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Progress, pitfalls and potential on the path to connected health

Evolution of Healthcare IT

Investment in EHR and IT is at an all-time high.But overall these systems sit in silos and, the fact is, they’re not yet ready to help usher in the hoped-for vision of connected healthcare. Rebecca Mayer Knutsen reports

On the electronic health record (EHR) play-ground, adoption rates continue to rise, but physician satisfaction remains in the dirt at

the other end of the seesaw. At present, physicians and other HCPs feel bogged down by the daily tasks of EHR without seeing the promise of better patient care. The industry is in desperate need of innovation to balance the health record lever on its fulcrum.

Investments in EHR and information technology are at an all-time high, with an end goal of data ex-change, cost and quality reporting, and process opti-mization. Massachusetts-based Partners HealthCare recently dug deep into its pockets to fund a $1.2-bil-lion EHR system for its network of 10 hospitals and

6,000 physicians. Developed by Epic Systems, the new system aims to address woes stemming from a dis-jointed approach that made network-wide sharing of data next to impossible.

The federal EHR incentive program sparked record participation, but some experts have expressed con-

cern at how quickly the demands were rolled out. Did the Obama administration force hospital systems to install haphazard and ill-equipped infrastructures?

The convergence of new technologies and moun-tains of data hope to bring a better version of health-care to a facility near you. Wearable devices and health apps swept through the analytics scene, pro-ducing data that seeps into every facet of our daily routine. But the promise of Big Data still needs to be harnessed and applied.

“Healthcare records are digitized but the data isn’t useful yet,” says Niko Skievaski, who co-founded the firm Redox with a group of other ex-Epic engineers. “It’s going to take a whole new generation of compa-nies to change that. It’s like the beginning of Google when you couldn’t actually ‘google’ anything.”

Physicians should be able to monitor and manage patient care in between visits, explains Jason Buck-ner, senior VP of informatics at The Health Collab-orative. “Analytics can help identify high-risk patients, monitor quality indicators revolving around health improvements and alert providers when patients are admitted to a hospital,” he conveys.

Manhattan Research’s research VP Monique Levy notes a trend of EHR vendors zeroing in on special-

ties, such as infectious diseases, to set themselves apart from the pack, which consists of some 300 to 400 vendors. “Those companies can go into the area deep and do it well,” she says.

The paradox is that high-quality data is only as good as the ana-lytical expertise needed to break it down into useful, digestible and sharable pieces of patient informa-tion. Someone needs to dive into the deep end of the growing pool of clinical data on the bottom and find the shiny penny: interoperability.

“We’re at the beginning of a revolution,” Skievaski says. “We’re trying to make integration a non-problem as fast as possible. There

shouldn’t need to be a technical discussion.”In an investor note by the research firm Stifel, ana-

lyst Steven Rubis suggests EHR vendors adopt a busi-ness model that encapsulates and prioritizes the needs of clients, in this case ACOs, IDNs and health systems.

Those who use EHRs daily are beginning to voice

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“We’re trying to make integration a non-problem as fast as possible. There shouldn’t need to be a technical discussion.”—Niko Skievaski, co-counder of Redox

94% of non-federal acute-care hospitals usea certified EHR tocollect data aboutpatients—ONC Report to Congress, Oct. 2014

Overview: Balancing act on the EHR playground

Percentage of Office-based Physicians with EHR Systems: U.S., 2001-2013

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opinions. The physician wish list is a mile long, with an April 2015 Circle Square survey revealing that 90% of physicians yearn for better functionality and an easier data-entry system.

“Many simply look at EHR as a must-use tool to document patient encounters, not leveraging it to make clinical decisions,” Heather Gervais, VP of commercial operations for Epocrates, observed at

an MM&M SkillSets Live event in May. Epocrates is owned by athenahealth, which sells a cloud-based EHR.

According to Manhattan Research (mR), more than three-quarters of physicians typically turn first to web-sites or apps when looking for clinical information during the workday. “Digital sources and dedicated EHR systems coexist side by side very nicely,” Levy shares.

mR found time spent on digital sources has re-mained static while time on EHR has increased. Phy-sicians are not, however, using digital sources less be-cause of EHR, Levy qualifies.

