Digital Health Fragmentation – Is Amazon the Answer?

Digital health updates are written by LoneArranger, an anonymous industry insider.

Thousands of startups in the digital health space offer a wide variety of features and functions, generally targeted at specific conditions and diseases or designed to address relatively narrow use cases. Relatively few of these are actually being prescribed by providers, and the most popular consumer apps do not typically ingest data from EMRs or other healthcare information systems.

They may have the capability to export data to these systems, but not necessarily in a way that yields any real value for providers or patients. Further, many are standalone tools or part of limited proprietary collections of loosely related applications that fail to offer the value proposition that would engage a large number of users.

This lack of critical mass has impeded broader adoption and limited the potential of digital health solutions to have a significant impact, at least in the near term. Other than the mobile versions of EMR portals like MyChart, few universally applicable solutions cut across large numbers of health systems and users. Even then, they may function differently depending on the sponsoring organization or local community policies. Just having a large number of mHealth apps in the major app stores does not constitute a critical mass for the purposes of delivering value that customers will actually pay for.

What is needed is a comprehensive, cohesive, and interconnected ecosystem that provides greater value for both providers and patients. The goal would be to create an environment that encourages innovation, but also provides a framework for connecting the myriad of applications into logical clusters and leveraging functionality and data that already exists in legacy health IT systems.

This may be the ultimate goal of the newly announced Amazon 1492 health research initiative. The 1492 group reportedly has been working on ways to streamline medical records management, to make the information more readily available to consumers and doctors. In addition, it reportedly has been considering a plan that could improve US healthcare for those with limited access to a doctor. The group is also exploring health applications for existing Amazon hardware, including Echo and Dash Wand. While there’s no evidence that the team is currently exploring connected health devices, it’s possible it could eventually do so.

Obviously Amazon has already built a comprehensive marketplace for selling and distributing a wide variety of goods and services, and global scale which puts it in a prime position to create a mass market once these new offerings are launched. It has existing relationships with many potential customers and through its portfolio of Cloud and other technology products and services has strong connections to enterprise customers, including many in the healthcare industry.

Amazon could use all of these capabilities to create a national framework for digital health delivery that could also provide local customization, working with leading health systems across the country. This would potentially enable patients to access a broad suite of connected apps and services that shared data across the ecosystem and also integrated with their existing patient records at various institutions where they existed. Data from all sources could be aggregated into a complete longitudinal record that could drive advanced analytics and artificial intelligence to enhance patient care and provide improved patient engagement and interaction with their providers to better manage their health.

This is one (but not necessarily the only) way that the true potential of digital health could be realized.

Digital Health Trends – 2Q17

Digital health updates are written by LoneArranger, an anonymous industry insider.

Digital health capabilities are increasingly becoming more integrated with core healthcare platforms and provider workflows, leading to major changes in the way healthcare is being delivered. There have been several recent developments in the application of technologies such as artificial intelligence, virtual and augmented reality, and wearable devices that have been disruptive, have the potential to change the practice of medicine and transform population health management and precision medicine.

Innovations in areas such as mobile apps, the Internet of Things (IoT), machine learning, and artificial intelligence are being incorporated directly into healthcare applications. As the digital health industry moves into the next wave of innovation, the following areas are those that many healthcare providers, payers, vendors, and digital health startups are targeting for development.

Artificial Intelligence (AI)

AI capabilities will become increasingly accepted and used by healthcare professionals as a clinical decision support tool to identify potential risks, mitigate errors, recognize patterns, and improve disease diagnosis and treatment. AI and Machine Learning will increasingly drive population health analytics, clinical decision support, and scientific research.

Blockchain

This technology framework has the potential to allow hospitals, doctors, and insurance companies to share data more securely, assuming the role of a trusted gatekeeper. Using the concept of a shared ledger, it makes it possible to share information selectively with others. Digital records can be stored with variable access controls and digital assets can be exchanged with minimal friction. Organizations are expressing increased interest in the significant potential blockchain has for improving healthcare information management.

