The year is 2019 and Imaging By Machines have fulfilled their prophesy and control all Radiology Departments, making their organic predecessors obsolete.
One such lost soul tries to decide how he might reprovision the diagnostic equipment he has set up on his narrow boat on the Manchester Ship Canal, musing at the extent of the digital take over during his supper (cod of course).
What I seek to do in this short paper is not to revisit the well-trodden road of what Artificial Intelligence, deep learning, machine learning or natural language processing might be, the data-science that underpins them nor limit myself to what specific products or algorithms are currently available or pending. Instead I look to share my views on what and where in the patient journey I perceive there may be uses for “AI” in the pathway.
Today on Health in 2 Point 00, Jess and I are back from Europe and there is a LOT going on in health tech right now. In Episode 86, Jess asks me about United Health’s big moves, between acquiring PatientsLikeMe and their acquisition of DaVita Medical going through; integrated mental health company Quartet Health raising $60 million; Xealth closing a $14 million round (maybe now they’ll make Epic relevant); Collective Health’s $205 million raise led by SoftBank,; Vida’s $30 million round led by Teladoc (who knows why Teladoc didn’t just acquire Vida); European telehealth company Zava raising $32 million; and finally, Phreesia going IPO (wasn’t Livongo the one to watch?). —Matthew Holt
We begin by commending HHS, CMS, and ONC for skillfully addressing the pro-competitive and innovative essentials in crafting this Rule and the related materials. However, regulatory capture threatens to derail effective implementation of the rule unless HHS takes further action on the standards.
Regulatory capture in Wikipedia begins:
“Regulatory capture is a form of government failure which occurs when a regulatory agency, created to act in the public interest, instead advances the commercial or political concerns of special interest groups that dominate the industry or sector it is charged with regulating. When regulatory capture occurs, the interests of firms, organizations, or political groups are prioritized over the interests of the public, leading to a net loss for society. Government agencies suffering regulatory capture are called “captured agencies.” (end of Wikipedia quotation.)
The extent to which HHS has allowed itself to be influenced by special interests is not the subject of this comment. This comment is just about how HHS and the Federal Health Architecture can act to more effectively implement the sense of Congress in the 21st Century Cures Act.
Can we reduce over diagnosis by re-naming disease to less anxiety-provoking makes? For example, if we call a 4.1 cm ascending aorta “ecstasia” instead of “aneurysm” will there be less over-treatment? In this episode of Radiology Firing Line Podcast, Saurabh Jha (aka @RogueRad) discusses over diagnosis with Ian Amber, a musculoskeletal radiologist at Georgetown University, Washington.
TEFCA will succeed where previous national health information exchange efforts have failed only if it puts patients’ and families’, and/or their fiduciary agents, in control of health technology. This is the only path to restore trust in physicians, and to ensure accurate and complete data for treatment and research.
As physicians and patient advocates, we seek a longitudinal health record, patient-centered in the sense of being independent of any particular institution. An independent health record is also essential to enhancing competition and innovation for health services. TEFCA Draft 2 is the latest in a decade of starts down the path to an independent longitudinal health record, but it still fails to deal with the problems of consent, patient matching, and regulatory capture essential for a national-scale network. Our comments on regulatory capture will be filed separately.
We strongly support the importance in Draft 2 of Open APIs, Push, and a relationship locator service. We also strongly support expanding the scope to a wider range of data sources, beyond just HIPAA covered entities in order to better serve the real-world needs of patients and families.
However, Draft 2 still includes design practices such as the lack of patient transparency, lack of informed consent, and a core design based on involuntary surveillance. This institution-centered design barely works at a community level and leaves out many key real-world participants. It is wishful thinking to believe that it will work with expanded participant scope and on a national scale.
My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on “Marcus Welby, MD.” I didn’t have a motorcycle, but I did have a snazzy SAAB 900.
Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home Companion. He was kind and methodical. Joe didn’t seem quite as rural, moved quicker and wore more formal clothes. I never could read his handwriting.
