Where does IT go from here?
To commemorate our 30th anniversary in healthcare IT, Health Management Technology asked industry experts about the most significant technologies introduced over the past few decades and what new technologies and challenges they see on the horizon.
The past 30 years has seen a lot of technology change. What do you see as the most significant, game-changing technologies introduced in the past few decades? What technologies do you see providing the most significant opportunity for healthcare providers going forward?
The most game-changing technology has been the object-oriented database. This has enabled healthcare IT systems to better fit the extreme data intensity, need for rapid flexibility, numbers of concurrent users and massively scalable databases required for large healthcare enterprises. Moving forward, coordinating care for millions of complex patients, in large regional or even national systems, is possible only with applications based on massively scalable and flexible core technology.
I can no longer imagine (or care to) a world without EMRs and their supporting technologies. These technologies help clinicians pull together all the critical content in the right context of where and when they need it. As a result, clinicians have an easier pathway to making the right decisions safely and more efficiently. Bar code medication administration (BCMA) and computerized physician order entry (CPOE) have also made great strides in helping providers improve patient safety and efficiency.
Today, mobile technology has the greatest opportunity to impact care delivery. When you take the aforementioned technologies, the Internet, search engines and other relevant clinical applications and load them onto, say, an iPad, technology accessibility and usability increases dramatically. Even social media provides new forums for collaboration among friends and entices even the staunchest of laggards to jump online and get their feet wet exploring new uses of technology.
In radiology, we have seen the introduction of multi-slice CT scanning technology, hybrid imaging modalities such as PET-CT and contrast-based MR studies that deliver advanced anatomic and functional studies. In cardiology, we have seen the introduction of flat detector imaging techniques in angiography and drug-eluting stents for revascularization procedures. In pathology, we are at the beginning of the curve for clinical adoption of whole-slide digital imaging. In the lab, molecular and esoteric testing deliver DNA-specific data that is just now being used to determine more personalized treatment plans for individuals.
All of these technology advances within different clinical disciplines have something in common. That "something" is the need for information technology to manage the much larger and more complex data sets that these new technologies produce. These data sets require more robust IT solutions to interpret, store, manage and transmit. This data also provides the content for the "evidence," upon which evidence-based treatment protocols are based.
The most significant opportunity for healthcare providers is healthcare information technology. Interoperable and robust HIT solutions provide the infrastructure that will enable providers to take full advantage of new clinical technologies that can positively impact the patient diagnostic and care process.
I can't stress enough how fundamentally necessary standards-based interoperability is and how far it has advanced. I think the healthcare information-technology industry has done a good job internally of advancing data exchange prior to federal initiatives to streamline and integrate clinical, financial and administrative tasks. Going forward and taking interoperability as a baseline, the electronic health record provides the core for many future advancements. By constructing a digital patient chart that patients can access through their own PHR or portal, we can really expand preventive care and wellness. Integration of clinical processes from mobile devices, images, dictation and clinical alerts — such as drug allergies, patient history alerts and electronic prescribing — are all major clinical opportunities. I'm describing the leading EHRs of the present as much as the future, but it's the widespread acceptance and adoption that will provide that significant opportunity.
Far and away the most significant, game-changing technology has been the Internet. Prior to inexpensive, widely available high-speed Internet connectivity, any concept of connectivity for electronic data interchange or data sharing was expensive, slow and technologically challenging; envision connecting to a health information exchange at 9,600 baud over a dial-up modem.
The ability to connect opens an unlimited ability to foster collaboration to ensure cost-effective quality of care. In the future, wireless mobile Internet connectivity is the game changer. Healthcare is an "always on," ubiquitously available service, and it needs a technology platform to match. Platforms are king, as social media and the iPhone have demonstrated. Platforms that securely connect providers and patients will be the next game changer.
CPOE, e-prescribing and clinical decision support; they transformed the computer from a passive reporter of facts to an active partner in care, and they showed up on the scene just in time for the 2000 IOM report, which exposed the problem of preventable medical errors.
One of the biggest game-changing technologies will be filtering and targeting of information. Technologies are emerging that can dissect the wealth of medical knowledge from millions of pages of books and journals and deliver the most relevant patient- and situation-specific information.
