May 2009 FEATURE ARTICLES
Health Plans and Technology
Health Improvement Technology
Industrial-age-model health information technologies were never designed to address our national health shortage and under-performing delivery system crises at their root cause levels.
By Dennis Schmuland, M.D.
Today, we are not only faced with an economy and healthcare system that are in poor health, but collectively, as a nation, we also are in poor health. In fact, in the last two decades, our health has plummeted to the point that we are now in the midst of a health shortage that’s reached epidemic proportions and is getting worse every year.
Over the last century, the U.S. has fallen from one of the healthiest nations on earth to the bottom quartile among developed nations; and yet, what’s missing from the current debate on healthcare reform is the fact that our worsening health shortage will confound every well intended attempt to fix our current healthcare system.
In other words, we cannot solve our nation’s healthcare cost crisis until we simultaneously chart our course back to becoming a much healthier nation.
The Root Cause of Runaway Medical Costs
The United States continues to lead the world in spending and wasting more resources on healthcare, in both real dollars and as a percent of gross domestic product, than any other nation in the world. To reverse this terminal trend of runaway medical costs that now threatens our economic recovery, government and industry must attack medical inflation at the root causes that drive our habitual overuse, underuse, misuse and inefficient use of finite health resources.
First, we need to stop the rising prevalence of chronic disease. With a greater demand for advanced and costly medical treatments and technologies to treat the acute illnesses and complications of chronic diseases, we’re left with a vicious cycle of soaring medical costs and plummeting health. Our current delivery system, as well as the information systems that run them, were never designed to expertly manage chronic disease or improve population health. Each were originally designed to reactively treat acute illnesses, injuries and procedures, rather than proactively addressing (and where possible, preventing or detecting) the chronic conditions that require newer but higher cost drugs and treatments.
In this new economy age, shouldn’t we be asking what technology innovations can equip us to become a healthier nation at a lower cost per capita, rather than how can we digitize and exchange medical record data?
The second area we need to address is that of disengaged consumers. As a nation with a growing burden of chronic disease and obesity, we are less healthy than ever before. Chronic disease now affects more than 30 percent of the U.S. population and accounts for more than 75 percent of our current health expenditures — at least half of which are caused by preventable conditions related to lifestyle choices, such as non-adherence to medication, tobacco use, poor diet and inactivity, and alcohol and drug use.
Our obesity epidemic is only making things worse: 64 percent of Americans are now overweight and 30 percent are in the "obese" range according to the Centers for Disease Control and Prevention. These trends, if unchecked, guarantee the growth of medical costs and chronic disease for future generations as more and more Americans are diagnosed with diabetes, hypertension, heart disease, stroke or some form of cancer.
Unfortunately, for the most part consumers are effectively disengaged from their own health and not in the habit of proactively improving their health habits and making value-based decisions, or managing their own health, risks and conditions. A majority of consumers still expect the healthcare system to take care of them, rather than taking their own care and health risks into their own hands.
Lastly, in the U.S., we have the highest per capita cost of care worldwide. We are saddled with a reactive care-delivery system that, by design, under performs because it is largely rewarded for procedural care. Hospitals profit when beds are full and imaging schedules are booked, and doctors profit from high-cost procedures and repeat visits. Neither hospitals nor physicians are rewarded for keeping patients healthy or preventing chronic disease from developing in the first place. Ironically, and unintentionally, they actually profit from it.
Unless these root causes are addressed, any cost shifting or subsidies to expand coverage in the near term are destined to fail in the long term as long as medical costs are fueled by the vicious cycle effects of the growing prevalence of chronic disease, disengaged consumers and an overpriced, reactive care-delivery system.
Becoming a Healthier Nation: Supply and Demand
The current economic downturn will force every nation to re-frame their healthcare reform debate from "How can we afford healthcare?" to "How can we become a healthier nation to compete in the financially contracted global marketplace?" This is the new health economy.