Doctors are spending a disproportionate amount of time on EHRs, and often in the patient’s presence, which screams opportunity. So how does pharma edge its way into the party? Physicians are not going to send a signed and sealed invitation, but it’s possible they may not turn pharma marketers away at the door.

Gervais, who straddles the pharma and physician sides professionally, believes pharma’s ability to adapt to this fast-evolving area of health IT has met a cross-roads of challenge and opportunity. Pharma should take caution to tread lightly.

Overview: Balancing act on the EHR playground

From Gervais’s perspective, athenahealth physi-cians know precisely what they do and do not want from the healthcare ecosystem, and pharma is contin-ually in hot pursuit of the latest trend in the marketing channel.

Messages that appear in EHRs need to be target-ed—highly focused, in fact—or physicians will feel bombarded, invaded and frustrated, which could be

detrimental since pharma already skates on thin ice in many cases with HCPs.

“Physicians think they own the patient care data—everything from their decision to put the patient on a particular treatment to what dose is appropriate,” says Bryan Cote, managing director, Berkeley Re-search Group. “Pharma thinks they have the solution, and they kind of do.”

“Pharma needs to test and learn so once the segment gets hot, they know how to execute,” Gervais says. “I’m not here to tell them the secret sauce and the blueprint on how to crack EHRs.” The companies that have been successful, so far, are trialing different methods with a handful of trust-ed partners in the space.

The fact is that EHRs may not be ready for pharma. Digital patient records must first square away the data piece. “We live in a world where phy-sician marketing has become about specific and tar-geted messaging,” Levy concludes. “There are so many choices of platforms and tactics, pharma needs to choose wisely.” n

“There are so many choices of platforms and tactics [with respect to digital patient records], pharma needs to choose wisely. ”—Monique Levy, VP, research, Manhattan Research

14%of office-based providers electronically share patientcritical healthinformation with outsideproviders—ONC, 2014

Most Physicians Don’t Like Their EHR

Source: Circle Square, HIT Trends, April 2015

42%58%

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EHRs face a bevy of hurdles on the road to interoperability. Perhaps the biggest involves integrating healthcare’s broad network of stakeholders. Until experts find the source of data-sharing disconnects, little traction can be made.

W e’ve all heard the rumor about the hospi-tal in which the 9th floor’s EHR system is not connected to the one employed on the

8th floor. The thing is, it’s not a rumor. And it’s not just one hospital—it’s many.

During the past four years the government has forked over nearly $30 billion in incentives to promote electronic health-record adoption. And as the fed-eral incentive program shifts gears from fostering the exchange of health information to enabling real inter operability (the ability of EHRs to analyze and make use of data for other purposes), there’s room for improvement. A mere 11% of providers polled in a recent Modern Healthcare survey can reportedly exchange data with providers in other parts of the country.

EHRs are meant to be digital nets that snare valu-able clinical data to be shared securely across a broad network of stakeholders, including competing health systems, all in the name of good patient care. At this point, however, interoperability is a theory at best.

Where is the data disconnect? Some say it’s in the hands of government agencies, some blame tech gurus and others say hospitals themselves need to play a bigger role.

“Unfortunately, there are health systems, EHR ven-dors and many other players who resist such sharing of data,” says Jason Buckner, senior VP of informatics at The Health Collaborative.

The Office of the National Coordinator for Health Information Technology (ONC), the government entity tasked with breaking down these barriers, is-sued a report to Congress after fielding numerous complaints about vendors and providers engaging in health-information blocking. The report aims to curb activity that devalues taxpayer investments and derails US healthcare transformation efforts.

This comes closely on the heels of ONC action to topple a long-practiced vendor custom of charging fees for exchanging patient data. The ONC mainly

wags its finger at health IT developers for thwarting patients’ ability to export, receive or share health in-formation housed in EHRs. Response to the rebuke was led by athenahealth and Cerner’s agreeing to drop fees through 2020. Market giant Epic Systems eventually joined in on the fun, but the response was less than swift.