Genomics

A substantial amount of funding has gone into the study of genes as researchers and providers pursue new disease treatment options and patients seek more tailored and personalized healthcare plans. Pharmaceutical companies are leveraging genomics research to develop new medications for cancer and other serious conditions as well as other therapeutic compounds for advanced immunotherapy treatments. Many EMRs are now configured to maintain genomic data in the patient record, along with existing medical data, to provide a more complete picture for providers.

Internet of Things(IoT)

The use of data from portable devices and sensors has given providers more real-time information on patient health status and patients the ability to have tailor-made strategies to combat illnesses and to take a more proactive role in managing their health. The connectivity of healthcare solutions and devices improves patient management, disease management, and the outcome of treatments. Since patients and providers both benefit from IoT, it will have a bigger presence and impact within the healthcare sector over time.

Mobile Apps

The major shift in this area is the evolution from standalone applications to ones that are more tightly integrated with legacy healthcare platforms and the clinicians who use them. Apps that connect providers and patients are gaining traction. These are being used to help coordinate and manage patient care, increase patient engagement, and support more effective treatment of chronic disease conditions.

Telemedicine

As technology becomes more affordable, remote treatment options continue to grow in popularity for both doctors and patients. For the elderly and those living in rural areas, telemedicine provides increased access to healthcare services that otherwise might not be possible, from remote diagnostics and monitoring to medical education and outpatient services. Both public and private payers are also starting to provide increased reimbursement for telemedicine services and state laws are changing to remove restrictions and facilitate the provision of telemedicine services.

Virtual and Augmented Reality

The use of VR and AR technologies will expand in healthcare for medical education and training, surgical support, other types of decision support, and pain management. They can be used for simulation of scenarios, decision support for providers performing procedures, and distraction, education, and entertainment of patients.

These technologies are enabling a variety of new applications in areas such as:

Behavioral Health

Behavioral health conditions are increasingly prevalent and challenging to treat. The insurance industry and self-insured employers recognize that the costs of treating mental health conditions, including depression, are increasing. Although long-term efficacy has yet to be demonstrated for most digital solutions, insurers and employers are increasingly willing to pay for digital behavioral health pilots. It is increasingly reimbursed by Medicare and investors are beginning to fund this sector. The hope is that more engagement and interaction, facilitated by digital technologies, may help patients with depression, anxiety, substance abuse, PTSD, and other behavioral health conditions.

Chronic Disease Care Management

Chronic care interventions use a combination of health, behavioral, and contextual data – such as glucose levels, sleep patterns, weight, food consumption, activity, social factors, time of day, and weather — to improve patient treatment plans. Digital health tools can also be used to improve care team communication and coordination. These applications have demonstrated such compelling clinical efficacy that insurance companies are starting to pay for them because of improved patient outcomes at reduced cost. Pharmaceutical companies are also interested in integrating digital interventions with their drugs to improve outcomes, differentiate their products, and engage directly with patients.

Data Aggregation and Analytics

In the past few years, there has been a dramatic increase in the amount of digitized health data stored in EMRs and ancillary systems, fitness and health data captured from mobile devices and wearables, and genomic data. There are many potential uses for this explosion of new healthcare data. Insurance companies and companies that pay for employees’ health care directly can use additional data to help refine actuarial models. Physicians can use analysis of this data for diagnosis, quality improvement, and decision support. Patients may benefit from the mining of data for predictions of their propensity for acquiring certain health conditions. As a result, real-time alerts and guidance to patients and healthcare providers are becoming more feasible and useful.

New Payer Models

A recent and intriguing area of investment in digital health is in alternative insurance companies. These startups often compete directly with major industry players, which have also been exploring and deploying digital health solutions. However, these new insurance industry entrants have some advantages over the incumbents. These entrants are unencumbered by existing infrastructure and relationships and thus can establish tighter relationships with provider networks and provide more flexibility. They can also build their technology stack from the ground up which enables them to more effectively use digital health data and solutions to target specific, stratified patient groups. Their primary challenge is achieving sufficient scale and differentiation to compete effectively against the larger, more established payers.

