The Sequoia Project is a public-private collaborative working to implement an interoperable health information exchange across the county. Mariann Yeager, Chief Executive Officer, shared the ten-year journey of the project and how it is currently working to overcome the interoperability challenges.
Mariann Yeager CEO of The Sequoia Project
Now celebrating its tenth anniversary, the inspiration for the Sequoia Project came as patient information began to be shared in the private sector through governmental facilities. The project was launched to provide a corporate home in the private sector when the evolution of health information networks began.
As governmental agencies shared information through the ONC's Nationwide Health Information Network (NHIN), a decision was made to move the network's operational support, eventually leading to the project.
The Sequoia Project was chartered as a non-profit 501C3 with a mission beyond supporting and providing network operational support. There was also a need to have an organization bringing together stakeholders from the private and government sectors to work on the issues impeding interoperability.
The project could also stand up for other independently governed initiatives because it operates with public admission. With a need to partner with the government, it is not made to be an extender of the government's work. Instead, it is a boots-on-the-ground experience in an operational capacity, Yeager explained.
There are specific building blocks necessary to share interoperable information seamlessly, according to Yeager.
One of these blocks is establishing and integrating standards within health IT platforms. There needs to be specificity and constraints on standards, which gives consistent interpretation and allows systems to exchange information between systems to interoperate.
It took the Sequoia Project seven-to-eight years to mature its standards within existing programs to attain consistency and constraints based on rigorous interoperability tests. In doing so, the program recognized a lack in data value, which they worked to fix by supporting content testing programs and data sources.
After stewarding the e-health exchange and later rebranding from the NHIN, the project was contacted by stakeholder groups wanting to connect networks like the e-health exchange with others in a standardized frame. This model influenced the building blocks for 21st Century Cures.
After four years of implementing guides, it supported the testing program for the Radiological Society of North America. These activities operated under a single corporate entity, Sequoia, pushing the project to create a separation of interests.
A restructuring resulted in three organizations with individual boards, network governance, and management services, she explained.
"The important thing for us to realize is that Sequoia is adept at incubating and launching new initiatives. And so we realized there needed to be a systematic approach to identifying priorities to work on," she said.
This realization led to the formation of Interoperability Matters, a public-private cooperative that assesses the pain points of interoperability.
"We wanted to create a community of practice and spirit of cooperation around that again to help navigate these very complex policy and technical issues, which are really at the heart of what we do day-to-day," Yeager said.
In December 2016, Congress passed the 21st Century Cures Act, a law discussing the need for a government-endorsed approach to promoting interoperable health information exchanges for the nation. Additionally, it pinpointed the need to look at existing components for further enhancements.
Congress charged the ONC to convene stakeholders to develop or support the Trusted Exchange Framework and Common Agreement (TEFCA). The idea was to create a framework that networks could receive a TEFCA-compliant government status by agreeing to the terms of a common agreement. This agreement allows for an enhanced exchange of information among qualified health information networks.
While the health industry progresses by enabling health information sharing, other players interested in accessing and sharing information are not yet participating, Yeager explained.
She believes the government support of TEFCA creates a piece of critical infrastructure that had previously been unrealized.
The Sequoia Project became the coordinating entity (RCE) in August 2019. This allows the project to operate with the ONC under a cooperative agreement, creating an integrated team.
Beyond compliance, there is a need for increased participation in health information networks, according to Yeager. The only way interoperability will work is if there is more network participation.
Another aspect is a willingness to share or request information through networks. However, there are challenges around this, which is why the project works with policymakers to appease concerns about violating HIPAA.
The patient is the heart of 21st Century Cures, which is why there is a continual need to make it easier to access information. TEFCA, for example, ensures patients requesting information receive information unless prohibited by law.
According to Yeager, consumers are insufficiently educated about their rights to access information. They need to know what can be done with their information and its consequences. At the same time, the goal is to equip them to use these capabilities.
The challenge is not a technical or legal issue; instead, it is a policy issue dovetailing into the difficulty of patient matching.
Currently, the Sequoia Project is launching a consumer work group looking into the challenges consumers face in accessing their information. The goal is to make this process understandable and promote health literacy.
Interoperability in the next five years can be game-changing, Yeager explained. As apps and service providers provide capabilities for patients to better access information, she believes it will continue to progress.
As more apps and platforms release and policies evolve, interoperability will continue to gain momentum. Technology-savvy consumers create a demand for information access—advancing the bar for longitudinal records available to the next generation.
While there are many problems surrounding interoperability, Yeager suggests unpacking one at a time.
Data usability is a top issue because low-quality, uncodified data diminishes the value in its end-use. However, it is a long process to define expectations from an end-user perspective.
"I think so much of it is solvable. The data usability one is a heavy lift. It's one that we certainly are going to stay focused on for some good long time," she said.
Patrick Woodard, VP and Chief Digital Officer at Methodist LeBonheur Health, has a mission to transform the system’s digital health technology to integrate user-friendly and interactive platforms to expand patient engagement. Woodard shares his perspective on the transition with host Bill Russell.
Patrick Woodard, VP and Chief Digital Officer Methodist LeBonheur Health
Methodist LeBonheur is a six-hospital system based in Memphis, Tennessee. It partners with St. Jude's Hospital and has 100 clinics serving urban areas. As CDO, Woodard is tasked with transforming the health system's digital health technology and strategies by integrating user-friendly and interactive platforms and expanding patient engagement.
The timeframe of success is important to define when beginning this process, he explained. Health systems are extremely complex, which means large investments can take time to achieve.
Implementing digital health strategies that will unite industry best practices with real-time, evidence-based care requires knowing what the right platform will be for the foreseeable future. Composable layers at the application or platform layer should be created to implement innovative technologies without additional fragmentation.
Methodist LeBonheur Health wants to be innovative, connect patients to their health, and support clinicians.
"People come to work to do a good job every day, and they don't want to have to fight with the systems that they have. So it's our job to make sure that the platforms are in place so that we can take those kinds of innovative elements and really grow from there," he said.