Widespread concern suggests that our government is all talk, and no action. “In the first stage of Meaning-ful Use, the ONC defined those three standards and, voilà, EHRs could finally talk to each other,” quips Matthew Douglass, co-founder and VP of EHR expe-rience at Practice Fusion.

Moving from MU Stage 2 to Stage 3 is a make-or-break proposition. “Either MU will fail or regula-tory people, providers and vendors will step up and achieve what the HITECH Act was supposed to achieve,” says David Lee Scher, cardiologist, digital health technology consultant and founder/director at DLS Healthcare Consulting.

Scher agrees that while the government has issued guidelines and offered advice, there has been no real traction in interoperability implementation. “The agencies haven’t provided the support expected,” he determines.

Industry experts, including Humana’s CEO Bruce Broussard, are vocal about the interoperability issue stemming from culture, and not technology. Broussard recently wrote, “Interoperability is multidimensional, not linear. It doesn’t just connect the doctor and the patient. It also connects caregivers, the gym, the phar-macy, social support network, the family, etc.”

Healthcare does not appear to be lacking in the technology department. “There are great tools out there,” relays Redox co-founder Niko Skievaski. “The problem is in adoption and the biggest roadblock is the integration.”

In the quest to interoperate, EHRs are staring down a course full of hurdles. “We’re in the most difficult part of the process now, so the next few years will be immensely important for our interoperability goals,” Douglass says. n

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The Quest to Interoperate: Integrating healthcare’s network

“Unfortunately, there are health systems, EHR vendors and many other players who resist such sharing of data.” —Jason Buckner, senior VP of informatics at The Health Collaborative

11%of providers can exchange data with HCPs in other parts of the country.—Modern Healthcare, April 2015

51% of hospitals canelectronically search for critical health information from outside sources.—American Hospital Assoc., 2013

S addled with legacy EHR systems that func-tion as little more than patient-information depositories, hospitals and health systems are

banking on the ingenuity of third-party app and soft-ware developers to extend functionality.

The industry is anxiously awaiting the perfect rec-ipe of EHR and mobile health (mHealth) to propel its data-capturing ability forward. Historically anti-bureaucratic in nature and less inclined to stymie ad-vances, tech start-ups may have what it takes to push innovation to the next level.

Today’s patients recognize the value of services like Uber and Amazon, industry disrupters meeting the needs of time-strapped, price-savvy consumers. It’s only a matter of time before they demand the same

from healthcare. Products are being developed left and right to work alongside, and not replace, EHRs to provide better tools for physicians and patients.

“It’s not enough for a health system to be integrated with Epic,” observes Redox co-founder Niko Skievas-ki. “Custom integration needs to be built so different networks can talk to one another.”

Companies such as Redox, Mana Health and Zynx Health are striking while the market is hot for work-around solutions to healthcare’s data communication

With industry anxiously awaiting the perfect recipe of EHR and mHealth to propel its data-capturing ability forward, third-party software and app firms are attempting to sell their wares into the enterprise healthcare IT systems to extend their functionality. Do tech start-ups have what it takes to push innovation to the next level?

woes. “We help EHRs provide the API [application programming interface] layer they will need in MU 3,” says Mana Health co-founder and exec utive chair-man Raj Amin. “The ultimate result will be hundreds of potential apps.”

Healthcare apps live in the cloud but need to con-nect and share data with the EHRs in a hospital’s server room. An API can function as a seamless go-between in this tricky endeavor.

Skievaski believes technology can help healthcare unlock its efficiency goals. “There is so much ineffi-ciency in healthcare, one-third of every dollar spent is wasted,” he explains. “There is enormous growth potential for apps.”

By adding apps—a sector of technology predict-ed to grow 25% annually—to the arsenal of patient tools, hospitals can streamline efficiencies and reduce costs. “Mobile is one of the biggest change agents in all indus tries right now, and API is enabling the data e cosystem to exist,” Amin shares.

Within the past year, about 33% of physicians rec-ommended an mHealth app to patients and 47% used their own devices to show patients images, according to a Manhattan Research survey.