Web-based applications have had a significant impact on the healthcare industry. In terms of adoption of clinical applications by physicians in particular, we needed to offer significant advantages to them in terms of convenience and quality improvements before they were going to embrace those changes. Web-based applications have certainly made that hill easier to climb. Of course, mobile technologies that are intuitive and can present only the information needed at the time will be the next big leap.
Obviously, the Internet is the foundation for all that followed, but the ubiquity of connections and devices, combined with the most recent generations of software for security, identification and user interfaces, mean that the tools will be good enough and available enough for the first time. Finally, the developments occurring with natural language processing, search engines and decision trees (business applications of many artificial intelligence concepts) are creating reference tools that trump anything previously available. Creative implementation of these technologies will enable the human mind to concentrate on the exceptional and the critical. The best technologies for healthcare are still in our future, but in the very near future. We will build them as the connections begin to spread over the next several years. It's the aggregation of information, and ready but carefully authorized access to it, that will drive the development.
What do you see as the healthcare provider organization's biggest challenge in the next 10 years? How does it match or contrast with the CIO's / IT department's biggest challenge?
The most important change is the advent of the personal computer and its adoption in the industry. When I entered healthcare in 1988, PCs were not the standard. Many users in the hospital had terminals, but these terminals enabled access to the mainframe systems and nothing more. We didn't have e-mail and no one I knew had ever heard of the Internet. The introduction of file servers, faster PCs, expanded memory and interoperability has enabled providers to employ best-of-breed applications from multiple vendors to meet their needs.
I believe the future will see a profound expansion in diagnostic testing systems and their ability to simulate outcomes based on virtual procedures. This will enable the clinicians and physicians to determine the best course of action for treating conditions and predict outcomes more effectively.
From a financial perspective, provider organizations will need to ensure that benefits and payments are managed to the best possible level as higher co-pays become reality and we have more people assuming the responsibility of paying for their healthcare. Further, providers will need to provide more access via portals or Web sites to their patients to enhance the patient experience and effectively render their services.
Assuming that the ARRA/HITECH and other federal and local initiatives work as advertised and are expanded upon, the CIO's greatest challenge will be helping to shape both the organizational and technical evolutions implied in the present initiatives. Right now, everyone agrees at a high level that costs should be better controlled and care should be coordinated. But getting from high-level aspiration to real practical change is complicated. Taking only a few steps in the direction of those goals exposes the conflicts, difficulties and competing interests of many different players. Many of the underlying incentives in the United States reward inefficiency and inhibit true care coordination.
The evolutions in organizational, cultural and financial systems, as with all evolution — intelligently designed or not — are difficult and disruptive. Advances in HIT, and increasing adoption, will make it obvious that most healthcare organizations are not structured to make truly informed planning and policy decisions involving both detailed clinical and business activities. Just as business and clinical departmental IT systems will become more integrated, the IT and clinical departments must organizationally evolve to better coordinate their activities, make decisions and recommendations to senior management and flexibly execute plans. This will require a better understanding of each other's domains and an increase in staff members who have the ability to think and problem solve in both clinical and technical domains. This is not to minimize the difficulties inherent in specific IT system selection, implementation, maintenance and training. But with the increasing need for the healthcare organization to function as an integrated and coordinated whole, the success of those specific tasks, and the coordination of clinical tasks, will depend on organizational change.
It will be interesting to see healthcare reform's impact on the healthcare provider, with such potentially polarizing initiatives as achieving meaningful use. Increased fees on pharmaceutical companies and medical device manufacturers will help fund the bill. The entities, in turn, will most likely pass those costs onto the healthcare facilities. Also, government payments to Medicare will be reduced. As the flood of newly insured patients enters and moves through the system, reimbursement decreases while costs increase. That doesn't leave a lot of wiggle room in an industry running on such small operating margins. Providers must either reduce services or eliminate more cost from the equation.
The healthcare reform bill and ARRA/HITECH Act seem to be at opposition. Which will win? Those providers likely to have success will be those with a head start that can leverage their healthcare IT investments to drive efficiencies, improving quality and reducing cost while at the same time increasing service levels.
