The Five Year Plan

John HalamkaWhen my father died 3 years ago,  my comments at his funeral  noted  that the greatest aspiration any of us can have is to make a difference in the world.  My father’s life made a difference.

I’m always self critical and analyzing my own life.  I moved to Boston 20 years ago this month.   In those 20 years of service to BIDMC, Harvard, numerous federal organizations,  international governments, and industry, I’m hopeful that I’ve laid a foundation for 20 more years of trying to make a difference.  It’s hard to forecast the best path to have an impact on the healthcare ecosystem, but I can try.

The past 5 years belonged to government – with $34 billion spent on healthcare IT as a result of HITECH, the Meaningful Use program accomplished the goal of moving clinician practices and hospitals from paper to digital systems.    Although many challenges remain – improving workflow, enhancing quality/safety, and ensuring usability, the basic platform on which we can build future innovation has been created.

The government will continue to be very a important actor, especially CMS,  setting payment policy that will impact the behavior of all stakeholders.  However, I believe the era of prescriptive government direction of the IT agenda has ended.  Provider organizations are begging for an outcomes focus, instead of a process focus.

Where will the next innovations come from?

How about the large incumbent HIT vendors?   Despite rumors to the contrary our major healthcare IT vendors are well meaning and not spending their time information blocking.  They are devoting their resources to creating software which adheres to the thousands of pages of regulations introduced over the past few years.  One major vendor noted that their programming staff is already booked for the next 32 months just to ensure compliance with existing regulations.    The small amount of free bandwidth that incumbent vendors had reserved for innovation has been co-opted by regulation.

How about startups or high tech companies that have a startup mindset?   Startups, such as those making population health/care management, decision support, and consumer facing apps likely have more time to focus on innovation than incumbent EHR vendors maintaining certified EHRs.   Many of these startups lack domain expertise in heatlhcare processes, so they may not produce the products and services the marketplace really needs.      However, that’s ok, since out of many failures often comes one great success.   I think we need to watch companies like Apple, Google, Amazon, Facebook, and Salesforce for important healthcare innovations.

How about provider organizations?   Some academic healthcare systems have dedicated innovation resources and they will continue to lead important work.  However, provider organizations are faced with the compliance/enforcement side of the same regulatory expansion that is consuming the incumbent vendors.    Most provider organizations will devote 100% of their IT resources to operations and compliance.

So, it’s an edgy prediction, but I beleive the next 5 years of healthcare IT innovation will belong to the private sector, to companies we’ve not yet heard of and companies outside the usual healthcare IT mainstream.    The incumbent vendors may be able to crowdsource and leverage the resources of these innovators, as Athena will do with the More Disruption Please program and  Epic will do with its app store.

At BIDMC, we’ve launched our own crowdsourcing program and we’re increasingly dedicating resources to innovation.   We’ll continue our collaboration with numerous private sector companies, serving as a learning lab to test new ideas.

In my next 20 years, I hope to oversee innovative work on social networking communication applications, patient-facing mobile applications, population health analytics with workflow tools, and cloud-based healthcare IT services.    I turned 54 this month.   I’m hoping at 74 that I can reflect on 40 years in New England and say that my efforts have made a difference.

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9 replies »

  1. Thoughtful post as always John…. so why don’t I feel better about the future you paint? While I fully respect and appreciate the genius of innovation from apps developers and in particular those outside of the medical establishment, I am concerned that if the next five years belongs to them alone, we are in trouble.

    There is a long history of very bright people outside of medicine attempting to “brute force” their innovations without a deep understanding of the complexities and nuances of the monster we call a healthcare system in the US. And for the most part, with some notable exceptions, these efforts have failed. Some have failed as they were tech solutions in search of a problem; some failed because the problem they solved was not actually the barrier to broader use of innovative workflows; and some failed due to sequencing (the right, or a right answer, but too early in the payment reform cycle to be sustainable).

    I agree with your premise that this is the right time for non-regulatory innovation. But private sector innovation that is done absent involvement of the profession will at best address only one aspect of a virtuous cycle of innovation – that of technology. We need to concurrently address care delivery innovation.

    I also agree with you about the attention of medical professional organizations – who should be – in a post-MU world – all in on care delivery innovation. Further, health systems care and information leaders (CMIOs) should be poised to do the integrative work needed to marry tech and workflow innovations. However, unless at least the MU component within MIPS (ACI) is radically changed – I again have to agree with you; docs and their leaders will spend the next five years configuring their systems to achieve the new thresholds of ACI – which have moved from “we can do that” or “we need to dedicate an FTE to MU configuration” to – many peoples full time jobs for the next 5+ years will be spent on systems configuration to optimize checkbox compliance…. And only if there is spare time will we be able to remember… “oh yeah, I think there are patients we should be focusing on.”

    Another thing to consider here John… While many of us had our issues with certain metrics and thresholds of MU, many of us very much appreciated its intent, and the fact that until we were ready as a country to base payment (to some extent) on quality and resource use, we needed process measures…. That time is now gone – but we still have to focus on process measures of EHR use (which are not subject to evidence but rather politics) – which means the intense focus which MACRA intended – quality and resource use – will be limited.

    Maybe its me, but this misdirection of focus is supported by the very name of that CMS has chosen for the re-branded MU – Advancing Care Information. Perversely, all of my concerns about docs being distracted by having to be heads down in the wrong direction by the continuation of a single set of EHR process measures – could be answered by CMS with “we chose the term ‘Advancing Care Information’ because our new focus is not exclusively quality and resource use… advancing care information is a separate goal – and yes, a possible threshold of 100% is exactly what we intended, because doing more is advancing care information. Don’t make the case that doing more on a process measure does not necessarily mean that care for a patient isn’t better – that’s irrelevant. We don’t care if what you are doing is meaningful or not, as long as it advances care information.