One thing Woodard appreciates about healthcare is that everything tracks back to patients. While not everything feels like a positive patient impact, a health system's role is to impact patients by reducing anxiety and helping them feel better.
"It's what a health system is obligated to do for the patients in this community," he said.
It is important to prioritize the patient experience because they will not remember what a clinician says or does; patients remember how they were made to feel.
Woodard also emphasized noticing the employees requesting changes because they are the ones who want to enhance the way they are working.
Currently, the system is exploring digital solutions like extending the reach of a health system into homes. Exploring digital applications to extend platforms into semi-ambulatory areas to pre-alert patients and moving towards hospital-at-home care are among two specific areas Methodist LeBonheur focuses on.
The hospital desires to explore consumer relationships on a long-term basis, Woodard explained. A patient's relationship with hospitals is ideally with few encounters over a lifetime. This means hospitals must learn to promote a relationship catering to their needs.
"How are we promoting primary care, ambulatory, and outpatient relationships so that patients feel comfortable not needing to come into the health system or into the hospital," he questioned.
Care is primarily episodic, but Woodard sees it as becoming more continuous over the years. Most times, patients visit a clinic and wait for some time in between for a follow-up appointment.
Health systems can turn this into continuous care and improve patient outcomes. This is key for the necessary evolution of health systems and healthcare delivery, according to Woodard.
Woodard writes articles on rural health care access, stemming from his experience working with rural residents of Nevada.
Thanks to the pandemic, he believes those living in rural America now have greater access to care due to telemedicine. Other technological advancements like rural broadband access also benefit these communities.
There is still a long way to go for augmenting care in rural and frontier environments. People living in these locations need access to care, enabling healthy lives without spending a day traveling to receive care.
According to Woodard, the biggest challenge for health IT professionals is the abundance of good concepts. With many technologies to choose from, systems have to decide if a proprietary platform is the best option. These platforms offer cool technologies and applications but increase the number of supported applications which may not integrate with clinical record systems.
The interoperability layer is a challenge for health systems. Many systems have goals to reduce the number and cost of supported applications and improve the value of investments.
"I think we can create a level of interoperability that will ultimately benefit everybody," he said.
The future is filled with transitions to health assurance, further access to care through healthcare delivery companies, and changes to traditional providers through partnerships. Stephen Klasko, Executive in Residence at General Catalyst and former President and CEO of Jefferson Health, shared his perspective on how these elements are integral for the future of healthcare.
Stephen Klasko, Executive in Residence at General Catalyst and former President and CEO of Jefferson Health
According to Klasko, health assurance is transitioning from the either-or healthcare model and stopping the patient mindset.
"97% of people in this country do not wake up and say, ‘I'm a patient...’ They might have one of many chronic diseases, but they say, ‘I'm a person that would love to be able to thrive without health getting in the way,’" he said.
Seeing hospitals advertise themselves as patient centers frustrates Klasko because people are more than patients. People with chronic conditions do not want to live in an office. Rather, they want an invisible friend alongside them so they can have a normal lifestyle, he explained.
When health systems call themselves patient-centric, they pigeonhole themselves by communicating patients are cared about until they are discharged. The health industry lives in a sick care patient-centric model, which is the wrong approach, he explained.
When it comes to the future, the answer for many is increasing data. However, data does not go beyond what happens in the hospital, and stores like CVS hold data about the person that hospitals lack.
In the future, Klasko hopes hospitals are not well-known, since it is where sick people go. Currently, hospitals are defined by where the sickest patients go back to, he explained.
"When we fail to keep people healthy, it is partly what's wrong with American health," Klasko said.
There will be a break in the healthcare system, Klasko explained, because it cannot keep spending more money.
"We have to get over this myth that we have the best healthcare system in the world," he said.
The United States' health system lacks progress that other nations already possess, and this is because hospitals are paid to have people come to the hospital.
"It's hard to get somebody to do something when their salary depends upon them not doing it," he added.
With this in mind, Klasko believes some things will not work in the country's hospitals because it is part of an impossible system promoting the sick care, high fixed-costs model.
One way this can change is by acquiring a Medicaid or Medicare advantage insurance company. While CEO at Jefferson Health, Klasko implemented this, which allowed the system to look at preventative measures rather than just treatments.
The greatest source of bankruptcy in America is health-related costs. Pairing this with 80.5% inflation, Americans are looking for relief. Klasko believes up-and-coming CEOs, strategic payer-provider partnerships, and the frustrations of American consumers will shift the healthcare system into a new health assurance model.
Klasko is optimistic for the future because the future doctors, nurses, and healthcare workers will have a mindset for making things more efficient.
As Amazon, Walmart, and others enter the health industry, it presents increased access to care for much of the country. These services may act as an intermediary and direct consumers toward care.
While accessibility through technology is important, trust is above this, according to Klasko. This was exemplified with Google Health when patients were less likely to trust the company with their data. It was a bridge too far, he explained.
Companies like Amazon Care and Transcarent offer home health services, which disrupt the healthcare system. This allows for greater access to healthcare and flexibility in receiving care.
Companies like Walmart offer further accessibility with its stores, which is competitive with Amazon's at-home services.
Walmart, for example, has approximately 100 million weekly visitors, allowing for easy access to health services. This is why Klasko sees the company as a future player alongside Amazon.
The key to progress resides in partnerships between traditional healthcare and providers with these newer players in healthcare.
Some say that the role of the traditional provider is dying as it becomes harder to bridge the gap between providers and delivery companies entering the industry. However, Klasko does not believe the claim to this extent.
The riskiest thing traditional providers can do is nothing. It is a risk to focus on inpatient revenues and compete with neighboring providers, he explained. The future lies within partnerships and thinking toward the future.
"If you're unwilling to be with the future, if you're unwilling to do any of those things, then your patient won't be with you," he said.
