Predictions, Hopes and Aspirations for U.S. Healthcare in 2015€¦ · • The real predictions for 2015 • The aspirational predictions for 2015 • Poll questions for your predictions

Greetings and welcome to the 2015 Health Catalyst Webinar Series. As a quick introduction, Health Catalyst is a Health Care Data Warehousing and Analytics Company. My name is Anita Parisot and I will be your moderator today.

Because of the growing importance of analytics in almost every aspect of health care transformation, these webinars are intended to be educational opportunities to explore the many facets of analytics that can effect health care. Today’s session will be truly interactive. At the end of Dale’s prepared thoughts we will be opening the audio line so you can share your thoughts and opinions on 2015 with him. Think of today’s webinar as akin to a talk show where you can share your thoughts live and discuss them with Dale.

We will be giving you detailed instructions for how to participate later on in our broadcast. We are recording today’s session and shortly after the event you will receive an e-‐mail with links to the recorded on-‐demand webinar, the presentation slides and the results of the poll questions. We will also be providing a transcript of this webinar and will send out a notification to you once it becomes available. You can also follow us on Twitter. Our handle is @healthcatalyst.

Before we turn the time over to Dale, we have one poll question. To better understand our audience today, please let us know what your primary functional area is:

Predictions, Hopes and Aspirations for U.S. Healthcare in 2015

Dale Sanders Senior Vice President, Strategy

The results are: Our attendees are 27% executives. 9% clinicians, 16% IT, 15% data analyst or data architect and 33% other.

I will now turn the time over to Dale Sanders, Vice President of Health Catalyst.

Thanks, Anita. Very interesting poll results. I would say there are more executives than I expected and fewer clinicians. That’s interesting. Well, thanks everyone. Thanks for sharing your time. Especially, we hope it’s a good use of your time. We will do our best today to make this entertaining. It’s a little different format for us so we are having some fun here in the Health Catalyst studios in beautiful Salt Lake City this morning.

© 2014 Health Catalyst www.healthcatalyst.com Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.

Poll Questions

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How are you involved in healthcare?

a.  Executive b.  Clinician c.  IT d.  Data Analyst/Data Architect e.  Other

What is your primary functional area of expertise?

Today’s Agenda and Format

Today’s agenda will go something like this. The Marketing Team asked me to put together predictions for 2015 and actually asked me in November. The goal was to do this before the end of the year, but I went from being excited about it to being kind of bored about it because health care is so predictably unchanging year to year. So as I thought about what kind of predictions I can make, it didn’t first appeal to be very exciting.

So I am going to talk a little bit about why health care is so predictably unchanging year to year. I’ll look for some good news. There have been some recent developments and maybe we are going to change more effectively than we have in the past. I’ll offer some real thoughts and real predictions about 2015 that are kind of easy to predict and then some more aspirational sort of tongue-‐in-‐cheek predictions.

We’ll offer some poll questions at the end of the webinar and ask some of you folks to offer some of your predictions. Then we will open the telephone lines for your comments, questions and predictions as well.

And I want to say right up front I am a political independent. With some of these slides you may think he’s a bleeding heart liberal or he’s an ultra-‐conservative, but what you’ll find with me is that I tend to do my own thinking without much dogma from either political party. I decided to say that right up front so you don’t have to guess about it.


Today’s Agenda And Format

•  Why is so healthcare so predictably unchanging, year-to-year?

•  Is there any good news?

•  The real predictions for 2015

•  The aspirational predictions for 2015

•  Poll questions for your predictions

•  Open the telephone lines for your comments, questions, and predictions

•  I’m a political independent… so you can stop guessing !

And I want to thank the marketing team for the Carnac overlay on my head. For the younger members of the audience, Carnac was a Johnny Carson character and some of those YouTube videos are pretty hilarious. If you haven’t had a chance, go out and watch those.

Mean Time To Improvement

So the Mean Time To Improvement in Health Care is a concept that I kicked around for the last few years. I think there are some industries where you can measure their mean time to improve literally in hours, days and weeks. In health care we tend to measure our progression in years and decades. Not long ago there was a study that indicated it took us 17 years to start practicing the standard protocol for community-‐acquired pneumonia on a widespread basis. I’d like to think that we are better than that now, but we still have a long way to go and that’s one reason that year-‐to-‐year changes are relatively easy to predict. This concept is pretty straightforward moving from left to right. How fast can you move from recognizing the need for improvement based upon organizational and personal awareness as well as dated to support that awareness? It takes measureable, tangible improvement and folding that back on your behavior. The summation and average of all that, of course, is the Mean Time To Improvement.

And I really do believe that there are personal as well as cultural metrics that we can assign to this concept. How long does it take you as an individual to make a decision about your own improvement and the need for that? How fast can you turn that around and actually change your behavior; your thoughts, behavior, whatever the case may be.


Mean Time To Improvement Measured in years and decades for healthcare… why so long?

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We have a culture in health care that is kind of slow from a MTTI perspective. “Why is that?” is the question.

Change Rolls Up Hill

I would suggest that change tends to roll uphill. Organizations, countries, and industries don’t change. I don’t really believe in that. Its individual people that change and that rolls up to countries, organizations and industries, but it starts with individuals.

So I haven’t asked all you what do you do to lower health care costs and increase quality within your scope of influence? What do you do if your only scope of influence in health care is that of a patient? What are you doing to contribute to lower costs and increase quality in your own personal behaviors, lifestyle choices, and that sort of thing with your utilization of health care?

And if you are an organization, what are you doing to increase that progression of your culture at an individual level? Obviously if you are the CEO, Kaiser influences your scope, Kaiser Permanente. Your scope of influence is significant. CEOs should be doing things that are different than individual patients to change the state of affairs in health care. Although I am a little cynical about this, because we keep waiting for the system to change instead of taking individual accountability for that. So I encourage all of us to start thinking about what we do individually within the scope of influence that we have to make a difference because generations are going to suffer if we don’t now.

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One Part of the Bad News

So, this is only one part of the bad news. It is pretty startling. Health care itself is the third leading cause of death in the United States. If you can think about that for just a second. It’s the third leading cause of death in the U. S. Health care contributes, through errors to 400,000 deaths per year and serious harm is estimated in 10x to 20x of those deaths. There is an Institute of Medical study that came out a number of years ago that suggests that it was 98,000, but that date is about 30 years old now. This article that appeared in The Journal of Patient Safety is much more current and more thorough.

So the best that we can do, really, is start focusing on what we should be doing as health care organizations and individuals within health care to start reducing this number. There is no single thing that we can do that would have a greater impact on reducing the pain and suffering of those we care for than to deliver that care more safely and more effectively. Everything that we would do around cardiovascular disease, oncology, the other two leading causes of death in the US are going to take years and years to reach what we could do ourselves within the four walls of our organization.