Provider Workflow Enhancement

Digital technologies can help give time-constrained healthcare professionals the ability to see more patients in less time, while delivering a better patient experience, by using data analytics for decision support, more efficient workflow, and different forms of mobile communication and collaboration.

Additionally, the cost curve can be shifted by leveraging less expensive resources. Given decision support tools, artificial intelligence, and data analytics, primary care physicians should be able to do some of the work specialists currently do. Nurses and case managers will be able to reduce a physician’s workload, and increasingly, patients will be able to manage their own care at home with mobile devices.

Collectively, these new applications will dramatically transform the delivery of healthcare services.

Recent Investment Trends

According to a recent report from CB Insights, large technology companies are increasingly focusing on investing in new initiatives in the healthcare domain. Since 2012, the top 10 tech corporate players in the US invested $6.2B over 143 healthcare deals according to CB Insights. Deals and funding into the sector with participation from these corporate entities has increased every year since 2012 to hit a high of 41 deals last year and $2.7B in funding, triple the funding total in 2015. In their report, CB Insights summarized the healthcare activities of the major tech companies:

Google

Google is the most active tech corporate investing in healthcare in the United States. Virtually all of its activity has gone through GV. CapitalG, Google’s growth equity fund, has made investments into Oscar Health and Practo Technologies while Google itself has co-founded Calico Life Sciences and acquired Lift Labs. Lift Labs develops a swiveling spoon that makes eating easier for patients with neurodegenerative hand tremors.

Recent GV investments include everything from health insurance (Clover Health) to gene therapy (Fulcrum Therapeutics) to vaccine development (SpyBiotech).

Google has not been shy about investing in therapeutics. In addition to Fulcrum Therapeutics, GV has made deals to Magenta Therapeutics, Spero Therapeutics, Arcus Biosciences, and Forty Seven all in the last year. Magenta is working on stem cell transplantation, Spero is focused on bacterial infections, and Arcus Biosciences and Forty Seven develop cancer immunotherapies.

GE

Once focused on lighting and electricity, the modern GE is a multinational conglomerate operating across many sectors. It is also one of the most active healthcare investors among US-based tech corporates. Recently, the company has made deals to HealthReveal, which monitors and predicts adverse health events, EMR data analytics company Arcadia Healthcare Solutions, and primary care provider Iora Health. The largest deal with GE Ventures participation was the $220M Series B of genome sequencing company Human Longevity in 2016.

Apple

Apple has made very few investments in healthcare startups despite diving into the sector internally with services such as HealthKit, CareKit, and ResearchKit. Apple has made two recent acquisitions in the space, however. In August 2016, the company acquired Gliimpse, developers of a personal health data platform, and in May 2017 acquired Beddit, which developed a sleep monitor that tracks heart rate, breathing, snoring, and sleep quality.

IBM

IBM has invested through both its corporate entity and the IBM Watson Group. While IBM Watson is an natural language AI platform, the company has made deals to both pharmaceutical and genomics companies such as Pathway Genomics (2014, 2016), Lodo Therapeutics (2016), and Petra Pharma (2016), and ApoGen Biotechnologies (2016).

Amazon

Amazon’s only healthcare investments in the past four years have been cancer diagnostics company GRAIL and baby monitoring startup Owlet Baby Care, the latter being backed by the Amazon Alexa Fund. Steve Rabuchin, VP of Amazon Alexa, has stated that the company will integrate Owlet with Alexa. In March of this year, Bezos Expeditions and Amazon participated in GRAIL’s $914M Series B.

Intel

All of Intel’s investments in healthcare startups have gone through its venture arm, Intel Capital. The corporate entity has made two acquisitions in healthcare, Basis Science (2014) and IDesia (2012). Basis Science develops heart rate and activity monitors, while IDesia offers security identification technology based on a person’s unique heartbeat. Intel has participated in numerous rounds to both CareCloud and Sotera Wireless. CareCloud is a provider of cloud-based medical record and billing software, while Sotera Wireless develops wireless devices for in-patient monitoring of blood pressure, heart rate, oxygen saturation, and other biometrics.