He is optimistic that continual progress with social determinants, predictive analytics, natural language processing, and at-home care is the right area to focus on for the future.
After a career working at well-known companies like Geisinger and Google Health and currently serving as the President and CEO of Cerner, Dr. David Feinberg shares his unique technology lens regarding healthcare. Dr. Feinberg discusses the influence technology can have in improving patient and clinician experiences with host Bill Russell.
Dr. David Feinberg, CEO & President of Cerner
Dr. David Feinberg is driven toward making care better for everyone. Working a significant portion of his career in technology, he believes it is a potential tool and platform for this to happen.
His focus is to eliminate the waiting room. This includes the anxiety of access, communicating in ways patients understand, and making care accessible overall.
Inertia, or forces, keep the healthcare industry from reducing waiting room times and the overall connection with patients. However, the opportunity presented itself for an eliminated waiting room during the pandemic.
A new curve appeared in telemedicine where people realized a fundamental problem with the current health system. Dr. Feinberg explained that the present system is built around providers instead of consumers. When the system favors providers, more patients are within a waiting room, so a doctor's time is not wasted.
On the other hand, from a consumer standpoint, a system provides care 24/7, and information is accessible to patients.
During the pandemic, Dr. Feinberg was leading Google Health's efforts. From impressions, the team learned that people were looking for information on the virus early on. From that, they sought to provide accurate information that was not authoritative yet understandable. This effort could have a dramatic effect in saving lives, he explained.
In partnership with Apple, his team worked to create exposure notifications that took off worldwide. This brought a dramatic decrease in mortality. During a health crisis such as this, it became clear that access to information as consumers was integral.
With 15% of the 20 billion Google daily searches being health-related, the search engine proved to be a pivotal resource for the country navigating the pandemic.
Since his time at UCLA, Dr. Feinberg has worked toward patient satisfaction, where he helped the health system adopt this focus. Previously a place where two out of three patients would not recommend UCLA to a friend, after focusing on patient experience, the system shifted from the 28th to the 99th percentile.
The system flipped patient opinion by adopting the mission of healing humankind one patient at a time by alleviating suffering, promoting health, and delivering acts of kindness.
Dr. Feinberg took this experience with Geisinger and helped the system adopt its original money-back guarantee on specific procedures. The system holds care pathways where reinfection rates are calculated and having the surgery again is covered.
Proven Care is a no money-back guarantee on any part of a patient's experience with no questions. Through an app, patients can leave feedback about their experience and will be reached out to make anything right by staff.
"It was incredibly worth it to be able to refund money to people who we didn't do right by and learn where we did right. But we also were learning where we're doing really well," he said.
According to Dr. Feinberg, healthcare accounts for 20% of overall health. The other 80% revolves around a patient's zip code and genetic code.
In his work with Cerner, he sees how healthcare is delivered worldwide. For example, doctors can prescribe opera in Sweden because they combine social and medical care.
"If you're in a value-based situation where you're responsible for the outcomes of patients, you start thinking about the things that drive better outcomes. Things that drive better outcomes are not just making sure they don't get an infection during surgery, but figuring out how you can avoid surgery altogether," Dr. Feinberg said.
Transitioning to a value-based mentality means that health systems no longer should treat a patient's immediate physical need but also ensure they don't return soon. This is where considering other influencers of health outcomes like transportation, food, and loneliness is essential.
Acknowledging the need for people to access healthy, nutritious food and transportation are essential factors Dr. Feinberg wants the United States to implement.
By ensuring people have these necessities regardless of their background, he believes the healthcare costs in America would decrease by 50% overnight.
"It would be the biggest boom we've ever had in our economy because a lot of that would then go to wages, and everything would get better," he said.
Half of the disorders physicians treat are lifestyle disorders due to patients not readily having these needs met.
Cerner's primary focus is improving usability for clinicians. There is a need to dramatically reduce the time nurses spend looking for supplies or at their terminals.
Dr. Feinberg and his team pose the question of how technology can be used to help clinicians complete important tasks at the bedside as opposed to at a terminal. Improving product usability is Cerner's top job.
"I don't want to go incremental. I want to go leapfrog and really change how we do it," he said.
During the pandemic, clinicians struggled to find patient charts because they were physical copies locked in offices. Cerner has digitized records and is now working to make them usable for non-clinical needs.
He explained that disparate data sets need to be given back to people so they can make actionable decisions. By collecting larger pieces of data, clinicians gain insight into helping patients.
Responding to recent headlines that healthcare is too hard for big tech, Dr. Feinberg believes that Google is a healthcare company in many ways. For example, a large percentage of patients take time to research on Google before going to the ER or starting a new medicine. Google is also moving records to the cloud-like other health systems like Oracle, Microsoft, and AWS.
"Healthcare to me, fundamentally, is people caring for people, and technology is a tool," he said.
While tech companies try solving health through apps, it does not work on their own. More than this, it is about connecting with people, communities, and families, according to Dr. Feinberg.
Tech companies mess up when they see health as only a technology problem and negate it as a human problem.
Proximie is a global company with a team of over 140 people supporting over 90 countries and 40 device manufacturers. Dr. Nadine Hachach-Haram, Proximie Founder, Faculty Singularity University, TED Speaker, and surgeon, shares the company's mission to change and disrupt surgery rooms across the world.
Dr. Nadine Hachach-Naram, Founder of Proximie
Before Dr. Nadine Hachach-Haram was the founder of Proximie, she had a passion for helping others. Exposed at a young age to the fragility of life while raised in postwar Lebanon, Dr. Hachach-Haram questioned the purpose of her life.
"It exposed me to things that probably most teenagers aren't exposed to. And that made me think about what I want to do with my life? What meaning or purpose do I have by being on this earth? It was very much around helping people have a better quality of life," she said.
Choosing a career in reconstructive plastic surgery, Dr. Hachach-Haram continually involved herself in delivering care to more people.
In 2014, after involving herself with global health and device companies, she was left frustrated with variability in patient care and the analog environment in healthcare.