Only One Part of The Bad News

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There Is Some Good News

With that bad news, there is some good news recently that the industry is changing and I am hopeful that our MTTI will start to decrease. So there are some notable, very significant things in the news lately.

Blue Cross Blue Shield of North Carolina hosted its contract prices with providers with a very nice tool that’s easy to use. I have been playing around with it and it’s phenomenal and I applaud the leadership of Blue Cross Blue Shield of North Carolina for doing that. It’s unheard of and unprecedented and we need to see more of that. That kind of transparency is going to make a big difference in the economic model and the asymmetry of the information that I will be talking about later that is holding back progress.

Secretary Burwell announced a couple of weeks ago in The New England Journal of Medicine that our goal is that 85% of all Medicare pay-‐for-‐service payments is tied to quality or value by 2016 and 90% by 2018. That’s huge. A great acceleration of movement towards fee for quality and away from fee for service.

Three Republicans are offering what I think is an alternative to the ACA that seems to have significant merit. The unfortunate thing is that it is aiming for complete repeal of the Affordable Care Act and


There Is Some Good News Maybe our MTTI will start to decrease? •  BCBS of North Carolina posts contract prices with providers

•  http://www.bcbsnc.com/content/providersearch/treatments/index.htm#/

•  Sec Burwell announcing “Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.”

•  NEJM, January 26, 2015

•  Republicans (Hatch, Burr, Upton) offer alternatives to the ACA that seem to have merit

•  But aiming for repeal of ACA and replacing it with Patient Choice, Affordability, Responsibility, and Empowerment (Patient CARE) Act

•  UnitedHealthcare, Humana and Anthem Blue Cross Blue Shield offer HealthySavings discounts at grocery stores for buying healthy foods

•  Kenosha News, Feb 10, 2015

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replacing it with another act. I think complete repeal is unlikely, but I’m hopeful that there will be a compromise. There are some very good concepts in the new plan offered by Hatch Burr and others.

Finally, The United Health Care and Anthem announced a very innovative and interesting program in the news this week; just yesterday. Healthy savings discounts at grocery stores for buying healthy foods. What a great idea. What a risky adventure on their part. As I understand, the discount extends to 10% of the price of these healthy foods. So that is a pretty significant financial risk for those insurance companies and it will be fascinating to see if that has an impact on their costs.

It’s interesting if you look at this, virtually all of these initiatives are aiming at reform of the economic model of health care. I think that’s a good thing because as I have said in other settings, we are more homoeconomicans than we are homosapiens. Economic models tend to drive our behaviors; either good or bad and the economic model of health care is a disaster. All of these initiatives to improve the economic model and transparency of health care will have a significantly positive impact on the quality and safety of care as well.

Why is the System So Predictably the Same Every Year?

So, talking about this, why is the system so predictably the same year after year? I really believe it boils down to this amateur economic perspective that I have here which is degrees of separation between the earner and the spender.


And what I claim is that the first order of economics, where you spend your money, is generally a pretty efficient way to make sure you’re spending your money effectively. That’s not always the case, but it’s generally a pretty efficient way for the earner to spend their money.

One degree of separation from that, the second order of economics, is that I spend your money for you. There is a little bit of inefficiency in that I am making decisions for you and having to spend that money.

And the third order is that you pay me to spend your money for you. And that introduces yet another level of inefficiency and separation between the earner and spender. Now, obviously there are some things that individuals can’t afford to do and we have to pool our money for things such as military defense, health care for the poor, and interstate transportation systems. But we have to accept that as we pool that money we create these orders of separation that are going to create inherent inefficiencies in the model and we have to keep an eye on these inefficiencies. That is the problem we have in health care right now. The economic model is a disaster as we all know.

Relationships

This is my attempt to describe that in this diagram; all these different second and third order relationships between patients and employers, patients and government and health care providers, and insurance companies. Patients that are purchasing through self-‐pay is the most efficient, but also probably the least effective for managing risk. Direct contracting from employers to help providers are


Asymmetric information in micro and macroeconomics; Nobel Prize, 2001.

the offers that might consider mediation of the inefficiencies of the third order relationship between insurance companies. And I think we are going to see more of that happening. And of course, the government is just a form of insurance company through Medicare and Medicaid and the military health systems as well and that has some pretty significant inconsistencies as you move that into the commercial health care provider space.

The other thing that this diagram depicts is the information asymmetries that exists between the patients and the rest of the players in this environment. Patients in general don’t understand the complexity of the system; either the economic model or the care delivery model. As a consequence, as shown by Nobel Prize winners in 2001; the brilliant folks from Canada, this asymmetric information where the employers, insurance companies, providers and the government all know a lot more about this very complicated system than patients. Patients are left wondering what to do and not knowing how to change the environment that they are a victim of. It’s comfortably inefficient for everyone except the patients. So we have to change this and removing that asymmetry is one great thing. For example, what Blue Cross Blue Shield folks of North Carolina did by revealing all of the pricing that is associated with the health care provider contract that the insurance company has. Really bold move to remove that information asymmetry.

If you want to read more about this fascinating concept, there’s plenty to read about. Again, it’s a Nobel Prize winning concept in 2001 from the folks listed here.

© 2014 Health Catalyst

www.healthcatalyst.com Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.

Now let’s go into the real predictions and they are somewhat easy and straightforward. Some of these I take a provocative stance just to stimulate debate. Some I try to be more serious. We will talk about M&As, Supreme Court, ACOs, physicians, pharmaceutical drug reform, broad insurance and narrow coverage, HIE failures and the growing dissolutions with EHRs.


Now, About Those Predictions…

First, the most obvious… •  Mergers & Acquisitions

•  Supreme Court

•  Accountable Care Organizations •  Physicians

•  Drug reform •  Broad insurance, narrow

coverage

•  HIE Failures •  EHR Disillusionment

Mergers and Acquisitions

So I take a shot at some of our leaders here and given the demographics of our listeners today, I hope they don’t get too offended, but there is a bit of testosterone flowing around the mergers and acquisitions movement in health care right now. It’s the latest, greatest thing to do and keeping up with the Joneses is very important. What is happening through these acquisitions and mergers is that the CEOs and other leaders are forgetting about the importance of data so they are acquiring people and they are acquiring facilities and they are acquiring patients and capture areas, but they have left the data behind largely and missed that in the M&A strategy . Without that data you cannot effectively manage the new health care delivery systems in the future and you can barely manage the existing health care systems of today.

I see CEOs with a lower wardrobe budget looking for M&A opportunities being more pragmatic and more data driven. It’s kind of the second and third wave of M&As and I see more of that happening in 2015.

I am going to make a very provocative statement here, that by 2020, 70% of US health care will be delivered by very large regional networks, 9 of those. I think this merger and acquisition and the consolidation of the market is critically important to meet the efficiency of the economic model.


