1. The Collision
Technology worlds are colliding now in ways that may give the US healthcare system its last and best chance both to heal itself and to improve health. The collision gives health care institutions an opportunity to remain at the center of US healthcare, but at the center of larger new networks not just of providers and health insurers, but networks that include both medical device manufacturers and 24/7 connectivity to patients who need it. Before this collision, US healthcare has been about curing us, not making us healthy, as the numbers make clear:
http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf Source: OECD Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en; World Bank for non-OECD countries.
What in particular is costing so much? Care for chronic illnesses and comorbidity (which is the same thing, because it just means patients with more than one chronic condition, who cost up to 7 times as much as patients with only one chronic condition):
http://www.chrt.org/publications/price-of-care/issue-brief-2010-08-health-care-cost-drivers/ Copyright © 2008–2014 Center for Healthcare Research & Transformation
Before the impending collision, there is a world of biomedical technology – generally bigger, heavier, more expensive equipment purchased by provider organizations and devoted to curing medical conditions, and a newer world of health and fitness apps – generally smaller, lighter and cheaper and purchased by consumers.
The role and functions of biomedical technology have been morphing ever-faster in the big data world. Now the technology generally needs to change and learn and produce valuable information as it is used, generally by gathering information that is protected health information (PHI) under HIPAA. So the manufacturer of the technology, previously exempt from HIPAA, now becomes a business associate directly subject to HIPAA’s security standards (We are seeing it happen both in the provider negotiations and in the business plans of the manufacturers.).
As a business associate of its health care institutional customer, the manufacturer can not only get PHI from the customer; it can create and send PHI back to the customer, the provider and potentially the patient. The “velocity” of big data will be most powerful as it generates real-time insights impacting care and health decisions, and for those insights to be effective, experts or expert systems need to be able to properly interpret their messages at the point of care or health decisions.
What of the other tech world of health and fitness apps, thought to be the province of fitness zealots, quantifiers of the self, Tom Wolfe’s “social x-rays,” and other people with more time on their hands than us average Joes (or lazy slugs, your choice)? The biggest problem/opportunity for those apps in solving the woes of our healthcare system is that people with chronic diseases are precisely those who need care when they are living their lives away from the bigger, heavier, more expensive technology, but the early adopters of the health and fitness apps that go anywhere your phone and other sensors go are those with health to burn. And because neither we as a society nor those early adopters as individuals have any really compelling reasons to care about incremental improvements in their health, the health and fitness apps can be and often are tossed as soon as their users tire of them. And being so healthy, what does a fitness app user care if his or her information is breached? Nobody loses insurance or a job due to a BMI of 21 rather than 20.
On the other hand, who needs real-time information 24/7 more than someone trying to manage her or his own chronic disease, or someone trying (or something designed) to improve the health or contain the health care costs of that person? And as the literature of health apps tell us, those apps will keep getting used if someone who cares and is respected by the user is at the other end. The impending collision between the disruptive consumer health tech and the established biomedical tech creates the huge opportunity for the disruptive tech to get to the people who need it and to whom we need to get it. But they need serious information security and privacy….
2. The New Networks
Four factors point the way to a structure of the new health care networks with the provider institution in the center:
- The selection, interpretation and integration of information flowing both from the biomedical technology manufacturers and from consumer health apps all need an expert, experts and/or expert systems;
- After all of our unsuccessful tinkering with the health care system, we still trust our doctors;
- A strong and trustworthy maintainer of the privacy and security of health information is necessary for patients to consent (opt in) to participate in the new programs, which given current and likely future cyber-threats means sophisticated and adaptive security; and
- Love it or hate it, HIPAA, the privacy/security legal/regulatory structure that was put in place when government had not yet come to a standstill (and therefore not likely to be repealed any time soon), made the provider the covered entity on whose behalf the business associates (here the medical technology manufacturer and connected health apps) create, store, use and communicate PHI.
Here, by “connected health apps,” I mean apps that can connect into the health care system because they can credibly enter business associate agreements. The increasing demand for such apps is leading to the creation of platforms and rules that help enable compliance with those agreements and business associate regulatory requirements by the apps developed on those platforms and in accordance with those rules. If such platforms succeed, then, patients/consumers will be able to trust the security and privacy of the system enough to connect (opt in) to it, and will be connected to someone they still appear to trust – their doctors – through a system strongly incented to maintain trust – a medical institution’s information systems.
Mobile health, biomedical devices, what else? To stimulate debate and thinking — and believe me, it did! — I even advocated health systems taking information from data brokers, because if data brokers become business associates, consumers will (for the first time) have many of the rights — e.g., access, amendment, accounting of disclosures — that those who seek due process in the “scored society” could want.
Being at the center of this collision and these new networks is very good news for US hospitals, in my humble opinion. When digital health leader Dr. Eric Topol said that in 20 years,
I wondered whether he might be too optimistic about hospitals. Why put a data surveillance center in a hospital? Who or what will do the surveillance? The current collision and its aftermath, however, keep the medical system in the middle between the patient, physician and medical technology. That is why I humbly suggest that this collision may give the US healthcare system its last and best chance both to heal itself and to improve health.