"I started to imagine this world where you can almost imagine it digitally connected. A pipeline connecting operating rooms and turning these once analog and undigitized environments into connected, collaborative, and intelligent environments. And perhaps by creating this pipeline that connects all these rooms and this expertise, we could find better ways to connect, collaborate, and activate knowledge and information in a meaningful way," she said.
Dr. Hachach-Haram approached the digitized environment with her surgical background. She understood the need to provide immediate value for clinical teams. Telementoring and teleprompter-proctoring were the first critical use cases.
Proximie works on cases across the United States' coasts daily. The company also has doctors supporting work in countries like Ethiopia, Kenya, Brazil, France, Italy, and more.
Now in operating rooms, she mentioned that people are unlocking many new use cases. Medical schools utilize the tool to train students and provide more surgery access. Hospitals are also working alongside Proximie to optimize their efficiency.
Surgical training is designed around the idea of seeing, doing, and teaching, according to Dr. Hachach-Haram. However, this method also presents flaws in the system. When people learn through stores of training and experience, there are learning curves and challenges.
Learning through apprenticeship presents a natural learning curve, which is challenging to track or assess. While there is a significant evolution in how surgical training assesses competency, validation, and accreditation, she believes there is a lot left to do in the digital environment.
"My mantra has always been that we need to eradicate that concept...It should be a continuum called 'Prepare, Perform, Perfect' because it doesn't matter if you're a medical student, intern, resident, or even a surgeon at the top of your game. You will go through that journey because surgery evolves, new techniques come out, and new devices come out on a weekly, daily, and monthly basis," she said.
The learning cycle continues for those in medical careers, so there must be an environment to enable this preparation. Proximie presents opportunities for clinicians to join live cases in real-time, look at equipment utilized, or review past cases in a video library.
When it comes to performing cases, Dr. Hachach-Haram sees it as an opportunity to be beyond a moment in time. By recording cases, surgeons can later review their performance. This creates an environment where surgeons can give feedback to peers.
While Proximie is a telecommunications engine at its core, it is much more than that, Dr. Hachach-Haram explained.
The system contains a high proprietary video communication layer designed to optimize video and audio performance and direct and ingest direct video feeds. An additional layer of this experience within augmented reality allows a more immersive interaction. She mentioned that with such a robust system, even the UK military is a customer.
Proximie features a whole user journey around surgical instances. Compared to video conferencing platforms like Zoom, it is designed for surgical operating rooms and integrates with any operating hardware.
The platform approach allows Proximie to partner with third-party software to further enrich the operating room environment in meaningful ways.
Proximie often works in partnerships and licensing with health systems and hospitals. The company does not charge per minute or use like other telecommunication platforms. Prices are instead based per room each year to encourage as many people as possible to access the resource.
With this solution, health systems can deliver high-quality care to patients at lower costs. This is meaningful for both providers and patients and unlocks a long-term value chain.
In cases where remote providers in the United States are looking to up-skill surgeons for better care, there is an immediate value-added by reducing travel times, carbon footprint and delivering care to patients.
The partnership between Intermountain Healthcare's Castell Health and Arcadia has united technology and operations to elevate value-based care performance.
As part of ongoing HIMSS coverage, David Dirks, interim CEO of Castell Health and VP of Strategy for Intermountain Healthcare, and Michael Meucci, COO of Arcadia, sat down to discuss activating healthcare data supply chains.
By 2025, the compounded annual growth rate for healthcare data projected to be 36%. With increased needs to handle data, this percentage speaks to its power and of those accessing it.
David Dirks, Interim CEO of Castell Health
"Data is power, and the people who own the data are going to win the competitive race," Meucci said.
With a shift to remote patient monitoring, outpatient at-home care, and telehealth, there is an explosion of information. However, not all data is good or necessary, according to Meucci.
Dirks explained that it is important to look holistically at a patient, not just data produced from a healthcare perspective.
Castell Health is working to fundamentally change the perspective that healthcare must move from being reactive. An example of this is primary care physicians not waiting for problems to arise but starting each day thinking of who they should see.
Knowing who to see takes a different approach to data and analytics. Both healthcare and social determinant data must combine to create change, Dirks mentioned.
By using analytics and holistic knowledge of patients, physicians can align treatment with determinants--bettering the care patients receive.
Dirks explained that Castell Health is not using the data supply chain to load as much data as possible. Rather, they start with an end goal in mind and align data assets to inform and make decisions.
Michael Meucci, COO at Arcadia
Traditionally, interfaces were necessary, Meucci explained, but now there is a movement towards more liquid data. This is where Castell Health and Arcadia enter to become innovators around data. Advancing models that access data lakes and normalize data in real-time eliminates the need to go through the protracted process through interfaces.
According to Meucci, Castell activates their data supply chain by treating outputs like products. Normally, deliverable data like readmission rates are utilized, but there is a need to give rates into the hands of someone who can act.
"That's one of the areas that Castell has done a really nice job in--building these assets in their workflows of the people who could impact change and consistently maintaining those and evolving those as their performance evolves," he said.
From the beginning, Castell makes conscious decisions to direct and inform workflows by data and analytics. This allows for the greatest impact on populations efficiently using minimal resources.
Arcadia has been a critical part of Castell's understanding of the components needing to come together, according to Dirks.
"In order to inform that workflow at every point in time, we couldn't just do that on our own. It takes a lot of work to make sure not only that you're able to get all of that data in, but that people trust it and you can deliver it at the right place at the right time, in the hands of the right person," Dirks said.
This is the approach taken for the data supply chain, as it must inform the work being done.
During the pandemic, Castell and Arcadia worked together to discern those most likely to die from the coronavirus. Using Arcadia's data reference set of 150 million people from three of the earliest cities of the outbreak, the team built a machine learning model.
As the team monitored symptoms the CDC reported mirroring positive cases, the model continued to build. It continued to optimize with feedback, making the model smarter. This allowed for outreach programs to be developed where at-risk patients could ask questions about the virus.
