional modes of healthcare, when we consider electronic health systems in both ambulatory and acute healthcare settings, we have problems in terms of sharing the patient information across the various provider silos and making them interoperable. In unbound healthcare, when you distribute healthcare and you take it to the patient, you are expanding the level of interoperability required both in terms of complexity and scale. It is no longer just the electronic health record that needs to be interoperable, it’s the entire system incorporating home health and the various patient monitoring devices that need to talk to each other. In this scenario, alerts and reminders bridge all islands of information and decision support tools to aid clinicians so they can seamlessly traverse these independent silos of information.
Several initiatives have been jumpstarted to bridge the interoperability conundrum. Through the office of the National Coordinator of Information Technology, contracts have been issued to the HITSP [Healthcare Information Technology Standards Panel], which is setting the standards for interoperability for ambulatory care and acute care. Additionally, Intel has founded the Continua Alliance for creating interoperability between devices operating in the unbound healthcare space. CCHIT [Certification Committee for Healthcare Information Technology] is setting the standards for certifying electronic health records both in acute care and ambulatory care. Until these standards are consolidated, harmonized and adopted universally we will be burdened by the lack of a seamless longitudinal health record for the patient. The final goal is to provide better quality care, better safety and to remove the administrative waste from the system. One cannot underestimate the need for computable semantic interoperability in the rapidly expanding healthcare ecosystem.