The EHR giants are dipping their toes in the mHealth pool, too. In an effort to extend clinical capabilities, Epic added the Vocera Communication System to its EHRs and launched its own app store, and Cerner inked a deal with eClinicalWorks to add connectivity to mobile devices.

Many question the utility of these moves, including Stifel analyst Steven Rubis, who recently stated that Cerner’s “push into mHealth is likely driven by health plans rather than Cerner’s strategic thinking.”

On the flip side, Rubis lauds athena-health’s move to develop athenaCollector Enterprise, combined with athenaClinicals Enterprise, as a potential market disrupter

down the line.Skievaski believes the large EHR vendors may be

mainstays in the industry, but their structure is poised to change. “They will still store the data, but more apps will replace the front end like when a pediatri-cian needs a tool for a patient that Epic cannot sup-ply,” he says.

When would prove a better time for the healthcare industry to overcome its deep-seated fear of change? So much is at stake. n

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EHRs push into mHealth: Do tech start-ups have enough?

“Custom integration needs to be built so different networks can talk to one another.” —Niko Skievaski, co-founder, Redox

33% of physiciansrecommendedan mHealthapp to patients.—Manhattan Research

47% of providers usedtheir own devicesto show images to patients. —Manhattan Research

Redox dashboard

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MU Stage 3 requires that 25% of patients can access data from their EHR, up from the 5% required in MU 2. Patient-care data is top of mind. Experts say freeing it will unlock the value of what our nation’s healthcare system is trying to achieve. Yet there are roadblocks.

T he day has arrived for patients to have con-venient 24-hour access to their own personal health information. The trouble is, nearly

one-third of Americans polled in a recent survey by Xerox are unaware that these patient portals are available to them. Others must fork over a fee to view their own records. Surely, there is a better way.

“Patient portals should be the hub of patient en-gagement,” says cardiologist David Lee Scher. “The concept is to tie in patient adherence tools and wearables to make a truly interactive EHR instead of to a repository or email box.”

Patient portals aspire to give physicians the keys to better out-comes for their users. Some are concerned, however, about the potential onslaught of patient-to-provider email messages, patient misuse or complete refusal to use portals and lost revenue on the provider side for time spent com-municating with patients.

It seems that the two extremes need to meet somewhere in the middle for true effectiveness, with technology juggling the needs of both the provider and the patient. The two biggest roadblocks? Inter operability and cost.

“The current vendor-provided patient portals are meant to meet regulatory requirements, not the needs of patients and providers for true engagement,” Scher ex-plains. “The potential value is not being provided for the patient.”

The ONC recently stepped in with a provision that green-lights the use of APIs in place of patient portals. MU Stage 3 requires that 25% of patients can access

data from their EHR, up from the 5% required in MU 2. Via the API route, hospitals could meet the require-ments more easily and for far less out of pocket.

Apple’s HealthKit is revving its engine to win the race to combine consumer-aggregated data with data mined in a health system’s EHR. Epic gave Apple a chance to test drive its wares by providing consumer access through the Epic MyChart app. Early adopters complained of a clunky service that involves too many steps to capture data.

Epic conducted a successful pilot of HealthKit at several large health centers, including Ochsner Health System in Louisiana. The facility gave wireless scales to 100 heart-failure patients tasked with transmitting their daily weight to their EHR system. Physicians monitored the patients’ weight—an important red flag for fluid retention—so medications could be quickly

adjusted to prevent complica-tions.

“Patient care data is top of mind right now,” says Raj Amin, Mana Health co-found-er and executive chairman. “Moving to a value-based model hinges on understanding what happens to patients after they leave the doctor’s office. Currently that data comes from the doc calling the patient after discharge and asking questions about medicine adherence, episodes, etc. That won’t be the model of the future.”

Amin believes that freeing data will unlock the value of what our nation’s healthcare system is trying to achieve. He points to a larger economic and lifesaving impact.

Industry folks have won-dered when pharma compa-nies might try their luck in the patient-portal space. Accord-ing to Manhattan Research’s

Monique Levy, pharma is staring down a wide-open opportunity.