Mergers & Acquisitions CEOs with cufflinks and monogrammed shirts love mergers and acquisitions, fueled by the availability of cheap money and testosterone, until they realize they don’t have the data to manage the new company.

CEOs with a lower wardrobe budget will also look for M&A opportunities, but will be careful, pragmatic, and data driven.

The pragmatic settlers, not the pioneers, are going to create better, more efficient care through M&As in 2015.

By 2020, 70% of US healthcare will be delivered by 9 very large, regional health networks

Now of course, like all mergers and acquisitions we will have to keep a close eye on price gouging and monopolistic behavior, but it’s possible we can do it if we have the covariance processes in place to handle that sort of thing.

Supreme Court

So let’s talk about the Supreme Court. We have the upcoming King and Burwell decision. I would say given the Supreme Court’s past history, with the individual mandate and voting to support that, I would be really, really surprised if they don’t vote in favor of The Affordable Care Act in this case. Clearly to me this is an issue that is more technical in nature. There is plenty of precedence in the Supreme Court to rule against those technicalities and then interpret the spirit of the law rather than technicality of the law. The reality is if it is over turned, millions of voters are going to suffer financially from the loss of those subsidies.

As we all know, the perception of loss especially in social programs is significant. So taking that money away is not going to work well and I am sure the Supreme Court will consider that even though they should be apolitical. I’m going to come down very firmly with a prediction that they will rule in favor of the subsidies and The Affordable Care Act.


Supreme Court

The Supreme Court has two choices regarding King v. Burwell and federal subsidies: 1.  Interpret the spirit of the law 2.  Interpret the law’s precise wording

If overturned, millions of voters would suffer financially from the loss of those subsidies. The Supreme Court will rule in favor of the subsidies and the Affordable Care Act.

Affordable Care Act

So, speaking of The Affordable Care Act, Congress and the three Congressmen we have mentioned earlier, will threatened to repeal it altogether. Obama will threaten to veto the repeal, but eventually I think things will come back into an effective change and reengineering of The Affordable Care Act that Obama will support. I’m seeing what I call and those before me have called what I consider Compassionate Capitalism. If you look at a lot of our social programs and the balance between Karl Marx’s approach to social programs and an Ayan Rand approach, I believe that we can achieve Compassionate Capitalism that takes advantage of the efficiencies and benefits of capitalism without the inefficiencies of a socialized environment. I would say that Medicare, Medicaid and Affordable Care Act probably are a little to the left than center right now meaning a little towards Karl Marx type economics. I think that is one reason why we see a constant escalation of health care costs and the great inefficiencies in the ways that we see. So, hopefully moving just a little bit to right, but not being too greedy will result in a better version of the Affordable Care Act. I see evidence of that in the plan that was released this week.

Affordable Care Act

•  Congress will threaten to repeal it, altogether.

•  Obama will threaten to veto the repeal.

•  Eventually, the GOP will propose dramatic but effective changes that Obama will support.

•  Compassionate Capitalism

Accountable Care Organizations

I think we will continue to see these incredible administrative burdens bearing down on accountable care organizations from the federal level. This is a bit aspirational, but I would like to think in the reengineering of The Affordable Care Act, the federal government will start acting more like the world’s largest customer of health care, being less prescriptive about how to reform instead of acting like the largest bureaucracy of health care. Four hundred forty some pages delineating The Affordable Care Act and accountable care organizations is just ridiculously complicated and we have to reduce that. I would love to see the reengineering of The Affordable Care Act and the ACO previsioned in that more around principles rather than prescriptions and again acting as a customer of health care rather than a governor of health care. So, my hope is that the ACA will be rewritten, the trend improve and Obama will agree to the changes before he leaves office and it will help alleviate the administrative overhead that these accountable health organizations are struggling with right now.


Accountable Care Organizations Burdened by administrative overhead, federally ACOs will continue to struggle and underperform.

In 2015, the federal government will start acting like the world’s largest customer of healthcare instead of the world’s largest bureaucracy of healthcare governance.

The ACA will be rewritten, trimmed, improved and Obama will agree to the changes before he leaves office.

Physicians

I believe that physicians will be at the center of ACOs. I think we are going to see further crystallization of that as physicians start organizing themselves with data and government structures. I think it’s the natural tendency for human beings to gravitate towards an engagement and relationship model that is with a human being, i.e. a physician, not a hospital and not an insurance company. We’re seeing that trend and I think it is going to pick up and increase. I think it is a good thing. I would say the future of accountable care resides in the hands of the physicians and we’re looking forward to helping them do that.


Physicians In 2015, as the centroid of ACOs crystallizes around physician groups.

Physician groups are gaining ground and will increase their lead over hospital and insurance centered ACOs.

The future of accountable care resides in the hands of physicians.

Pharmaceutical Cost Reform

Pharmaceutical cost reform is going to hit the headlines and it already is with high profile drug costs such as Sovaldi. I don’t think there will be any meaningful progress on reforms because of the pharmaceutical lobbyists and week-‐kneed politicians that are affected by that. It is unfortunate. Our drug prices are completely unregulated compared to the rest of the world and I think that’s the reason the rest of the world benefits because we produce more pharmaceuticals. The US is now the center of pharmaceutical production in the world and for the most part US consumers subsidize that. It is very unfortunate, but I don’t see that changing this year.


Pharmaceutical Cost Reform

High-profile drug costs, such as Solvadi ($84,000 per regimen for hepatitis C), will spur debate and concern.

But no meaningful progress on reform in pharmaceutical pricing will take place in 2015, thanks to pharmaceutical lobbyists and weak-kneed politicians.

(US drug prices to consumers are 3x-5x more than in Germany and the UK, btw)

Issue of Modern Health Care

This is a Tweet that I sent out earlier this week that I thought was kind of interesting showing this big gap between the cost of the drug and the outcome of the drug. From 1995 through 2013 the average price of new cancer drugs was $65,000, almost $66,000 and it provided an average life survival benefit of less than six months. That just seems like there is something wrong with that model and we have to improve the outcomes. It has to increase and we have to do that through research and that sort of thing, but there’s definitely a problem with that model right now.


Broad Insurance, Narrow Coverage

I think that health care expenditures are going to hit 20% of GNP. That’s a pretty well understood prediction. Affordability of care is going to come back into the debate because as patients start realizing that these insurance policies are very narrow networks and force a lot of out-‐of-‐pocket expenses on them. The downside of this affordable insurance network that we have created under The Affordable Care Act is going to be in the headlines for sure. One of the problems of The Affordable Care Act is this; it really did nothing to drive out the economic inefficiencies of health care delivery in the US. It really did nothing to reduce costs, unfortunately, these insurance policies that we now all benefit from, and I do think it is a good thing to have everyone to have insurance. Unfortunately we are subsidizing that $750 billion in waste in the US health care system. It would have been a lot more effective for The Affordable Care Act to have included very firm processes and policies or rather maybe customer requirements on the part of the government to reduce these inefficiencies and these wasteful practices that are actually driving up insurance to be a lot less affordable than they first appear to be.