Others

Facebook, Amazon, Microsoft, Cisco, and Oracle have all demonstrated limited private market activity in healthcare since 2012. Below are listed a few deals with participation from these corporate entities.

• In 2014, Facebook acquired Finland-based Protogeo, a developer of fitness tracking apps.
• Microsoft has made two healthcare deals since 2012, one from the corporate entity into Advanced Dental Cloud,and one through Microsoft Ventures to Livongo Health. Advanced Dental Cloud makes software for modeling dental implants and Livongo Health combines coaching and connected devices to improve diabetes management.
• Oracle has made one acquisition and one equity investment into healthcare startups since 2012. It acquired clinical trial management software provider ClearTrial in 2012 and participated in Proteus Digital Health‘s $45M Series F in 2013. Proteus has raised on four other occasions since then, with no disclosed Oracle participation.
• Cisco has made no equity investments in healthcare companies since 2012. The one deal shown on the social graph above refers to a grant made to Teslon in January 2017.

According to CB Insights, funding this year has already reached over $1.5B spread across 18 deals. That’s already more dollars to the sector so far this year than in 2015. At the current run rate, 2017 is on track to reach $4B across 48 deals, a five-year high for tech corporates participating in deals involving healthcare startups. The historical and current participation of these companies in healthcare industry investments is summarized below.

Conclusions

Healthcare is increasingly being impacted and disrupted by digital health innovations. The digital health sector has moved beyond the first wave of simple wellness devices and applications to integrated solutions from companies that are beginning to have a deeper understanding of how technology can be used to make healthcare more effective and efficient. Consumer companies such as Fitbit, Apple, and Samsung are beginning to partner with major payers, providers, and pharmaceutical companies. As shown above, major technology companies are also investing large sums in the healthcare sector to augment their existing products and support new strategic initiatives.

Despite this shift, many experts agree that there are too many companies targeting the same narrow problems. Many digital health founders have come from the technology industry and try to solve a problem that they have personally encountered within the imperfect healthcare system, whether it is truly widespread or not. Others may have just graduated from college and have limited business exposure, let alone any healthcare experience, and don’t understand the relevant use cases very well.

The entrepreneurs who research and fully understand the complexities of this industry — including the relevant use cases, current workflows, the needs of providers and patients, and who will ultimately pay for these innovations — will be far more successful. Regardless of what digital health product or services startups offer, they will need to demonstrate a real value proposition and generate some evidence that outcomes are improved, revenues are increased, or costs are reduced or no one will pay for their solution or expend time and effort trying to integrate it within their existing health IT infrastructure.

Telemedicine Benchmark Survey Points to Increasing ROI and Improved Outcomes

Digital health updates are written by LoneArranger, an anonymous industry insider.

A recent survey conducted by Reach Health on the status of telemedicine initiatives at healthcare organizations identified that these programs are evolving from specialty offerings to mainstream services.

Survey participants represented a broad mix of healthcare organizations. More than half of the 436 respondents were from teaching hospitals or systems, with just over a quarter from non-teaching hospitals or systems and slightly over 10 percent from physician practices. Around a third (31 percent) of the organizations have revenues of $1 billion or greater, 21 percent have revenues between $50 million and $1 billion, with just under half (48 percent) at the low end of the scale with under $50M in revenues.

Patient-oriented objectives including improving patient outcomes, improving patient convenience, and increasing patient engagement and satisfaction were the most common objectives for telemedicine programs. Reducing the cost of care also ranked consistently high across objectives.

The overall priority of the telemedicine program at an organization, as ranked among other provider priorities, had a strong correlation with success. Telemedicine programs with a dedicated program coordinator or manager are also 20 percent more likely to be highly successful.

Reimbursement, both government and private, continues to create the most significant obstacles to success, accounting for the top four unaddressed challenges to telemedicine. Challenges related to EMR systems also create significant obstacles to success, accounting for three of the next four unaddressed challenges. Interoperability and integration issues continue to pose significant challenges.

Telemedicine platform features were rated by respondents based on their value to an organization. Three of the top six platform features were related to telemedicine data, including clinical documentation, ability to send documentation to/from the EMR, and ability to analyze consult data. All of these features were rated as critical or valuable by nearly 80 percent of respondents.