    So I hope your excellent predictions John are not 100% on target. Yes to the continued involvement of ONC and CMS; yes to the private sector and innovators; but please – also yes to doctors who care – and who have worked for decades as you have, to make the next five years with the patient in the center of healthcare, and not to advancing information that is not in the service of patient-centered care; and yes to engaging our medical professional organizations in this critically important work.

  2. Love Johns posts…although I don’t always agree.
    First, I think that CMS and ONC will not let go of the reins and are too arrogant and paternalistic to even consider what they have done to medicine is terrible. Even though
    it is so obvious. They continue to fluff their stats and backslap about the proliferation of EHRs and how great that is. Even though they are failing front line providers and patients daily.
    Apple, Google, etc are WAY to smart to get caught in the web of complex regulatory activity of this EHR government bureaucracy. If they thought they could make a buck and improve things, they would have been on it years ago. In fact, Googles personal health record, went bye bye a few years ago.So came and went. Don’t look to them.
    I actually think that the blowback from MACRA and these programs will be so bad, that there is a small hope that the market resets. And providers and vendors can actually work together to solve problems. Right now that is impossible.
    I also think that Andy Slavitt feels and sees the damage he is doing, while Karen Desalvo only cares about pumping up her resume and could care less about the front line provider. I do think that all that were involved with this latest debacle of MACRA will be vilified and universally scorned. It will probably take yet another act of Congress to stop the MACRA madness. Then again, I think it will be more of the same “doc fixes” year in and out with penalties being reduced so they do not lose a critical mass of providers.
    So my bet is…MACRA will proceed mostly as planned. CMS and ONC will blame the “law” as why they cannot change MACRA. But Congress will reduce the up and down swings to probably 5% or less, mostly on a year in and out basis, as 9% may devastate practices to a point of no return and then they will really feel the pain of having a doctor shortage.

  3. Yes, the next 5 years of health IT will probably belong to the private sector. The result will be a massive shift of open medical knowledge into secret decision support databases IT and secret machine intelligence IT.

    The essential ingredient of secret medicine is access to patient records because it’s the individual details and outcome of millions of patients that are the value in a decision support database or that “teach” a machine learning algorithm.

    Oh, and how are our health records going into the private health IT for the next 5 years. Through the $34 Billion of HITECH incentives to adopt private EHRs, of course.

    As with the real estate bubble almost a decade ago, we are witnessing the privatization of profit and socialization of cost and risk on a massive scale. Instead of secret finance practices obfuscating loan value we now have secret health IT practices obfuscating healthcare value. But the healthcare bubble we’re creating with secret, privatized medicine is already over $1Trillion in the US.

    The HITECH $34 Billion was a stimulus program to recover from the real estate bubble. It is now feeding the next bubble. Will the healthcare cost bubble be $2 Trillion in 5 years?

  4. from American Scientist, May-June 2016:

    “Cyber insecurity…headline grabbers: U.S Office of Personal Management data breach that compromised the confidential records of 22 million federal employees, the Anthem health insurance system breach that exposed personal data of 79 million people, the Target Corporation heist that harvested credit and debit card information on 40 million people, and the attack on Sony Pictures Entertainment that destroyed data and startup software on more than 3,000 computers, as well as disclosed pre-release films and embarrassing emails of executives.

    71% of organizations were victims of successful cyber attacks in 2014.”

    I realize everyone says that we can’t ever go back to written records. But you _know_ there is going to be a patient uproar sometime–sooner or later–and that some VIP patients will demand some other more secure data handling system….which might be some new network not based upon ITP TTP.

  5. Great point. How did regulation escape scientific and ethical scrutiny when applied to the practice of medicine?

  6. I couldn’t have said it better. Except that our supposed organizations may not be begging for “outcomes focus” but they are sure not fighting against it either. Meanwhile, the docs on the frontlines are drowning.

  7. A few observations:
    1) The government is not some incorporeal entity that handed down an overabundance of regulations from Mount Sinai every Friday at 4 pm. There were people actively working within this government entity, creating one batch of insane regulations after another, so let’s be clear about that.
    2) Yes, 5 years, tens of billions of dollars and hundreds of thousands of burned out doctors later, we got most personal medical data into computers, inefficient, ineffective and by now largely obsolete computers. Was that a great achievement? Was the sole intent here to prime the pump for “Apple, Google, Amazon, Facebook, and Salesforce” to make new fortunes in health “care”?
    3) I don’t know which “provider” organizations are begging for an “outcomes focus”. Physicians don’t seem to be begging (and yes, they are now reduced to begging) for anything except for this nightmare to stop.

    Anyway, I do agree that the next 5 years (or 50 years) belong to the private market and not just in IT, because that was the goal from the get go. Medicaid is practically all privatized managed care, Medicare is getting there as well by leaps and bounds, and Bernie Sanders definitively lost the primaries tonight 🙁

  8. Spot on. The government has set a path, but not the solutions. The EHR companies are consumed with regulation. The solutions will need to come from entrepreneurs, may who have yet to be named. Additionally I would note, regulation should be evaluated with the same rigor as drugs and device. Just because regulation is suppose to keep us safe or improve care, if results differ from the expected outcome, the “regulation” should be recalled.