Clinical staffing shortages, combined with an increased population over the age of 65 and more covered lives under the recently signed healthcare reform act, suggest that the balance of supply and demand will result in further stress to the healthcare delivery system.
Providers face challenges related to cuts in reimbursement. They are also challenged with meeting pay-for-performance objectives, CMS core measures and The Joint Commission's quality indicators. Additionally, the HITECH Act adds a little complexity to the equation by requiring specific interoperability capabilities, including communication with health information exchanges, state departments of health, personal health records and other external agencies. Interoperability is absolutely necessary to success in these endeavors.
Further, providers are challenged with being able to prove that they meet meaningful-use criteria, pay-for-performance goals, core measures, and quality indicators. The ability to quickly and easily monitor these metrics, and consequently manage the appropriate clinical processes, will be critically important. Business and diagnostic intelligence solutions that enable real-time analytics will become increasingly important.
For provider organizations, the biggest challenge — which we're already seeing — will be the ongoing evolution of adapting to payer and/or payment models and having the functionality in hand to do so. As traditional fee-for-service (FFS) models are beginning to give way to pay for performance, physician quality reporting initiative (PQRI) and a host of quality-reporting measures from private and public payers, such as the emergence of accountable-care organizations and the patient-centered medical home, the ability to maintain and enhance profitability will always be where provider organizations need to focus. Factor in the meaningful-use model, and provider organizations will have to continue to make sound and sometimes complex decisions based on their community-care model, practice model and patient population.
For CIOs, interoperability will factor right in with choosing future payer and/or payment models in terms of the ability to offer digital quality reporting and enhanced patient outcomes. CIOs will need flexible, customizable and innovative technologies that can share information within practices and hospitals, through referrals, with patients and with public health agencies. As standards-based interoperability becomes even more institutionalized, I think the challenges will be competently overcome.
The migration from quantity-based to quality-based reimbursement creates the greatest challenge for the provider organization over the next 10 years. Work flows and systems designed to maximize productivity and reimbursement must now be re-engineered based on best practices for demonstrating best outcomes. We are already seeing the next hospital integration wave, and it is likely that the definition of "independent" will change for practices choosing to remain independent.
HIT infrastructure needs to be readjusted in tandem to support collaboration between providers across the care community and within accountable-care organizations. The focus will move from administrative/financial systems with clinical components to clinical decision support and EHR systems with an administrative/financial aspect.
The biggest challenge for providers will be the movement toward outcomes-based reimbursement. Pay for performance is the tip of the iceberg in terms of where the industry will eventually head, and integrated systems are a necessary prerequisite. It will likely take 10 years before significantly different reimbursement models can fully take hold for hospitals, but it is my belief that we are headed that way. When the government has access to real-time data in large quantities regarding hospital and physician performance, it will be in a position to pay according to which organizations deliver the best care at the lowest cost.
Providers' issues include capacity, cost and reimbursement. If they are losing money serving one patient; they will lose 10 times as much serving 10 new patients. Providers and CIOs will need to accommodate an increasingly granular set of patient controls for access and sharing of health records, where the technology will struggle to keep abreast of regulations and our society's evolving understanding of privacy rights.
Without a doubt, the conversion to ICD-10 will be the biggest challenge our industry has ever faced. This will make Y2K and X12 look like a walk in the park.
IT will play a role in ensuring that existing or legacy systems are upgraded to handle both the 5010 implementation as well as the ICD-10 conversion shortly thereafter. Further, IT will need to ensure that the providers have systems that enable them to correctly code with ICD-10 and ensure that the payments from payers are accurate in the new ICD-10 world.
Lastly, it's too early to anticipate what regulatory requirements are going to come from healthcare reform, but you can bet that there will be many new mandates that will require new solutions or updates to
M.D., senior advisor, medical informatics, InterSystems
vice president, healthcare solutions and strategy,
vice president, marketing, Sunquest Information Systems
vice president, marketing, corporate development and government affairs, Greenway Medical Technologies; chairman emeritus, Electronic Health Record Association
president, Sage Healthcare Division
M.D., Ph.D., chief medical informatics officer,
CEO, Healthcare Management Systems
director of product management, HealthPort
executive vice president, sales and marketing,
The SSI Group