Running a care traffic control center is comparable to air traffic control, according to Dirks. With visibility of events informed by data and analytics, Dirks directs people to the appropriate place.
Real-time insights--layers called triggers or signals--inform Dirks with knowledge of both the healthcare system and of individual members and their primary care physicians.
Combined, it marries everything together, according to Dirks, to effectively meet member needs. Data points inform the protocols and workflows at each point.
Starting 10 years ago, Castell Health began with a plan to transform healthcare. This accelerated since Dr. Mark Harrison became CEO, Dirks explained, and realized traditional ways of treating patients within hospitals need to be disrupted.
"It's way too costly. We're treating illness rather than understanding how do we keep people well and how do we keep them out of our hospitals," Dirks said.
Disruption was not as effective in the 23-bed hospital system, so there was a restructuring of the organization. There is now two divisions: community-based care and specialty-based care groups.
Community-based care keeps people well and out of hospitals while the specialty group provides care with convenience and flexibility.
Castell Health takes the goal of keeping people healthy through proactive care seriously. According to Dirks, the organization looks for ways to put hospitals out of business.
"The best possible scenario for us is that we never need another hospital again because that means people are healthy," he said.
By making this separate component of the business where they aligned finance, incentives, and innovations to a non-traditional model, there is a significant transformation.
At Intermountain, there is a goal to leverage digital and virtual tools that meet people wherever they are while giving the best possible care. Castell has made large investments in its digital front door, Dirks commented, which is necessary for the interaction.
Dirks shared Castell Health is investing in convenient, cost-effective care delivery models in ambulatory settings for patients needing brick and mortar care.
Future hospitals will look very different because almost everything within its walls can be done at home, according to Dirks.
Patients traditionally acute can effectively receive care in home-based settings, which Dirks hopes will continue to grow. He expressed that he expects increased levels of convenience, and quality while keeping costs low by leveraging tools and assets.
Understanding individual patients and their needs and holistically tailoring an approach is a strategic imperative at Castell Health.
"Equity is important because, if I can understand each individual and their individual context and deliver them a set of tools that helps meet their health needs, then just purely from a strategic perspective, I win right now," he said.
Dirks explained this approach is profoundly strategic and great for society, as everyone gets the best care.
"The only way I can understand people at that level and tailor those services is if I have a very effective, high-performing data supply chain in order to inform that," Dirks said.
There is a need to expand AI data quality and radically revise EHR adoptions for the future of healthcare, posited Dr. John Halamka, President of Mayo Clinic Platform, as he shared the challenges the healthcare industry faces with AI and EHR innovation and the next steps for innovation.
According to Halamka, AI has a credibility problem in healthcare. Physicians do not know if data was developed on people like their patient population when buying an AI algorithm. There is a lack of credibility when there is no understanding of an algorithm's utility, bias, or likelihood of fulfillment. Halamka suggests addressing AI transparency is necessary for physicians to have algorithms that fit their patient populations.
John Halamka, President of the Mayo Clinic Platform
Halamka supports useful AI testability. He explained how it can ensure transparency and requires AI to fit specific purposes. There is a need to build a national and international framework for this testability, enabling any dataset or algorithm to come together in evaluation.
Explainability is a key aspect of AI and comes with a lot of debate. However, most algorithms are probabilistic, multi-tiered mathematical equations without easy explainability, so this aspect may not be attainable.
Algorithms come from various sources like academic health centers, companies, and big tech. Academic centers are usually based on their internal data and use, while companies are creating algorithms within a monetized bubble to provide value-generating services across large populations.
Currently, the industry sees government academia and industry stakeholders producing AI algorithms, but there are no national guidelines or guardrails for how these processes move, Halamka explained.
As developers continue to create new algorithms, he emphasized the need to accompany advancements with guidance.
Data variability within communities must be addressed when using EHR data. When data sets do not adjust to population sets, applications present errors. According to Halamka, there are three specific problems with EHR data sets.
The first of these is the fidelity of the data. When constantly writing unknown data elements into workflows, there is a concern with the accuracy of the recorded information.
The granularity of data elements is a challenge regarding race and ethnicity. For example, categorizing an individuals as "Asian" rather than noting a specific country of origin would result in a less accurate algorithm.
Another concern is creating significant amounts of noise in the EHR data signal. After recording through scripts and templates, it can be hard to separate the signal from the noise in algorithms, Halamka explained.
According to Halamka, while EHR has aspirations to be a platform, it is evolving as a transactional system. With FHIR and CDS Hooks, various aspects of interoperability, and information blocking tools, there is an ecosystem of partners at its core contributing and using data for novel purposes.
Policies primarily drive EHR like 21st Century Cures Act, yet policy change is far-reaching in forcing players to take this next step. Halamka describes this situation as the perfect storm for innovation to align technology, policy, and culture.
Developing FHIR, APIs, restful transactions, and various policies are necessary. However, there is also a need for demand–a cultural expectation for value and utility.
"I think we are approaching a point where there are enough apps and algorithms; maybe even your insurer will offer you a discount or special benefits if there are certain kinds of data you contribute...When that cultural change occurs, that is what is going to get us adoption," Halamka said.
Systems can be engineered to achieve a specific result. In the Meaningful Use era, Halamka recalled physician burnout due to emphasizing population health. The system required physicians to record 141 pieces of information while simultaneously interacting with patients. This is the result the system was engineered for, he explained.
Currently, EHR has FHIR interfaces and increased decision support, but it is not enough. There is a need for a complete paradigm shift for recording medical records. Using NLP and ML for human transcribing deep conversations into discrete data elements is not enough, he emphasized.
One of the challenges for this EHR rebuilding is regulatory complexity. There are requirements to ensure data, prevent treasury fraud and abuse, and provide meaningful use. Despite extraordinary strides in ambient listening and natural language processing (AML), it is difficult to comply with the current regulatory framework.