Broad Insurance, Narrow Coverage

Healthcare expenditure will hit 20% of GDP.

Affordability of care will be hotly debated, once again.

The expansion of “affordable” insurance policies will highlight the downside of very narrow networks and coverage.

Patients will find very limited coverage and enormous out-of-pocket expenses that will drive uncomfortable headlines and subsequent changes to the ACA.

Health Information Exchanges

HIEs are going to go deeper into the trough of disillusionment. There are technical reasons for that, but there are also economic reasons. The benefits of an HIE are generally in direct contradiction to the existing US economic law which rewards inefficiencies in care. So until we change the economic model of care to an incentivized greater efficiency there isn’t a whole lot of motive economically to start sharing data. This is a classic example of technology that preceded the need in the culture and economic model and why it’s failing and the failures are gigantic.

The other is technical. Doctors tend to perceive HIEs are largely driven because of the inefficient and inadequate design of the electronic health records are perceived as very low value by most clinicians. We need to make some changes in the technology of the HIEs and EHRs to improve their operability as well and we can’t keep funding this with temporary money from state and federal coffers. We have to create a sustainable economic model under these HIEs on their own.


Health Information Exchanges

HIEs will go deeper into the “Trough of Disillusionment”

The benefits of an HIE are in direct contradiction to the existing US economic model which rewards inefficiencies.

Document-centric HIEs will be the worst in terms of perceived value by clinicians.

EHR Disillusionment

EHR disillusionment will continue. I believe the pain of reality is just beginning. Eighty-‐three percent of clinicians have a negative view of EHRs and it’s going to get worse. The outcry is going to deepen as we understand and realize the limitations that EHRs have to support population health, clinical qualities, value based purchasing, patient’s safety and clinician efficiency. All of the things represent what I call Health Care 2.0. These EHRs were designed for Health Care 1.0 environments, circa 1960 for influence. You could argue that we are partly to blame for that, because the software reflects the system that surrounds it. So we have some blame in this and we need to start demanding a change to the system as well as a change in these EHRs to support these better motives. It’s not about just dropping a bill and treating the patient in a 15 minute encounter.


EHR Disillusionment The pain of reality is just beginning.

83% of clinicians have a negative view of EHRs.

The outcry will deepen and broaden as the limitations of EHRs to support population health, clinical quality, value based purchasing, patient safety and clinician efficiency become more painfully obvious.

They were designed for Healthcare 1.0, circa 1964.

Are they to blame or are we?

So I believe this is baring for our frenzy encounter the trial for disillusionment for HIEs is deep; it could get deeper. EHRs are sitting behind that and again, as all of us who have implemented EHRs and tried to manipulate those to support all those better motives, you will find that they are very, very difficult to modify.

So let’s move on to some of the aspirational and satirical predictions. A little bit tongue-‐in-‐cheek here.

© 2013 Health Catalyst www.healthcatalyst.com

© 2013 Health Catalyst www.healthcatalyst.com

Aspirational & Satirical Predictions

Meaningful Use

I would love to see and I am predicting a dramatic change in Meaningful Use. Legislation from Congress and NOC will force the EHR vendors to support the operability technically, contractually and economically. It’s one thing for an EHR vendor to claim that they can share data technically, but it’s another to charge on a per transaction basis for data sharing. That‘s a contractual barrier to interoperability and it’s also a contractual barrier to innovation. We could use legislative changes, which need to include pressure, not just technically on the EHR vendors, but also contractually and economically. It has to be economically affordable and incentivized to share data with partners in the care delivery network.


Meaningful Use As Congress debates Meaningful Use, it will come down to these two barriers:

1.  The EHR data interface is encounter specific rather than patient centric and inherently lacks an effective workflow.

2.  EHR vendors see interoperability as a threat to their market share.

Legislation will force EHR vendors to support interoperability-- technically, contractually, and economically.

Wal-‐Mart Disrupts GPOs

I predict that Wal-‐Mart’s entry into health care is just beginning through their primary care clinics and insurance market. The next step will be the disruptive introduction of their supply chain expertise that is going to completely unsettle the GPOs in health care in five years. I think Amazon is probably another supply chain expert that is going to threaten the GPOs too and enforce some great efficiency on the supply chain, which would be great.


Wal-Mart Disrupts GPOs

Wal-Mart’s entry into primary care clinics and the insurance market are the first steps towards the complete consumerization of healthcare.

In 2015, Wal-Mart’s next disruptive step is in the logistics and supply chain of healthcare, where they will completely unsettle group purchasing organizations (GPOs) in five years.

Cleveland Clinic Telemedicine

Cleveland Clinic, and you could cut paste other admirable health care systems like Intermountain, Kaiser, Kisinger. Lynon. I would like to think that we are going to borrow lessons learned in military operations and command centers that manage over 400,000 troops in Iraq. The Cleveland Clinic will open a telemedicine command center that can monitor, interact, and manage 100,000 patients at a time and post-‐acute home care, hospice care and chronic condition management. It is easy to do technically, a little challenging to do operationally, but organizations like the Cleveland Clinic can certainly pull this off.


Cleveland Clinic Telemedicine Borrowing from lessons learned in military operations and command centers that managed over 400,000 troops in Iraq, the Cleveland Clinic will open a telemedicine command center that can monitor, interact, and manage 100,000 patients in post-acute home care, hospice care, and chronic condition management settings.

Price Transparency

Getting back to the economic model, hospitals and physicians are going to continue dragging their feet on this even though this is required by The Affordable Care Act. I think states will take this over as an issue in 2015 and hospitals and clinics that do not post their prices on the web will not be allowed to pursue their bad debt collections through collection agencies or legal action.


Price Transparency Hospitals and physician groups will continue to drag their feet on the issue of price transparency, even though they are required by the Affordable Care Act to make their prices publicly available.

Several states will pass laws to address this problem in 2015.

Hospitals and clinics that do not post their prices on the web will not be allowed to pursue their bad debt collections through collection agencies or legal action.

DoD EHR Contract

The DoD EHR Contract contract, a big topic. Huge money at stake. Huge influence in the market. At one time the DoD was one of the most inefficient and wasteful operations in the world. Today it’s a culture that embraces constant change, adaptability, precision and execution. I think you will see that migrate over into the military health system and as a consequence, they are going to surprise everyone and delay the award of the $11 billion contract until existing vendors offer better solutions or if a new dark horse vendor appears with a modern fifth generation EHR.


DoD EHR Contract The DoD was once one of the most inefficient and wasteful operations in the world.

Today the DoD culture embraces constant change, adaptability, precision, and execution.

As a consequence, it will surprise everyone and delay its award of the $11B contract until existing vendors offer better solutions or a new, dark horse vendor appears with a modern, 5th generation EHR.