Over half of participants indicated their telemedicine platform was primarily purchased or licensed from a vendor. In general, larger organizations are more likely than smaller organizations to build systems internally. However, the survey results indicated that the mix of build vs.buy is highly consistent across the spectrum of organizational sizes.

Two-thirds of the survey participants indicated their telemedicine solution is a standalone system, and not integrated with their EMR system. Only 10 percent indicated their EMR system serves as their telemedicine system. This is beginning to change as vendors improve integration capabilities, but not rapidly.

Over the past three years that the survey has been conducted, there is a clear transition toward enterprise level programs instead of departmental initiatives. A key driver is improving ROI with several primary motivators, including improving patient satisfaction, keeping patients within the health system, securing reimbursement, enhancing the reputation of the organization, and increasing provider and staff productivity.

Activity has increased across the board and for all settings. However, active E-visit programs grew by 40 percent in 2017 and general practice initiatives also showed strong growth. Maturity levels of programs vary. Service lines requiring access to specialists, especially those in increasingly short supply, are maturing more rapidly than the more generalized service lines. Over 70 percent of the survey participants operate telemedicine programs within the boundaries of a single state.

Summary of ONC Interoperability in Action Day

Digital health updates are written by LoneArranger, an anonymous industry insider.

On Monday, March 20, the ONC held an Interoperability in Action session featuring a day of presentations from participants in a number of their innovation challenges as well as a few presentations by ONC staff. Many of the presentations covered applications that utilize FHIR resources to support discrete data exchange.

Patient Data Aggregator App Challenge

Two Patient Data Aggregator App Challenge winners were presented, including MyLinks (PatientLink Enterprises) and Green Circle Health. The MyLinks application uses cloud technology, FHIR, and secure messaging to help patients gather data, participate in research, access information Direct remotely, and engage with interactive tools.

Green Circle Health uses FHIR to power an integrated patient health data dashboard, allowing users to gather information from wearables and other Internet of Things Devices as well as schedule health reminders through a single interface.

Provider Experience Challenge

Two Provider User Experience Challenge winners also gave presentations, including Herald Health and a collaboration of Duke Health, Intermountain Healthcare, and University of Utah. The Herald Health application allows users to manage EHR alerts and alarms. The system offers the ability to create customizable push notifications that can be tailored to personalized preferences and the priorities of specific patient groups. It is currently live at Brigham and Women’s Hospital and will be implemented at Boston Children’s in the near future. The application uses SMART on FHIR integrations with Cerner and generates alerts based on rules driven by test results and other data.

The Duke Health / Intermountain / University of Utah collaboration has produced a clinical decision support tool for detecting and treating infants with jaundice. Their Bilirubin app is in production in the Epic system at the University of Utah and also available in the CareWeb EHR. They are updating it to the CDS Hooks specification in the future.

Move Health Data Forward Challenge

Five groups that  were selected as Phase 2 prototype winners presented during the Move Health Data Forward Challenge session. The focus of this initiative is to promote the development of solutions to authorize movement of data by patients. They included CedarBridge Group, EMR Direct, Docket, Live and Leave Well, and the Lush Group. The next phase is the test these solutions in “real life,” with submissions due by May 1 and two finalists to be selected by May 31.

CareApprove: Cedarbridge Group

A patient-mediated solution for sharing information between providers based on a Javascript platform and uses the IHE MHD profile and FHIR for clinical data exchange. Patients have a mobile app to review and approve each transaction, authorizing providers to exchange records between their EHRs. They can also limit the amount of information that is exchanged by category if desired.

EMR Direct: HealthToGo

This presentation highlighted that there are too many different portals for patients to access, resulting in “portalitis.” However, APIs and FHIR offer potential opportunities to solve this issue. Based on HEART profiles and UMA, it allows patients to authorize access to their records. It is also soon to be Direct secure messaging enabled.