They each had their own patients, but covered seamlessly for each other. They were like a pair of spouses in the sense that they answered to each other as much as to their patients. They had to make everything work for the benefit of their shared practice, their shared livelihood. Their mutual loyalty was essential and obvious, although allowing for their differences in temperament and personalities.
Invited to stay on and enter into a partnership, I hesitated. How did I fit in? Could I follow in their footsteps and become an equal partner, covering for them and doing things similarly enough to fit in for the long haul?
On Episode 85 of Health in 2 Point 00, it’s our last night in Helsinki. In this episode, Jess asks me about GE selling off Ventures, Neurotrack raising $21 million to detect and track dementia, and Allscripts acquiring ZappRx, a prescribing tool. Also, find out my favorite things from Health 2.0 HIMSS Europe, including a cool pill tracker, Popit, and a great panel on femtech (even though there were not enough men in the room). —Matthew Holt
Electronic health records (EHRs) are a polarizing issue in health reform. In their current form, they are frustrating to many physicians and have failed to support cost improvements. The current round of federal intervention is proposed rulemaking pursuant to the 21st Century Cures Act calls for penalties for “information blocking” and for technology that physicians and patients could use “without special effort.”
The proposed rules are over one thousand pages of technical jargon that aims to govern how one machine communicates with another when the content of the communication is personal and very valuable information about an individual. Healthcare is a challenging and unique industry when it comes to interoperability. Hospitals spend lavishly on EHRs and pursue information blocking as a means to manipulate the physicians and patients who might otherwise bypass the hospital on the way to health reform. The result is a broken market where physicians and patients directly control trillions of dollars in spending but have virtually zero market power over the technology that hospitals and payers operate as information brokers.
What follows below are comments by Patient Privacy Rights on the proposed rule. The common thread of our comments is the need to treat patients and physicians, not the data brokers, as the real stakeholders.
Comments to the ONC Rule
Overview: 21st Century health care innovation, policy, and practice is increasingly dependent on personal information. This is obvious with respect to machine learning and risk adjustment, but personal information is now central to the competitive strategy for most of the health care economy, clinical as well as research. ONC’s drafting of this rule reflects the importance of competition to innovation and cost containment.
Slide into Health in 2 Point 00 (or rather, Health 2.0 HIMSS Europe) with Jess and I today! On Episode 84, Jess asks me about the big news that CVS has now made it possible for employees to get reimbursed for Big Health’s Sleepio, an insomnia digital therapeutic, and about Atrium Health’s $10 million investment in an affordable housing plan, addressing the social determinants of health. Hear some of my key takeaways from the conference so far, too. –Matthew Holt
Far more attention has been devoted to the ways in which
industry consolidation has driven up health costs than to proposals on how to
remedy the situation. But the introduction of Medicare for All and Medicare for
More bills—however dim their short-term prospects are—has changed the terms of
the debate. It is time to think about how we can eliminate the market power of health
systems without causing harmful dislocations in health care and the economy.
Before we get to that, here are the main facts about
consolidation: As a handful of health insurers have become dominant in many
markets, health systems have done likewise in order to maintain or improve
their negotiating positions. That has proved to be an effective strategy in
many cases. Even dominant health plans cannot do without the largest hospital
systems in their areas, especially when they employ many of the local
According to a Kaufman Hall report, 90 hospital and health system deals were publicly announced in 2018. This was a decline from the 115 deals unveiled in 2017, but the average size in the revenue of sellers hit a high of $409 million.
The biggest provider mergers are staggering in scale. In February 2019, for example, Catholic Health Initiatives and Dignity Health formed a new organization called CommonSpirit Health, which has 142 hospitals, 150,000 employees and nearly $30 billion in revenues. The union of Chicago-based Advocate Health Care and Wisconsin’s Aurora Health Care in April 2018 created a giant with 27 hospitals and $11 billion in revenues. A month later, Atrium Health (formerly Carolinas Healthcare System) joined with Wake Forest Baptist Health to form a system with 49 hospitals and combined revenues of $7.5 billion.