Becoming a healthier nation requires a grassroots industrywide effort by every key stakeholder to engage consumers in their health and defragment care. The entire industry will need to address both the demand and supply sides concurrently, before tackling the growing prevalence of chronic disease that perpetually keeps healthcare coverage unaffordable.
On the demand side, the industry will need to engage consumers in their health by promoting healthier habits, environments, social support and individual accountability.
On the supply side, the industry will need to defragment care delivery to promote better outcomes, prevention and early detection, and condition self-management.
The Currency of the New Health Economy: Collaborative Team Processes
Whereas the currency of the old healthcare economy in the last century was information, the currency of the new health economy is collaborative team processes. Forging and improving collaborative team processes between and among payers, providers and consumers are no longer "nice ideas;" they are now mission critical to sustainable healthcare reform. This requires a new focus on digitizing and re-designing collaborative processes, which involves connecting the people, information and processes that improve health and outcomes at a lower cost per capita.
In the new economy, the most successful organizations will digitize, re-design and commoditize the collaborative processes driven by people and teams that erase inefficiencies, drive down operational and medical costs and improve personal and population health.
But unlike the current administrative transactions, which are mostly sent and received by programmable machines, collaborative team processes are much more difficult to digitize and automate because they tend to be unstructured, people-triggered and highly collaborative; and, run end-to-end across the workplace, the home and multiple company boundaries.
But digitizing and re-designing collaborative team processes opens a frontier of new opportunities to realize breakthrough gains in productivity, cost savings, outcomes and even population health. This is because, at the end of the day, it’s the collaborative processes and decisions, driven by consumers and providers day-to-day, that have the greatest impact on medical cost inflation and outcomes. For example, it is the providers who, in collaboration with their patients, solve complex problems and choose the tests and treatments that account for 87 percent of healthcare spending; and, it’s consumers’ day to day lifestyle choices that account for 50 percent of all causes of death, disease and disability.
The potential upside in productivity and efficiency gains from digitizing collaborative processes is immense because the vast majority of collaborative processes in healthcare today are conducted by phone, or by in-person meetings, paper notes and checklists, and fax. As a result, these processes tend to be inefficient and prone to error, delays, and all too often, failure.
Avoidable Medical Costs
According to the RAND Corporation, 30 percent of medical costs are avoidable if evidence-based medicine (EBM) is consistently practiced by providers all of the time, rather than only 55 percent of the time as they do today. With annual healthcare expenditures in the U.S. now at $2.2 trillion, the potential savings of this approach could reach $660 billion per year.
What’s conspicuously missing from our fragmented ecosystem are the basic online communication and collaboration technologies to make it easier and less time consuming for plan and provider teams to communicate, share insights and information, and to work together. As a result, it’s no surprise that patients, providers and health plans often feel like they’re working off a different page.
In the new economy, the most successful organizations will digitize, re-design and commoditize the collaborative processes driven by people and teams that erase inefficiencies, drive down operational and medical costs and improve personal and population health.
Ironically, at a time when the industry should be focusing on digitizing and coordinating the collaborative processes that improve health and outcomes at a lower cost per capita, many health organizations remain fixated purely on digitizing and exchanging medical record data (EMRs, EHRs and PHRs). To succeed in the new economy, however, they will need to shift their focus to collaborative processes and consider data and information merely as valuable inputs to those processes, but not the end goal. The fixation of the industry and health information technology community on digitizing and exchanging health data and information has caused the industry to undervalue the breakthrough possibilities of collaboration technologies.
In this new economy age, shouldn’t we be asking what technology innovations can equip us to become a healthier nation at a lower cost per capita, rather than how can we digitize and exchange medical record data?
