5 Drivers of Healthcare’s Decentralized Future
By Indu Subaiya & Matthew Holt
The contrast between the recent hurricanes in Texas and Florida is illustrative of the progress made in health IT in the past decade or so. In 2005, there were huge losses of patient data after Hurricane Katrina, because the information was available only on paper. However, because of advocacy from the health IT community and partly in reaction to that disaster, the 2009 HITECH Act provided more than $32bn in funding that drove electronic medical record (EMR) adoption. Today, virtually every hospital and most practices are using them.
Fast forward to Hurricane Harvey. In Houston most hospitals stayed in operation. If you were a patient your data was likely accessible if you were at a care setting you had previously visited. However, for patients who visited a hospital where they hadn’t had a previous medical encounter, data often wasn’t accessible. Despite all that investment and adoption, EMRs are enterprise-centric and based on the technology that was available in the 2000s (and before). Easily portable patient-centered data remains elusive.
There have been plenty of initiatives to create interoperability and data transfer between systems, with some clear local successes. But overall at a macro-level, health systems continue to rely on a fragile system of arbitrary bridges between silos. We need a new metaphor.
Perhaps that new metaphor is cellular membranes. They are semi-permeable and exist within living systems. In health care we need truly decentralized and interconnected information and services that are continually optimizing in response to our actions. In this model, the system is never at rest, it’s always on and communicating across all the environments we inhabit. It’s a technological shift breaking down the divide between enterprise-specific hospital technology and the outside world.
But decentralization in health is not just technological. It also reflects the roles of patients, consumers, or citizens. While the barrier between the health care delivery system and the outside world of the patient and consumer is now dissolving technologically, at the same time the e-patients and activist consumers are working to tear that barrier down culturally.
Here are the five main drivers of the coming decentralized health care system:
1. THE NEW INTEROPERABILITY—FHIR AND BLOCKCHAIN
Fast Healthcare Interoperability Resources (FHIR) is a next-generation standards framework created by HL7 that can be used for mobile phone apps, cloud communications, and EMR-based data sharing. FHIR offers better security, as it does not exchange data via text files and uses standard interfaces for access to data across multiple platforms and modalities. FHIR is based on Representational State Transfer (RESTful) web services, based on the approach used by many web companies, like Google and Facebook.
FHIR is radically changing the way we think about integration of innovative applications, making it faster, easier and less disruptive to workflow. It allows developers to create medical applications which can be easily integrated into existing systems.
SMART on FHIR is a related utility which allows web apps to run inside a browser so clinicians can use them without leaving the EMR environment. More than 35 provider organizations have exposed their FHIR APIs and at Health 2.0 in 2017 multiple companies were using FHIR in their products.
The second mechanical building block of the new interoperability is blockchain. Blockchain is the technology behind cryptocurrencies like Bitcoin. It’s a distributed database which can’t be changed, but uses what are known as smart contracts to automatically enable “trustless” transactions.
The implications for healthcare may be huge. Blockchain technologies can deliver a new way to affirm identities; ways to move data around quicker and cheaper; easier transactions, like payments, claims and data sharing. If your business model is based on owning or controlling access to data, this is pretty threatening because it cuts out middlemen and pushes power to the edges of the network.
The emergence of blockchain, FHIR and other technologies leads to a bigger question. Current systems like Cerner or Epic have one user front end, one underlying transaction system, and in general one system for data storage. What happens to health care when there is unfettered data access and the monopoly of the user interface goes away?
2. NOVEL MODALITIES AND ANALYTICS
If there’s no monopoly over user interfaces because of the decentralized networks enabled by FHIR and blockchain, this creates momentum for two things: new analytics and new modalities.
First, increased access to data that exceeds a human’s ability to process and make meaning of it requires more sophisticated analytics. The answer to that is the emerging field of machine learning and artificial intelligence (AI).
Second, because users need to interact and communicate around that data in new ways there’s been a parallel development of new modalities–hence all the form factor innovation in augmented reality (AR), virtual reality (VR) and AI now coming into health care. We can only begin to imagine the possibilities this will lead to, but the point is the current trend is an integration of data analytics with new types of physical devices.