Employer Sponsored Medicine

Employer sponsored medicine is direct contracted. That first order to second order economic is always more efficient. In a bold experiment to dramatically cut costs and improve quality of care, Toyota will acquire two hospitals and two physician clinics near their San Antonio facility in 2015. If this experiment succeeds and it is expected it to, Toyota will expand this model to all their manufacturing plants in the US after 2015.


Employer-Sponsored Medicine

In a bold experiment to dramatically cut costs and improve the quality of care to their employees, Toyota will acquire two hospitals and two physician groups near their San Antonio facility in 2015.

If this experiment succeeds—and it is expected to—Toyota plans to expand the model to all of their manufacturing plants in the U.S.

Medical Tourism In Your Backyard

Dr. Devi Shetty will borrow from his lessons learned and his methods of delivering health care in India and Health City, Cayman Islands. He will bring medical tourism into our backyard by opening a 1,000 bed hospital and affiliated clinics on a Native American reservation in the central US operating under the benefits of sovereign nation protection. It will be a huge economic boost to the tribe and it will be a big disruption to the delivery of health care in the US where he can deliver better quality outcomes surgically than US hospitals at one-‐eighth the price than at most US academic medical centers.


Medical Tourism In Your Backyard

Dr. Devi Shetty, founder of the 29-hospital Narayana Health System in India and Health City Cayman Islands, will open a 1000-bed hospital and affiliated clinics on a Native American reservation in the central U.S., most likely Oklahoma, providing a huge economic boost to the tribe, while operating under the benefits of sovereign nation protection.

Affordable, Accountable Insurance

State governors are going to follow the lead of Colorado that requires all hospitals and physician groups licensed in their states to offer their own health insurance plan. Again, it is getting back to that first and second order economic model where the balance of health care delivery and economic affordability falls under the same government structure. It’s exemplified for decades by organizations like Intermountain Health Care. This is the model of the future. We will see many state governors encouraging this through legislation and other incentives in 2015.


Affordable, Accountable Insurance

State Governors will follow the lead of Colorado and require all hospitals and physician groups licensed in their states to offer their own health insurance plan, thus encouraging the same organizational balance between quality-of-care and cost-of-care as exemplified for decades by organizations like Intermountain Healthcare.

Elimination of Federally Managed Medicare

In a very bold move, there will be an initiative to move federally managed Medicare down to the state level. Medicaid will be expanded to include senior care. Several independent analysis will indicate that we will take billions of dollars without sacrificing quality in care and the quality of care will be improved, tailored to regional personalization and local accountability. Again it’s moving the economic model closer to the wage earner. Very bold move. This is one when everyone could be guessing my politics, which is why I indicated, right up front what I was.


Elimination of Federally Managed Medicare

In a bold, bipartisan move, Congress will eliminate Medicare at the federal level, replaced by an expansion of Medicaid services and funding at the state level.

Several independent analyses will indicate the move will save billions of dollars without sacrificing patient care.

Quality of care will improve through tailored, regional personalization and local accountability.

Taxation on Violence

Violence in the US around guns is a public health issue and we can’t just do nothing. We have to do something about this. Even if it’s imperfect, we have to keep making some kind of progress in this issue. I am suggesting in 2015 ammunition will be taxed at 50%. Proceeds will fund a national insurance program for major victims and major life disabilities caused by firearms and the development of a behavioral health cultural awareness and sensitivity program that starts to deal with our love affair with guns and violence in the US.


Taxation on Violence

An anti-tax, 2nd Amendment Congress, will ensure all ammunition will be taxed at 50% and the proceeds will fund:

1.  A national insurance program for all victims of murder and major life disabilities caused by firearms

2.  Development of a behavioral health and cultural awareness and sensitivity program that deals specifically with the reduction of gun violence in the U.S., particularly mass shootings.

The NFL and Genetic Medicine

Finally, being a Durango, Colorado born and raised boy, I’d love to see the Denver Broncos borrow some genetic material from Russell Wilson from the Seattle Seahawks , might would insert Tom Brady in that now and we’ll see the Broncos go undefeated in 2015 and win five Super Bowls in a row. I had to end with a nonsensical predication here.

Jimmy Hoffa Mystery Resolved

Oh, I almost forgot. This might be the biggest predication of all. Two of the biggest mysteries of our generation can simultaneously be resolved when Mr. HIS talk reveals his identity in 2015 and it will be Jimmy Hoffa. Who knew that Jimmy Hoffa could operate a website?

So that’s it for the predictions, friends.

We are going to go through a few poll questions and collect your feedback on some of these. Then we will open up the phone lines and you can also post questions on the go to meeting control panel. I’ll turn it over to Anita and she’ll pop up the first poll question.


The NFL and Genetic Medicine The Denver Broncos will steal DNA material from the Seattle Seahawks quarterback, Russell Wilson, and splice that into Peyton Manning's genome.

The Broncos will go undefeated in 2015 and win five Super Bowls in a row.

Anita: Poll question #1 results

76% attendees say yes, the Supreme Court will rule in favor of Burwell and the Affordable Care Act.

Dale: OK. So we came down on the same side with that. That will be interesting, friends. We will revisit these predictions and see if we are right. I am pretty sure we will be right on this one.


Poll Question #1

Will the Supreme Court rule in favor of Burwell and the Affordable Care Act?

a. Yes

b. No

37

Anita: Poll Question #2 results

82% attendees say, no, they will not reach a favorable agreement on improvements to the Affordable Care Act.

Dale: Well I am going to keep holding out that naive Pollyannaish hope that they can and will. We will see if it happens or not.


Poll Question #2

Will Congress and the President reach a favorable agreement on improvements to the Affordable Care Act?

a. Yes

b. No

38

Anita: Poll Question #3

Attendee’s say couldn’t hear number

Dale: Interesting again, look at that. Surprising. So maybe a dark horse will come from that. Wouldn’t that be interesting? A kind of a skunk works. Let’s hold out hope that something better goes into the DoD than we have right now.


Poll Question #3

Will the DoD award an EHR contract to:

a. Epic

b. Cerner

c. No one

d. A surprising dark horse

39

Cheryl Keller� 2/15/2015 7:55 PMComment [1]: 0:39:52.5 Unable to hear poll results

Anita: Poll Questions #4

71% attendees say yes to 29% no

Dale: Yay, good numbers. So there is some optimism. We have to propagate that perception and desire. It is very, very important. That is great.


Poll Question #4

Will we make any significant progress on price transparency and availability, e.g., publicly available costs published on the web?

a. Yes

b. No

40

Anita: Poll Question #5

Dale: I baited this question a bit. It will be interesting to see what you folks think. Wow, almost even. Every interesting. It couldn’t go down much. Hopefully it will improve through the improvement through the EHRs. Very interesting.