"It’d be tough. We have to take a careful look at what we want to achieve and engineer what we want to achieve. That’ll require regulatory change," he said.
Now that there is market acceptance for EHR adoption, a radical revision of how it works is the next step, Halamka explained.
Laying the proper foundation for analytic capabilities requires quality data, which directly impacts the success of value-based contracts for Accountable Care Organizations like Summit Health. Dr. Jamie Reedy, Chief of Population Health, and Dr. Ashish Parikh, Chief Quality Officer, shares Summit's foundation for ACO analytics, ensuring data quality, and how data can drive ROIs.
About a decade ago, Summit Medical Group–now known as Summit Health after a recent merger– learned that it offers care with better outcomes and lower costs for Medicare patients. This is because Summit is a multi-specialty outpatient structure, featuring over 80 specialties and comprehensive, coordinated care. Understanding this, the organization began its ACO (Accountable Care Organization) journey.
Jamie Reedy, MD, Chief of Population Health at Summit Health
As the group progressively added value-based agreements, they controlled the number of contracts and the overall level of risk. According to Parikh, as the number of patients in the ACO increased, the group added to its physician team and invested in its population health management infrastructure.
The key to successful ACOs or any value-based care is accessibility to lots of data. When Summit started assessing its analytics options and potential vendor partners, it first needed specific foundational capabilities.
The first of these capabilities is creating an expansive dataset, which allows for integrating disparate data sets. The organization grew in contracts and population, transitioning beyond limited clinical data within its EHR. They began incorporating medical and pharmacy claims data from health plan partners and clinical alerts of encounters beyond the organization's walls.
Another foundation is creating data-driven workflows, Reedy explained. Use case data was a priority for the clinics in their workflow journey. The group invested in FTEs to support coding, quality, and patient management.
The third component is ensuring analytics teams have direct access to normalized sets. This allows teams to calculate the performance in critical areas of value-based success. Summit’s care teams can better use data to inform workflows by developing enhanced and predictive analytics to grow in sophistication.
Data comes from various sources across healthcare ecosystems, Reedy explained. In the beginning, Summit integrated common data sources like health plan eligibility and claims data, clinical EHR and practice management data, and information from core facility partners.
Ashish Parikh, MD, Chief Quality Officer at Summit Health
The organization continues its data journey by progressing deeper into its risk journey, where adding risk adjustment data and coding gaps are critical. Additionally, pursuing telehealth, remote physiologic monitoring, and socio-demographic data is necessary for coordinated and comprehensive virtual patient care.
The data sources chosen for integration are driven by the organization's business news and prioritized by considering technical challenges associated with accessing its data.
Obtaining medical and pharmacy claims data from health plan partners is critical for mutual success. Complete claims data presents full visibility, Reedy explained. It aids with managing financial risks in ACOs, as they require insights on patients, patterns of care, and utilization beyond organizations.
Pharmacy claims data, for example, helps calculate providers and generic prescribing rates, so providers are held accountable within Summit's incentive program. Other types of claims data assess where patients receive specific care and educate physicians about cost differentials.
Organizations need quality data to build out their analytics infrastructure, which is why Reedy recommends incorporating quality into the overall strategy of data integration.
Reedy further explained how organizations must consider the consequences of data quality. If care teams find flaws and are not confident with the data, they disengage with analytics. Care teams will further disengage if the data is inaccurate or efficient for its intended purpose.
Summit desires strong data engagement, which is why the organization is hyper-focused on building data-driven workflows. Building a strong data quality review process ensures all integrated data sets are dependable.
According to Reedy, several key signs bring end-user confidence in data quality–correctness, completeness, integrity, validity, and data relevance.
Providing education for providers regarding the data sources and how they are validated is critical to successful data use. While variances are possible, the key is minimizing them upfront through strong data quality processes.
While claims data is integral to managing financial risks and outcomes, it is necessary to assess the common data issues with claims.
Privacy regulations require sensitive diagnoses and procedures to be masked or hidden and result in knowledge gaps about longitudinal care. Reedy explained that some health plans offer selective or exclusion criteria, which leave pharmacy claims files useless for clinical teams.
Another challenge is how health plans change file formats or alter data elements. These changes are frequent and result in failure of automation and delays in data access.
With these issues in mind, Reedy recommends that organizations develop proactive strategies for managing claims data quality. Summit regularly educates the health plans it partners with about how data guides members.
"When the health plan understands the importance of the data to the care of their patients, there's so much better cooperation with us," she said.
To reduce complications with data, the organization builds language into its contracts to require the timely and complete provision of claims-based data feeds.
Summit has three areas of priority for driving value from data. The first of these is for data to inform daily workflows–immediately impacting patient outcomes.
Another area is using expanded data sets to give providers real-time visibility in performance and opportunities to improve care. This informs incentive programs for both physicians and care team members.
Thirdly, Summit heavily invests in resources and infrastructure for best-of-breed population and health management. The goal is to assess the impact of investments and create ROI analyses to inform future strategic decisions, Reedy explained.
This data infrastructure is the foundation, which is why Summit prioritizes value in these specific categories. The organization refined these priorities upfront, which informs key questions internally.
"Revisiting the value question is what helped us to make sure that we had the right expertise internally to use and understand all of the data sources," Reedy said.
A significant decision for quickly driving data value is partnering with experienced vendors. Summit works with Arcadia to learn how to best utilize data for these priorities.
Creating better outcomes should be the driving factor for prioritization, Parikh explained.
Summit desired to use its analytics platform and data to improve patient outcomes, bringing success with value-based contracting.
According to Parikh, spending more on patients in ambulatory settings alleviates the costs in expensive care settings like hospitals and emergency rooms. This is why the organization focuses on reducing hospitalizations.
"Whenever we think of value, and we try to convert all of our stakeholders into value-based believers, we always use the value formula–improve outcomes, which is basically better quality, better patient experience," she said.