Foxwall Wythe: Docket

This is an augmented patient intake application which includes a superset of patient intake templates that are questionnaire based and can be tailored to meet the needs of specific provider practices. It uses a “Boarding Pass” tool to load information on providers and includes appointment check-in capability and appointment cards, and generates reminders and alerts. Fitbit and other wearable data can be automatically linked via Bluetooth and the Apple Health app and providers can suppress information they don’t need.

Live and Leave Well

This tool provides access to trusted end-of-life medical documents when and where needed via secure access and sharing and includes a mobile app. Their focus is on people at end of life and also people who want to ensure access to appropriate care in the event of hospitalization. The tool includes the ability to create and share documents online and maintains a to-do list of pending actions and shows the status of the completeness of information. It leverages the HEART profile to connect providers and patients, provides personalized guides based on patient values, and allows providers to invite their patients to sign up. They are looking to partner with emergency medical providers and geriatric providers.

Lush Group: HealthyMePHR

This tool is based on FHIR and HEART standards and allows patients to access and share health data securely. It is focused on patient mediated information sharing where patients control all aspects of the process. Policies are created by the patient for each provider and they can limit timeframe when data is shared. Transactions leverage an authorization server using Google IDP but it can use other methods as the industry evolves. Data can be imported by patient from a FHIR enabled portal which enables patients to start using the app immediately.

Med List Project

During the afternoon, the program shifted to presentations addressing the Med List Project, with over 150 vendors, providers, and other organizations involved. The focus is on interoperable medication lists using FHIR-based APIs. Demos were conducted at the Connected Health Conference in December and at HIMSS in February.

MediSafe: This tool provides medications adherence reminders and notifications and also provides patient education. It has over 3.5 million registered users and is integrated with Google Fit.

CareEvolution: Offers a medication list summary and identifies therapeutic alternatives that may be less expensive. It reviews discount card opportunities for medications for cash payments and also looks at medications eligible for patient assistance payments.

MyFHR: An untethered version of the cFHR platform, which aggregates data from multiple sources. It is FHIR based and provides access to medication data and other information from other sources.

Cedars Sinai and Epic: An implementation at Cedars Sinai using Epic. There is an issue of FHIR resource maturity (production ready). Epic supports 16 resources with read capability. It will support write capability and CDS Hooks in the near future. A provider gave a demo of access to multiple sources of medication data and a presentation in a mobile app via interfaces with Epic MyChart.

Hackensack Medical Center: They have created an app using API-based tools built on Epic API framework and integrated with HealthKit. It uses biometric identification to access and share data with other providers. Using an API management layer, it allows integration with trusted vendors and partners using tokens. They demonstrated a method for exchanging medication data between different organizations.

Trinity Health: They have created a virtual pill box of medication reminders utilizing data from many EHRs across their organization including Cerner, Epic, Athena, Care Evolution, and NextGen. They maintain their own MyID Care consumer ID store and a data lake for patient-generated information and leverage Cerner mPages for providers. There is a mobile app for the patient with access to medications and other information.

NY Columbia Presbyterian: They have developed a medication reconciliation app based on the HL7 Argonaut FHIR specifications. They leveraged their CSC integration engine and the Allscripts EHR sandbox to enable the integration. The system is connected with other systems at Weill Cornell Medicine, which uses Epic. They are using the MyFHR app for consumer access and can present an integrated medication list across multiple facilities.

High-Impact Pilots

The next session covered the High-Impact Pilots which last for one year, with about six months left to go. The categories include:

• Comprehensive medication management
• Care coordination
• Lab results
• Self-identified topics

Four awards were given to:

• Health Collaborative: Patient-centered data home
• Lantana Consulting Group: pharmacist care plan
• RxRevu: prescription decision support
• Utah Health: closed loop surgical referrals

Health Collaborative: Their approach routes data between HIEs based on the patient home address. This Heartland Pilot includes seven HIEs in the Midwest. Safety, privacy and security, and interoperable exchange were the areas of focus. They are using IHE cross-gateway profiles and HL7 ADT and CDA standards and VPNs and web services for connectivity.