Poll Question #5

Will clinician satisfaction with EHRs improve, decline, or stay the same?

a. Improve

b. Decline

c. Stay the same

41

Anita: The last Poll Question #6

We don’t have a lot of Broncos fans today. Thank you for entering those polls.

Dale: Oh, no. (Laughter) Wow. We won’t tell that.

Anita: Thank you for entering those polls today.

Dale: Thanks everyone. That was fun and interesting.


Poll Question #6

Will Peyton Manning and the Broncos win the Super Bowl in 2015?

a. Yes

b. No

c. What’s the Super Bowl?

42

Dale: Well, that wraps up the slides part of the presentation. We want to offer a thank you and also advertise some upcoming educational opportunities. Dr. Greg Spencer, one of our clients at Crystal Run Health Care. It’s one of the most forward thinking position groups in the country that are a federally qualified ACO. They are a NCQA certified ACO. They have filed for their own insurance plan. Seriously, one of the most amazing cultures for a position group that I have ever seen and I have enormous respect for Dr. Spencer and Dr. Heinz and we are enormously grateful that they are Health Catalyst customers. You will hear from them a discussion from the trenches about how they are using analytics as an ACO to drive clinical and operational. I highly recommend if you can, to attend.


Thank You Upcoming Educational Opportunities How One ACO is Using Analytics to Drive Clinical & Operational Excellence Date: February 18, 2015, 1-2pm, EST Hosts: Gregory Spencer, MD Chief Medical Officer and Chief Medical Information Officer Crystal Run Healthcare Scott Hines, MD Co-Chief Clinical Transformation Officer Crystal Run Healthcare Register @ www.healthcatalyst.com

Anita: Now is the time to open the phone lines where you can share your thoughts and opinions with Dale. You can do this by clicking on the hand icon of your control panel. You can see on the top there is a little hand and if you click it, it will go up to raise your hand and then we will click it to lower it for you. As we wait to see all of the questions we have coming in.

Dr. Robert Cole: This was a superb presentation. One of the best ones I have ever attended. I already submitted three questions in the chat box, but the key question based on this Argonaut Project announcement in December of 2014. Do you, as a technology expert, believe there is a potential for successful development and deployment of fire-‐based public APIs to lower the combusts of creating interfaces between health IT systems enough that in five or more years connectivity will be commoditized instead of obscenely expensive and proprietary.

Dale: That is a great question Dr. Cole. I am hopefully optimistic that the Argonaut Project and there is kind of a parallel project that is being advocated by Stan Huff and their NOT health care and others. There is certainly a need to move away from message-‐oriented architectures for interoperability and document-‐centered architectures to a fire-‐based API-‐based, services oriented architecture. Technically it is very, very important. The problem is and I’ll share with you a story. When I was at Northwestern we had EPIC, we had Cerner, we were considering All Scripts and in some situations we had canonical works on the campus IDX. I pulled the senior leaders from those VHR vendors together and asked them. We have to start opening up the APIs and we have to have services-‐oriented architectures and things


1.  Go to your audio control panel.

2.  Click on the icon to raise or lower your hand.

3.  Dale will tell you you by name when your line is open.

4.  Dale will mute your line and lower your hand when done.

Time To Open The Telephone Lines!

Click to raise

Click to lower

A Green Arrow Means Your Hand is Down

A Red Arrow Means Your Hand is Up

like that. To their credit three of the four DMR vendors that we hosted in those meetings left and initiated very open systems architecture projects in their companies. One of those vendors and I quote said and this is indicative of their mindset. “Dale, we see ourselves as more than a data-‐based vendor.” What that was saying is they don’t want to open their APIs and they don’t want to be interoperable because it’s a threat to their business. But it’s so contrary to what’s happened in technology when both the APIs in fact increases your market share. Android, Sales Force, Apple Operating System and what Microsoft has done with their Windows API. Everyone has moved toward this ecosystem of broader open API and easy to build applications around. So it’s going to be a combination of things. We have to start demanding it in the industry. We have to start putting our foot down. If it takes legislation to do that then we have to do that. Right now there is no economic incentive at all for most VHR vendors to be interoperable. It’s a threat to their business right now and that’s their mentality instead of opening those APIs. And that’s not even mentioning the technical barriers. Most of the VHRs were written at a time when open systems standards and open architectures were fairly new and there are some exceptions to that which are Insides, Nextgen and Allscript they have fairly open APIs by their nature. So it’s going to require some retooling on the part of a lot of the VHR vendors to make these APIs more open technically, not to mention culturally. Thank you that was a great question. I appreciate it very much. It’s a really important topic.

Mark Johnson: Thanks for the talk today. Just a quick question for you. You sited Dr. Shetty’s hospital down in the Cayman Islands. I am not sure if you are aware, but it does run in the public cloud and I was a little surprised that you didn’t have any predictions on the thoughts involved. What’s your take on that? Thanks.

Dale: The Cloud is sort of the inevitable part of the future of all computing. As a CIO I can tell you right now that I could care less if I ever know the model number of a server ever again in my career or the storage architecture. All I want is service. So I am a big believer in The Cloud. There are still some folks in the industry who are worried about security, but I just got back from four days at Microsoft where I spent a lot of time interacting and studying the Azure Cloud that they offer. I have a background in the military and national security agency and a background in security and protection of information systems. I can tell you right now there is no way that I could replicate the security Microsoft has created around their cloud. I could not do that locally. You have to choose your partners carefully, of course, but I just think The Cloud is an inevitable part of health care and as long as your choose your partners carefully, it is considerably more scalable and it’s considerably more affordable and security is not an issue. There is no way any of us could replicate on a cost effective basis what organizations like Microsoft has created. I am a big fan of that. Thank you for the question, Mark.

Dale: I will address some of the other questions that have come up through the link.

Mark Kidd: He says, “Dale aka Carnac, give me your prediction that the provider lines get by 2020 that will result in nine regional providers. Can you look into the future and share your predictions regarding the payer landscapes?

Dale: I think the opposite is going to happen with payers. I think we are already seeing that where we will see less consolidation among payers and I am absolutely sure we are going to see the greater disintermediation of the large payers where position groups, hospital’s ATOs are direct contracting with employers and pools of small business and also offering their own insurance and stop loss coverage. So I

actually see the opposite of consolidation. I see the commoditization of risk bearing models in health care and fewer big payers. Of course, that’s going to take years and years, but that’s what I think is going to happen.

Kent Gallogan: Do you think independent physician’s associations will still be around in the next 1-‐5 years?

Dale: I think it is going to be harder and harder for the IPAs to survive and that goes against my country boy upbringing where we had physicians that gave house calls when I was young growing up in Colorado. I think the nature of the economics and efficiency of belonging to the larger networks is going to make it very difficult for every individual physicians to survive in the future. We are certainly seeing a lot more physicians popping out of independent practices and moving towards those organizations. It’s kind of unfortunate. It’s like the demise of small businesses in Main Street America being replaced by big box stores. Romantically it’s kind of difficult to swallow, but economically it’s almost unavoidable.