“We may eventually see pharma activity in patient portals,” concludes Sarah Bast, VP, Publicis Health Media. “But for now, we all need to focus on helping patients use the portals to get what they need.” n

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The Hub of Patient Engagement: Patient portals

1 in 3 Americans are currently unaware that patient portals are now available to them—Xerox

“The concept is to tie in patient adherence tools and wearables to make a truly interactive EHR instead of to a repository or email box.”—David Lee Scher, MD

28% of adult patients were reportedly offered access to their medical records; of those, 46% actually viewed their record online —ONC phone survey, 2013

Mana phone app

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The Patient Lens: Adding Context to Care

The industry is ripe for disruption from cloud-based offerings and ACO experimentation. Hospitals and health systems that have adopted the cloud, however, don’t always know how to interact responsibly.

L egacy EHR systems—often widely criticized for their static components—are growing stale. Emerging cloud-based EHRs are dis-

rupting the space with nimble, time-sensitive solu-tions and capabilities that may be just what the doctor ordered. Will health IT advances unlock the patient-data vault?

Heads have turned to wearable technology, both at home and in hospital settings, tasked with trans-forming the patient experience and forever changing behavior. These high-tech solutions are the product of our often-distracted, busy culture. We need prompting to chart and record our blood pressure in the cloud for physi-cian consumption.

Ah, the ubiquitous cloud. IDC Health Insights forecasts show 80% of health-care data will pass through the cloud by 2020. As providers increasingly use the cloud for data collection, aggregation, analytics and decision making, EHR vendors are scrambling for a piece of the intangible storage locker.

“Health systems are banging the drum with their internal departments to determine whether EHR vendors can unlock the data,” quips Mana Health’s Raj Amin. “We, as a country, cannot allow data to be unfairly held.”

Whether cloud-based or traditional, EHRs have changed physician behavior, explains Practice Fusion senior VP Dorothy Gemmell. “Cloud-based tools give physicians a more flexible workflow,” she explains. “When we implement a change, it appears the next morning. In bigger EHR systems, changes can take weeks or months.”

Partnerships with Apple are running rampant to update bedside care. The Apple Watch delivers more than the time for mobile-crazed physicians who want quick and efficient solutions. Vocera, athenahealth and other companies are working tirelessly to peel

docs away from the computer screen and provide subtle in-the-moment access to EHR schedules and messaging functions.

New Jersey–based MD Anderson Cancer Center at Cooper teamed up with Polaris Health Directions to track the behavioral patterns of breast-cancer pa-tients. Data gathered via an Apple Watch app helps physicians weigh treatment side effects, sleep informa-tion, activity levels and mood.

An emerging issue for the ACOs and IDNs is the vulnerability of patient data. “Someone’s identity can be stolen on an EHR, but it’s worse because the thief also runs off with personal health data,” Redox’s Niko Skievaski says. “The industry is grappling with the cul-ture around EHR and patient privacy.”

Some health systems that have adopted the cloud don’t know how to interact responsibly, Skievaski

reports. “Those hospitals are poking holes in the firewall with each app they onboard, leaving them vulnerable for a potential data leak,” he says.

In all of this, the question of pharma’s role is tricky but there is certainly a glimmer on the horizon. Companies are exploring population health management and medication voucher avenues to assist phy-sicians who opt in to improve patient care. “We aim to make the patient population healthy by helping physicians pro-

vide the right treatment plan,” shares Sarah Bast, VP, Publicis Health Media.

Over time, outfits like Practice Fusion will track and measure the success of interventions including the use of coupons, Gemmell shares. Do coupons help pa-tients get medications faster and adhere to the dosing plan? Peeling back these layers of data is what we’ve all been waiting for in the Great Data Capture of the 21st Century. n

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“When we implement a change, it appears the next morning.”—Dorothy Gemmell, SVP, Practice Fusion

80% of healthcare data will pass through the cloud by 2020—IDC Health Insights

65% of consumer transactions with healthcare organizations will be mobile by 2018—IDC Health Insights

The Future of Health IT: Unlocking the patient-data vault

The Apple Watch