Lantana: They are working with Community Care of North Carolina and six pharmacy organizations on a pharmacy care plan use case based on the C-CDA on FHIR specification. They have created bi-directional transforms to convert between the HL7 CDA care plan and CDA on FHIR care plan formats. They will update to STU 3 when completed and the transforms for CDA on FHIR when updated. Their system can also convert to JSON format.

RxRevu: This presentation covered prescription decision support tools at Banner Health via a SMART on FHIR integration using their RxCheck platform. The focus is on consistent prescribing, optimized spend, and patent safety. Leveraging Cerner Ignite APIs and the Cerner Millennium EHR, they concentrate on Medicare Blue Advantage members at Banner Health to provide a medication reference with therapeutic alternatives and medication reconciliation and adherence tools. Clinical quality, cost efficiency, and interoperable exchange were the primary areas of focus.

Utah Health: This initiative involves closed loop surgical referrals based on a SMART on FHIR dashboard within the Epic EHR. It is also deployed at Intermountain using Cerner. It includes care coordination and closed loop referrals with a focus on clinical quality, cost efficiency, and practice efficiency. While developing the dashboard, they interviewed end users, including PCPs and surgeons, and conducted a usability session. Referral requests initiate the workflow, which includes a visual timeline of the status of activities related to the procedure and hospitalization. The tool also provides follow-up guidance to the PCP after the procedure. It is based on the FHIR US Core Encounter and Care Plan resources.

Standards Exploration Awards (SEA Program)

The next session covered winners in the SEA program including Arkansas SHARE, Cincinnati Children’s, and SysBioChem.

Arkansas SHARE: The State Health Alliance for Record Exchange is a statewide HIE in Arkansas. The focus of the program is on bi-directional integration of behavioral and physical health records. Using role-based access, it leverages XDS.b exchange standards and the HL7 C-CDA document standards. HISP secure messaging and a virtual health record portal are used by most behavioral health users across 10 hospitals and 133 clinics that lack integration capabilities. They are planning to survey providers after the pilot to evaluate outcomes and user experiences. Barriers included the cost of a Netsmart module to connect to SHARE, lack of IT knowledge, and concern about duplicated expenses.

Cincinnati Children’s CCHCP: The biomedical informatics department was challenged by case review forms for clinical trials, which are created manually now. Their focus was on cost efficient pre-population of eCRFs to reduce manual data entry. They retrieve the form for data capture (RFD) using FHIR web services to capture common data elements and populate the forms. This will ultimately be deployed to production, but they are expecting validation challenges with FHIR.

SysBioChem: The purpose of this initiative is to make family health history available to drive better risk predictions for clinical care. There is a problem with lack of standardization and a need to harmonize different approaches. The focus was on building a minimal viable product initially. They use an interoperable message based on FHIR resources across many data silos include lab, EHR, family health history, genomics, and others. MGH/Dana Farber and Intermountain Healthcare are involved in the project. They use the Hughes Risk Module Analytics Module and make a round trip to get a risk profile from the analytics module using FHIR and HL7 V3 conversion. They are building a harness to submit large data sets from IMH and hoping to consume 3,000 patient family histories during the project. They also identified the need to create a US realm profile for family health history Their architecture is housed in AWS.

Blockchain in Healthcare

The last session of the day covered the recent Blockchain in Healthcare code-a-thon event and presentations from the top performers. All of these applications were created in 24 hours or less.

Team TMI: Trust My Identity is an approach for provider identity credentialing based on Identity Management and APIs. Inaccurate information and limited sharing between institutions creates a lengthy and laborious credentialing process which is cumbersome with lots of duplication of effort. The technology is based on IPFS, Monax Blockchain, and BigChain DB (noSQL DB). The provider creates a profile and launches the process. A payer then certifies their network affiliation and board credentials reviewed and approved. In the future, they feel distributed provider directories should include blockchain since significant cost savings can be achieved.

Nucleus Health: Project Health Genesis involves identity management and medical record sharing for images. Cloud-based medical imaging systems are growing, which affords the opportunity to use an approach based on blockchain. They demonstrated a provider to patient sharing use case. ID Management is via Ethereum, authentication is done with digital signatures and they use Smart Contracts for authorizations. DICOM Web requests are made to a VNA and the patient can then retrieve and view images. The code is available on GitHub – Open source, and a complete Docker container system was built to support the test implementation.