And these devices are not just new interfaces into artificial intelligence (like VR headsets), we now also have several physical manifestations of artificial intelligence becoming mainstream. These are better known as robots! While we are seeing these emerge in transportation (e.g. self-driving cars) and in industrial and military robotics, there are plenty of similar applications such as supply robots, avatars and even experimental nurse assistants coming into health care.
Once these new modalities have gotten a footing in a healthcare environment, will data, transactions and services become extensions of those modalities? It’s only natural to wonder, and it’s only obvious for companies to pursue those opportunities.
3. NEW ENTRANTS
It’s not as if there isn’t a raft of potential new entrants coming into health care. All the consumer technology giants, like Amazon, Google, Facebook and Microsoft, are already leaders in those new technologies. They also have huge cloud computing capacity and multiple consumer access points. Additionally, the giant drug retailers like CVS and Walgreens have been involved in telemedicine and primary care for a while.
But it’s not only those giants. Many smaller companies are coming in from adjacent sectors. For example, Ritual is a new vitamin company that is using online ordering, transparency, community and consumer branding in a new way to change how women think of vitamins. Habit is taking a combination of DNA sequencing and experience from the baby food industry to personalize diets. Manifest is using its founders’ experience from Crossfit to tackle the burden of chronic disease using digital coaching.
Back in 2007 when Health 2.0 started Microsoft and Google were launching their first efforts in personal health records. Ten years later they are back and not just with software but have multiple new hardware form factors–Microsoft’s Hololens in AR, Alphabet with Google Home using voice, and its subsidiary Verily with new types of devices, including watches, smart cutlery and more. This convergence of new modalities with access to more data and processing power can have a huge impact.
4. BUSINESS MODEL DISRUPTION, MARKET AND POLICY SHIFTS
How are existing and new companies adapting their business models and their relationship to technology? We think there are three main flavors:
First, existing care delivery systems are adopting new technology. Cedars-Sinai, UPMC, Providence and many others are now buying or investing in technology companies, or using other service providers.
Second is the rise of new startup delivery and financing models, such as Iora, Parsley, Forward, Crossover, and Privia on the provider side, with Oscar, Clover, Bright Health and Collective Health on the payer side. Not only do they usually only have one word in their name, but they have raised very large amounts of capital, and many are building their own tech platforms.
The third flavor is that some of the emerging health tech platforms themselves might layer on services and become care delivery models. Companies like Omada, Livongo, Glooko and several others already have technology, consumer outreach, and clinical coaches working with patients. They could easily add on their own doctors, nurses and physical facilities and partner strategically for functions they don’t have like insurance and payment. New “diabetes reversal” startup Virta Health already has a “virtual clinic.”
It’s of course not just new tech platforms that are potential entrants here. Huge players like Philips, Nokia, Qualcomm are bringing more clinical monitoring to everyday life. What’s to prevent them—and, of course, the likes of Apple and Amazon—from adding clinical services at home around these technologies?
5. NEW ENVIRONMENTS
All of these transformations are occurring within a much larger transformation which many are just waking up to—health care and health happens everywhere.
The role of communities, public health departments, universities and others is larger than ever. For example, in Los Angeles County librarians are connecting visitors with health services. In Orlando, FL, Rosen Hotels has been using savings from its own rationalization of its employees’ health care use to put its employees and their kids through college, and reinvigorate local parks. And more than a dozen colleges are now using the reporting system Callisto to help identify and prevent sexual assault. These all lead to an improved culture of overall health.
The idea of moving health care beyond traditional care settings is not only common sense, it’s starting to make financial sense. Health care organizations are starting to invest outside of their walls, and payers, governments and providers are starting to approach community health and the social determinants of health, not as an afterthought but as the core of their business.
All of this leaves us with two questions. One touching on who is paying for what, and the other about who is supplying those services and how they are doing that.
First, as the identities of who is purchasing, selling, and controlling access to data and providing services are changing, we need a new definition of value from all perspectives. The old ideas about who makes money from what part of the clinical value chain will no longer make sense in this world. So, in a decentralized future what does “value” mean?
The second question anyone who is working in health care needs to think about regarding health care’s decentralized future is: what services, technology or process can your company uniquely defend? Who will you compete with? Who will you collaborate with? And who is your customer? In other words, as Clayton Christensen once famously asked a milkshake, what’s your job?