Monica Caldwell: Do you mean that organizations like Wal-‐Mart and Amazon will replace GPOs or they will work together to enhance health care?

Dale: I think they are going to push into the GPO market. That’s my prediction. I don’t think they are going to collaborate much. I don’t see Amazon or Wal-‐Mart trying to collaborate with GSA or Premier. I think they are going to work on displacing them and capturing that market share. I think that is the nature of the competition. Health care supply chain management is demand driven and many multiple billions of dollars market. I don’t see Wall-‐Mart or Amazon feeling they need to do anything but compete head on. Thank you for that question, Monica. I appreciate it.

William High: Doesn’t for-‐profit medicine take money out of the system? Why is this necessarily better than the claims inefficiency of public delivery?

Dale: That’s an interesting question. One of the nice things about working in the Cayman Islands I got to see firsthand the laboratory environment this balance between public and private, but access to care. In the Cayman Islands it actually worked very well and it was very efficient. Obviously if a for-‐profit system starts taking gigantic profits out of the model, that’s going to create problems. But I do think we can have a social safety net, a health care system that is publically available, government subsidized, commercially operated that would mirror what I experienced in the Cayman Islands and I think it could work very effectively in the US. Again, it’s kind of that balance that I sketched out between Karl Max and Ayan Rand. I think it comes somewhere just a little bit right of middle that that model supports.

Mike McClure: What are your predictions and thoughts on retail and smart phone implications in health care?

Dale: That is an interesting question, Mike. There is some movement and I’d like to think it is more optimistic, but I’m not that optimistic that it’s going to have a giant impact on health care in the next few years. I do think that over time as we start collecting more biometric, social, economic and socio-‐economic data they become a device that supports the collection of that data about lifestyle, behavior, or exercise and that sort of thing and it may help. There are some things that you can do to improve position efficiency and quality of care by enabling global applications. I have done that as a CIO giving physicians the ability to monitor patients at a distance, for example; giving physicians the availability of

lab results and being able to refill prescriptions and submit orders remotely. I think that improves the efficiency and quality of life for the physician, the clinician and it certainly can support better care for geographically isolated patients. Other than that, I don’t see a gigantic change in health care due to mobile apps for a long time. I think we have a long way to go before monitoring biometrics and exercise routines and that sort of thing where they are folded into the care delivery model and actually have an impact. I am cautiously optimist. I have some experience with those sorts of things in the past where they are proven and I think we ought to start establishing more of those type of things where it is proven beneficial to the patients and clinicians.

Samuel Do you think inoperability should be mandated by regulation or just left for market forces to decide?

Dale: Unfortunately, what we have done is we created a situation with $25 billion in federal money that has eliminated market sources for interoperability. So we stimulated the rapid uptake of these very mediocre, barely interoperable systems and now they’re installed and they are operating in the health care system in the US and we funded it. We eliminated any free market capitalistic incentives for those systems to be interoperable. Again, the economic policy of the US being what it is, there’s no motivation on anyone’s part, very little anyway, outside of innovated delivery network to share data because sharing data reduces inefficiency and reduces patient’s safety problems, and reduces redundant testing. All of those things are economically rewarded. Eighty-‐nine percent of our health care dollars are still spent on fee-‐for-‐service encounters. Until we get to 50%, the tipping point, there’s not a lot we can do. I don’t know how we are going to unwind what we have done, but we need to figure out a way to instill a little bit of market Darwinism back into the EHR market. I don’t know if we can, though. We have invested so many billions of dollars in existing products. I just don’t know how you unwind that. So maybe the answer is that it has to be mandated by Congress and ONC, but if we do that, it has to be better than what we have so far as interoperability standard because it’s not working. These HIEs technically are not very effective right now and that, by the way, is not necessarily the HIEs fault, it is partly the design of the EHRs that are so encounter specific instead of patient specific so when you start sharing data it becomes awkward figuring out how to file that data against the patient record without creating an encounter in the EHR. So the fundamental design of the EHR is being encounter centric instead of patient centric. It also makes it very difficult for the poor HIT vendors to do the right thing and clinicians to get useful data.

Reed Hoss: Do you think CMS will offer a passing percentage created for meaningful use participants rather than all or nothing and there will be passing grades to avoid penalties just as the AMA proposed?

Dale: Yes, I think that’s a much better approach. Kind of a scorecard of sorts instead of pioneering on a rod, did you or did you not pass. I totally agree. Whether ONC will do that or not, I don’t know but I think those of us who think it’s a good idea should lobby ONC and our congress people to implement that kind of thing because as you know and I can tell from your question you have been in the trenches with this. There are gradients of meaningful use of EHR. Some organizations are scoring one out of ten in their effective use of an EHR. Others could technically pass a meaningful use audit, but they are probably only scoring a three or four in the total scheme of things so I think it would have benefits for everyone if we made the meaningful use criteria more fuzzy and less binary. Great question and great thought.

Steve Camel: Dear friend for many years; let’s see what Steve asks here. With data being more and more recognized as an asset, when do you predict patients will start to demand more returns such as discounts or use fees for the use of the data as an asset?

Dale: Isn’t it kind of intriguing, friend. Wouldn’t it be great if you agree to share your socioeconomic data, for example, for the health care system, your buying habits, your exercise habits, your diet habits, where you live, if have a car or not and if you agree to participate in that level of data sharing, your premiums and your health care per transaction costs would go down. They would be subsidized for the value of that money. I think it’s a wonderful idea. I don’t know if it will ever happen. In theory, if we all contribute our data to our health care providers, health care providers should be turning that data back to you at better care at a lower cost. In essence we should see our subsidy in a roundabout way anyway, but wouldn’t it be interesting, though if we actually economically and directly economically incentivize patients to participate in the data sharing process. I think it would be a great idea. Thank you, Steve

Rob Clark: Will ACO use increase or decrease in 2015 and beyond?

Dale: I think federal ACOs use is going to decrease because it is so administrative and burdensome. If you look at the MSSPs and the pioneer ACOs it’s brutally difficult for them to beat the requirements of the federal ACO program. So I think the more pragmatic approach is going to immerge through the commercial payers and the integrated delivery networks that have always been an ACO anyway. I wouldn’t be surprised to see, and I would kind of like to see, the very prescriptive requirements of the federal ACO to become completely eliminated. And instead, the US government ought to be asking or demanding as the world’s largest customer, the health care industry, we will no longer pay you on a pay for service basis. We are going to pay you on a fee per quality basis, on a per capita per year basis, and a bundled payment basis for procedures. You guys in the industry figure out how to get there. We’re not going to tell you how to do it, but we’re just telling you as the world’s largest customer, we are not going to put up with any more and let the industry figure it out. The federal ACOs right now are in an administrative nightmare.