Health Passport: This group won the ONC Blockchain code-a-thon with a patient-centered health record system involving patient identity verification and medical record sharing. Either MetaMask or uPort identity management can be used with a QR code used to access information and this approach can also integrate wearables data. Transactions currently take many seconds to complete with Ethereum taking 14 seconds to respond due to the distributed block confirmations required. The objective is to get it down to three seconds per block in the near future, but the speaker cautioned that the industry still needs to be cautious about the privacy aspects.

More information is available at:

www.healthit.gov/blockchain

Like the Rest of Healthcare IT, Limited Interoperability is a Big Challenge for Digital Health

Digital health updates are written by LoneArranger, an anonymous industry insider.

In the Connected Health Pavilion at the recent HIMSS17 conference and exhibition, several attendees commented during a Q&A session that “connected health doesn’t seem to be very well connected.” It is easy to understand why they may feel that way.

There has been a proliferation of individual consumer health apps over the past several years, though many of these could be classified as “fitness” vs. “health” apps. Although consumers are increasing their adoption of digital health tools according to a 2016 Rock Health report, they are not necessarily connected in any way to each other or to mainstream provider or payer HIT systems.

Tethered apps offered by healthcare providers and payers don’t always include data from other healthcare settings or insurers and often don’t accept wearables data. Therefore, most consumers (and their providers) cannot easily maintain a complete longitudinal health record.

Most major EHR vendors offer customers mobile apps that are extensions of their patient portals, but these are essentially closed systems. Although some vendors offer platforms to exchange data across their different customer sites, they do not generally include the ability to share data easily across different vendor platforms. The CommonWell and Carequality initiatives are starting to address this gap, but it will take time to expand their footprints.

Wearables are not growing as fast as anticipated and although younger consumers are adopting them in large numbers, older consumers are not, even though they might actually benefit more from doing so. In fact, only 10 percent of Baby Boomers own a wearable device.

According to the same Rock Health report, the majority of health tracking is done mentally, with 54 percent of people who track weight and 58 percent of people who track medications doing so in their heads. Of those tracking their health electronically, the most common metrics recorded using an app are physical activity (44 percent) and heart rate (31 percent), which are clearly more related to fitness and performance than diagnosed health conditions.

There are many innovative platforms and apps emerging that offer more comprehensive capabilities, but they are still often limited by the inability to exchange data with legacy systems and other digital apps. Although HL7 FHIR offers substantial promise for the future, there are few implementations that are currently operational in production environments and the normative standard is not yet finalized.

For providers, the data from external sources also need to fit into their workflow to be useful. This requires full semantic interoperability, or at least cross-mapping of common data elements, beyond just basic data exchange. In most cases, this requires customized integration and terminology services.

There are some glimmers of hope emerging in this market space, with a variety of middleware solutions for feeding patient device data to EHRs starting to gain traction, and increasing willingness by providers to accept external health data and share data with others. Remote patient monitoring seems to be gaining ground recently and is delivering real value to both patients and providers. The remote patient monitoring market grew considerably in the last year, with 7.1 million patients worldwide enrolled in some form of digital health program featuring connected medical devices as a core part of their care plan, according to recent research data.

These tools are generally prescribed or recommended by providers and connected to their EHRs and/or care management systems. However, their focus is primarily on patients with chronic conditions or those who are recovering from acute procedures. The clear benefit is keeping track of these patients and reducing hospital admissions and readmissions while allowing patients to remain at home or in a community rehab setting.

In the long run, digital health applications have tremendous potential for adding value and improving care, but they must first overcome similar interoperability hurdles as those faced by the rest of the HIT industry. They must also become more tightly integrated with clinical and financial systems and associated workflows and offer a more nearly seamless user experience to both patients and providers. The future of digital health is looking brighter, but the open question is how long it will take to get to the tipping point where these tools are fully integrated with mainstream healthcare infrastructure.