Summit leads its providers and clinical teams, explaining that value-based care will be better for patients and bring better outcomes. However, the organization also aligns incentives with it.
The Universal Provider Incentive Program (UPIP) is for specialty physicians where 20% of their compensation is tied to value-based outcomes. These outcomes include quality measures, patient experience, and acute disease burden capture.
"For our primary care physicians, we wanted to really move that one step further and tie panel-based outcomes and performance and its impact on our value-based contracts," Parikh said.
Summit's vendor partner, Arcadia, works to help create multiple bonus measures for primary physicians, such as risk-adjusted admission and quality impact score.
"With these elegant measures, we were able to give primary care providers data that shows them how well they're doing on their panel, how it impacts our value-based contracts, and how then, secondarily, it will impact their incentives," she explained.
This January, Transcarent announced they raised $200 million in Series C funding. Additionally, they have partnered with Northwell Health, Intermountain Healthcare, and Rush Medical Center in its mission to change the healthcare industry. CEO Glen Tullman outlined the vision of Transcarent and how they are in creating a quality care experience.
According to Tullman, Transcarent was built with urgency to solve an urgent problem in healthcare.
"Every day, people aren't getting the care they need. They're paying too much for the care. We're denying care. We have a broken healthcare system," Tullman said.
Today, co-insurance healthcare costs are the single largest reason for personal bankruptcy in the United States. People are having surgeries and treatments without understanding their personal obligations.
Concurrently, some of the largest payers in the country are making record profits and denying a record number of claims, he explained.
Acting in urgency, Transcarent had plans to raise capital in 2022; however, they did not expect it in the last two weeks of 2021.
An unsolicited term sheet offered 200 million dollars, and after speaking with other potential investors, Transcarent had four term sheets--allowing the organization to raise capital.
"There was tremendous interest. We have incredible investors and those investors span both financial investors and also some important strategic investors, partners, customers. But we were very pleased," he said.
Glen Tullman, CEO at Transcarent
Transcarent's aims to create a new type of healthcare experience for members, clients, and providers alike. They collaborate with self-insured employers or government agencies to connect two sides of healthcare: health consumers and those providing care.
This is how the organization's unique model for health systems and providers was created. Transcarent pays for surgeries in advance, offering a bundled price so providers know what they are getting paid. In exchange, providers must deliver a high-quality experience.
New investors like Michael Dowling, Northwell Health CEO, acknowledge Transcarent as truly valuing the high-quality work providers can offer--being the first to also pay them upfront for that level of care. This is an opportunity that all types of health professionals can partner with Transcarent for.
"The new model extends not just from the experience that we create for our members, not just for the unique savings and quality that we provide for our clients and self-insured employers, but also for the people who do the work," he said.
Health systems represent five of the top ten largest employers in every state. Transcarent is pleased to have many of these systems joining as customers of this model.
A broken system cannot be navigated, which is why Transcarent does not describe itself as a navigator.
"Navigators today spend 20% of their time talking about bills. We don't even have bills. Navigators spend time trying to figure out where you should go. We've invested millions of dollars to come up with algorithms that help us figure out what is the highest quality experience we can create," Tullman compared.
To ensure a quality experience, Transcarent considers if care is necessary, the best facility to send patients, and provider quality. Members receive this and get to decide what they want to do.
Transcarent puts health consumers in charge of their experience by providing unbiased information.
"We're giving you trusted guidance because nobody is paying us to send you anywhere; [we're] not taking rebates from not taking fees. We're simply providing you the best options. And then, last but not least, when you choose, we're making it easy for you to get that care," Tullman said.
Ultimately, Tullman and the Trannscarent team offer the future for healthcare, focusing on giving the best quality care and helping people get healthy.
After their Series C raised $200 million dollars, Transcarent focuses on transforming four specific areas of the health industry: prescription costs, surgical costs, care at home, and complex care.
Transcarent believes people are paying more for both co-pays and overall prescription costs. This is why the company is partnering with Walmart to change the way people access prescriptions.
Consumers often have prescription co-pays that cost more than the drug itself, Tullman explained. Transcarent is working to either eliminate co-pays in these situations or have consumers pay the lower of the two costs.
Another situation the company is working to identify is saving consumers money on overall prescription costs. However, it is not about the money to Transcarent; instead, it is a matter of accessibility. As prices and co-pays decrease, care is more accessible.
"This is an equity issue. We have to make healthcare more affordable," he said.
Transcarent has joined with BridgeHealth, which is a leader in surgical solutions. Already offering high-quality care options at lower costs, Transcarent is learning from a decade of experience.
The organization now presents consumers with local options for high-quality providers and different site options. The options available vary depending on the type of care a member needs.
In the end, Transcarent's main focus is quality, making it a company he trusts his family to use.
"I actually trust that our people will always put quality first. There may be cases where quality costs more, [but] so be it. We think, on average across the board, that quality actually pays. It's the right thing to do. And it ultimately results in lower costs," he said.
A significant amount of care in hospitals is deliverable at home. Patients often prefer home care but believe they cannot afford it. On average, at-home care with a private health professional costs 30% less and is safer, according to Tullman.
By offering care at home, Transcarent gives members more choices and options for quality care at a lower price--all while avoiding a hospital facility. The organization is partnering with local health systems to provide these services.
This is a primary way Transcarent aims to inform consumers better, which leads to a better care experience.
As cyber attacks become more sophisticated, frequent, and malicious, health systems need the right tools to detect potential threats. Jim Brady, Vice President of Information Security & Operations and CISO at Fairview Health Services and Ryan Witt, Industries Solutions and Strategy Leader at Proofpoint, outlined security strategy and navigating threats, ransomware, and supply chain attacks.
Ryan Witt, Industries Solutions and Strategy Leader
Using a sporting analogy, Witt described the current level of cybersecurity in healthcare to a football game.
"Cyber criminals are essentially running the ball right now, and they're going to keep running the ball until healthcare institutions can stop the run. And right now, healthcare institutions are not stopping the run," he said.