Raj Monecom: Can you make a prediction around “The AMA wakes up to the real need of patient care, stops putting its considerable lobbying efforts to continue the status quo and continue the fee for service and instead get behind and support pay per value. “

Dale: It’s interesting isn’t it Raj. The AMA has become the guardian of old school, hasn’t it? Again, it gets back to that diagram where everyone in that diagram on slide 6 or so is comfortable with the inefficiencies of the market, but I would say AMA represents a minority of physicians now. I think the AMA stands on and their resistance to fee for quality initiatives. It’s going to be pushed aside. The AMA is becoming sort of disconnected from their original constituents and they’re certainly disconnected from the better interests of patients on a lot of issues.

William Hyman: Comment -‐ One person’s inefficiency is another person’s source of income.

Dale: I think this a great point and it’s one we have to remember. It is very true. And the economists will remind us of that, inefficiency that we instill with the health care system will have an impact on employment. The latest numbers I saw had 15% of US workforce is now associated with health care. So if you start talking about the removal of one-‐third of the waste in inefficiency in health care, how that

translates to employment could be pretty significant. I don’t think that should pull us away from doing the right thing. I just think we ought to be smarter at how we do it. That’s just the nature of life as well as industries become more efficient, and more commoditized, jobs change. I think we can’t hang on to old Health Care 1.0 practices just because those inefficiencies keep people employed. Not when 400,000 patients per year are suffering from unnecessary death and ten times that many suffering from debilitating injuries. We can’t let employment issues stand in the way of doing the right thing. Great point, William. Thank you.

Robert Colley, M.D.: Can you believe that the Supreme Court will completely ignore Grubergate?

Dale: I think the Supreme Court ruling will be what it is. They will interpret the spirit of the law not the technical wording of the law and I think they are going to come down on the side of the Affordable Care Act. Interesting thought.

Mark Johnson: Can you go a little deeper on the nine health system predication?

Dale: What I did is I put a little geographic map together that estimated the anchor health care delivery systems in nine circles that I drew over the top of the United States. So I broke the United States up into these regions that I think make sense demographically and somewhat politically as well. It turns out, and I am a total amateur doing this, it’s just me doing it toying around, but I think there are about nine different regions in the United States to kind of act and think and act similarly on a variety of levels. Then I laid over the top of that the dominant health care systems in those areas. I believe those dominant systems in those areas are going to continue to grow their dominance. I think that is going to be a good thing. If we manage it carefully from an anti-‐trust perspective, I think it is going to be a good thing for health care and for the patients and less fragmented care. That is a little deeper on that. It doesn’t go into any kind of dissertation, it was a little intellectual exercise on my part.

Robert Jamison: Comment-‐ VA hospitals started after the Civil War and they are still operating.

Dale: Yes, that’s an interesting observation. I don’t think I knew that, but it makes sense that they started after the Civil War. It certainly has had its ups and downs, but I think its ups and downs are more a reflection of our lack of oversight in management and leadership than anything inherent about that model. I think that model can work just fine and it’s the right thing to do. I’m a military veteran. I’m a big, big proponent of taking care of our veterans, especially our young men and women coming back from our most recent conflicts. I think any reason the VA system hasn’t worked is because of lack of oversight and leadership on the community’s part as well as our Congressional leadership. So no reason why it can’t be a good system.

Dale: We’re running out of time now, friends. We have 110 people still on the line. I need to jump out and catch an airplane pretty soon so I’ll take two more questions. Thank you so much for submitting questions. It would be really boring and uninteresting if you didn’t and I always learn from these questions as well. Thank you.

Brian Young: Do you see restrictions on data use privacy in health care loosening up as led by federal policies on that issue?

Dale: I sure hope so. I came into health care 18 years ago largely from a military background, various teams in information security risk management, and risk litigation. HIPPA and the 18 factors that make

up PHI is a complete disaster. When I was at Intermountain I had the opportunity to work on the inputs of those HIPPA regulations and I was really disenchanted with the way HIPPA rolled out. HIPPA needs to change, but we also need to be smarter about the way we interpret HIPPA What I see a lot of times, especially with CIOs is overly conservative interpretation of HIPPA. I have run my own patient surveys asking patients how concerned are they about sharing their healthcare data and the patients are remarkably open to it if they know it’s going to improve their convenience, their car and lower their cost of care. CIOs need to start be smarter about what I call misplaced risk mitigation and worrying about things that don’t matter and spend their time worrying about things that do. I think what I would also like to see is a greater adoption of what the Office of Civil Rights allowed us to do around EP identification which is expert opinion and getting away from that very black and white criteria that HIPPA recently came out with. It’s a cultural thing and I actually think that the health care industry is more paranoid about this than patients are. So we need to line up our risk litigation strategies around what patients want rather than what we think they want.

Plesh: Can HIAs in their current model get out of the trough without a complete rework of the technology?

Dale: There are some HIVs that are better technically than others, obviously. And those that will allow the exchange of excrete data as opposed to document based data are hands down the best in communications and will be the best going forward. As I mentioned, God bless the HIV vendors. They are also somewhat restricted by the flexibility of EHR. It’s not as useful data from an interoperability standpoint unless you can service that data in an EHR in a meaningful, useful, disgustful way. I was talking to members of the Western Health Car Alliance last week and they were bemoaning to me this document centric architecture where a patient can be in ICU for a week and they will generate a continuity of care document that’s hundreds and hundreds of pages long. Well there is no way a clinician is going to sift through that. There is no way you can do anything analytically with that to require decision support. So the document eccentric approach to HIEs is going to be a complete disaster. It is a really terrible compromise on what we need to do. I think there are some HIEs that are going to survive the trough, but it is also is going to require that we have better EHRs and better ways to surface this data in these EHRs than what we have now

Dale: OK friends. Thank you so much, but we have to end the webinar today. Again, thanks for participating in this experiment with the phone lines and hopefully we will work those things out later. I’ll turn things over to Anita.

Anita: Thank you, Dale. Before we close our webinar today, we have one last poll question. As we said at the beginning, our webinars are meant to be educational about various aspects effecting our industry particularly from a data warehousing and alibis perspective. However we have many requests for more information about what Health Catalyst does and what our products are. If you are interested in the Health Catalyst introductory demo please take the time to respond to this last poll question.

Shortly after this webinar you will receive an e-‐mail with links to the recording of this webinar, the presentation site and the poll question summary results. Also, remember to look forward to the transcript notification, which we will send you once it is ready. On behalf of Dale Sanders as well as the rest of the Health Catalyst team, thank you for joining us today. This webinar is now concluded. Have a great day.

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Predictions, Hopes and Aspirations for U.S. Healthcare in 2015€¦ · • The real predictions for 2015 • The aspirational predictions for 2015 • Poll questions for your predictions