The New HIT: Health "Improvement" Technologies
Improving personal and population health and coordinating care must become the core strategy to contain medical costs in the new health economy. This shift in strategy will fuel demand in the technology market for a new generation of innovative, Internet-based health improvement technologies (HIT), best defined as "innovations that improve personal and community health at a lower per capita cost by coordinating care and delivering seamless experiences across the workplace, home and devices." These technologies will follow providers and consumers wherever they go and adapt to their analog and digital worlds. This new generation of HIT will better engage consumers in their health by making it easier and much more natural for consumers to: self-manage their risks and conditions; communicate with payers and doctors and share insights; and, work together and coordinate care across the workplace, home and company boundaries.
Consumers
For consumers, HIT will focus on participatory processes. In order to get and keep consumers continuously engaged in their health, providers and health plans will need to untether the growing stockpiles of actionable insights, PHRs, tools and trusted guidance buried in their portals and incrementally intermingle them into consumers’ analog and digital lifestyles at the right time and place. This means that the right tools and processes must follow consumers into their homes, workplaces, mobile devices and everywhere in between. Self-service portals are too much work for consumers and don’t adapt to their digital worlds.
Direct-to-consumer channels and software agents that digitally go where consumers go will enable providers and health plans to generate an ongoing rhythm of personalized "moments of participation" for each consumer. We describe these moments of participation as "polite and personally meaningful interactions with people, software agents, software interfaces and devices that promote incremental behavior changes in the direction of better health habits and value-based decisions."
These real-time collaboration capabilities include the ability to communicate with a provider or health plan through multiple channels that are familiar to members, such as cell phones, text messaging, instant messaging, television, virtual chat agents, e-mail and Web conferencing. For instance, with the permission of the consumer, a health plan or provider could use the consumer’s instant messenger or calendar as a channel to politely nudge the consumer to take a walk or, if the consumer has a specific health risk, such as metabolic syndrome, ask them to input their weight, blood sugar and/or the number of daily servings of fruits and vegetables they’re getting.
Participatory processes like these are needed to get and keep consumers continuously engaged in value-based decision making and self-managing their risks and conditions.
Health Improvement Technologies and Providers
For providers, HIT will focus on coordinating care team processes. This requires new virtual connections that promote cross-boundary collaboration and the hard-wired EBM support that providers need to reduce unwarranted practice variation and coordinate care within the context of their existing workflow.
But before our care delivery ecosystem can begin to defragment and coordinate chronic care, we need an innovative, next-generation collaboration infrastructure that supports the cross organizational collaborative processes necessary to improve outcomes, early detection and the proactive management of chronic conditions. This new infrastructure must work with whatever existing IT investments are already in place and enable individual providers to: be accountable; conduct virtual consultations; consistently deliver EBM; monitor, track and improve the health status of patients; scale the services and impact of primary care, human coaches and care managers; and, promote self-management of health.
A communitywide collaboration infrastructure will make it easier and less time consuming for providers to share insights and make collaborative decisions with both patients and colleagues, and equip them to coordinate care against a single care plan as patients are seen by multiple providers and facilities. Too often, no single person or team is accountable for ensuring that care is coordinated and continuous. Until providers are equipped to coordinate care workflow across the community ecosystem of care managers, patients, providers and family members, patients will not receive evidence-based care consistently.
A Call To Action
The inevitable shift toward improving personal and population health and coordinating care as a core strategy to contain medical costs will fuel demand for a new generation of innovative, Internet-based health "improvement" technologies. This new generation of technologies, if aligned with proper incentives and policies, can accelerate the return of the U.S. to healthiest nation status by digitizing and commoditizing the collaborative team processes across communities that improve the outcomes, prevention, early detection and chronic conditions of populations.
An industrywide consensus and movement will be needed to drive a meaningful market shift and re-frame the current debate from subsidizing legacy health information technologies to advancing and proving the cost effectiveness of a new generation of health improvement technologies.
Dennis Schmuland, M.D., FAAFP, is the
national director, U.S. Health Plan Industry, Microsoft Health
and Life Sciences. Contact him at
dennissc@microsoft.com .