While most attacks come in the form of ransomware, it is integral to watch out for email and other fraudulent base attacks. According to Witt, health systems lost more money through fraud than ransomware attacks.
Credentials are the Nirvana state for cybercriminals, Witt said, which is connected to the rise in fraudulent attacks. Once criminals have access to credentials, it is easy to access networks and begin their real work.
Attackers are sophisticatedly launching attacks from well-known data repository sites like Office365 and SharePoint. The trust of the sites leads people to trust links they click on, Brady explained. He recommended email isolation technology to combat the never-ending battle of clicking phishing links.
Isolation technology has allowed users to open links and attachments from incoming external emails. They can be routed to a container, preventing a potential bad link from spreading through the organization.
According to Witt, the good news is that healthcare does not have to wait for new technology to be developed or roadmaps to be accelerated. However, the bad news is that this technology is tried and tested, readily deployed for years; it simply is not in healthcare yet.
James Brady, CISO of Fairview Health Services
With this in mind, many solutions are available like isolation technology, cloud security capability, and DMARC protocols. Technology is a primary way for health systems to move forward in security.
"You just can't train your way out of this. You can't put enough processes in place to get yourself out of this. The technologies are available. Healthcare has got to make much more focus on putting those technologies in place," Witt said.
Technology alone, however, is not the solution. Progress must also include how health systems process and think.
The healthcare industry has only begun dealing with data breaches and fines over the last 10-to-15 years. Now, as health systems are shutting down for weeks due to attacks, organizations need to acknowledge the problem. Systems must take ownership of the problem from the top-down, Brady explained.
Like a neighborhood watch committee, building awareness with reporting malicious activity can help alleviate the number of successful threats. Progress will continue as awareness spreads, according to Brady.
When it comes to presenting cybersecurity to a health system's board, a 50-page report on firewalls and packet encryption will not win them over, Brady explained. It is important to quantify the risk by focusing on the finances.
According to Brady, the first step of preparation is a risk assessment. He also recommended looking at high-priority gaps and the likelihood they will occur, which may require engaging the system's insurance company or broker. Altogether, this information creates an overall picture of the impact and financial volatility from an actuarial perspective.
The next step is connecting this data to the lines of business, Brady elaborated. Based on how the health system makes money, this step is creating a potential plan for covering the finances necessary to implement security measures, which minimizes the probabilities of loss without closing security gaps.
This process goes for large and small health systems alike, as the extent of security holes outnumbers the money most systems will have to invest.
"I think it's just giving the board and the leadership the tools and details so that they can make the right decision on how much should we invest in cybersecurity to address a potential loss," Brady said.
According to Witt, if health systems are fighting a ransomware battle, they are fighting the wrong battle. This is because the likelihood of bad actors already being within the network is high. They are likely already in, having an understanding of the environment, and setting up a control center.
Data shows that bad actors can be in an environment for up to six months before detection. Witt compared this to someone living in a spare bedroom for months, understanding how a family runs its household; cybercriminal are squatting in the walls of the network, observing and stalking their victims.
"You need to work very strongly to keep people out of your environment to keep people away from getting credentials," he said.
User credentials are powerful because they unlock parts of the network, data that cyber criminals do not use lightly. Their goal is to exploit the network in the most beneficial areas to maximize their ROI.
Witt suggested locking down external-facing systems pointed to the web and preserving credentials as the primary focus for cyber activity.
Multi-factor authentication (MFA) is a must-have for most organizations. However, it is not enough to keep internal applications safe because many are legacy and unable to support MFA, Brady explained.
MFAs focuses primarily on cloud-based applications, leaving a significant gap where cyber attacks can enter.
"I think we spend a lot of time trying to prevent people from coming in, but not enough time detecting, are they in?" Brady said.
Being able to respond to attacks requires more detection efforts. Threat intelligence and technology that detect anomalies are important to have as part of a system's cybersecurity arsenal.
"We can't just think that we can just block everybody from coming in because they're going to sneak in. And then once they get in, if they're allowed to have stayed for a couple of months, they have the ability, I guarantee you at most organizations, to go undetected, with a regular account," Brady said.
Staffing is expensive if systems want to keep higher-end employees on staff to manage services. Brady estimated over 50% of a potential one million dollar budget allocated to staffing costs. A way to reduce rates is by looking at outsourcing or strategic sourcing. Lower rates are available at cyber security operation centers, for example.
If it were achievable, Witt also estimated a 50% allocation to staffing. However, he emphasized the need to view technology as more of a solution, as it is not as readily deployed as he would hope.
For example, isolation technology is a strong tool and only 15 - 20% of healthcare institutions deploy it. MFAs are not used enough, nor are tools like micro-segmentation, Witt elaborated.
"I'm not trying to say it's all about technology, but there are some easy wins out there," Witt said.
If systems have not made initial investments, there are easy wins that can pay exponentially higher initial dividends. If an organization is already down the path, Witt recommended focusing on processes investments. Therefore, they can see where the system fits on frameworks for benchmarking and guidelines.
Witt compared preparing architectures to the way athletes begin spring training; they are in shape and ready prior to the season starting.
"We need to rethink our expectations, our attitudes towards the whole way we look at our IT architectures with the idea of getting much closer to that hundred percent sort of patching," he said.
Healthcare is on a long runway with an unprecedented level of cyber attacks. Attacks will not dissipate until the industry finds a way to keep bad actors away, Witt explained.
He encouraged systems not to let up and focus on understanding the most valuable assets in the environment, threat vectors, and how to protect critical people in institutions.
During the pandemic, health systems learned how to laser focus on specific tasks and do them well. According to Brady, the same thing is necessary for cybersecurity, as it is an organizational risk. The best way for this to succeed is by getting the top-level buy-in.
Brady also emphasized the need to plan what to do in the case of a ransomware event. A run book is essential to outline what everyone within an organization does post-attack. Emergency preparedness and communication can decrease the mayhem during a potential attack.
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