HL7 Standards » HL7 Blog

January-28-2015

15:30

Topol_bookEvery once in a while, a book hits upon a convergence of science, technology and society in ways the existing incumbents are not at all ready to hear. To them, it might sound like someone describing a dream. Marshall McLuhan’s work in the 60s on media and culture come to mind and technology, as do business, and innovation authors such as Kevin Kellyl and Clay Shirky. These are the writers who seem to be more than 80% right if you allow a few years for the trends to play out. Their forward-thinking ideas eventually play a large part in changing the mindset of the incumbents. I see Eric Topol’s latest book, “The Patient Will See You Now: The Future of Medicine is in Your Hands” as firmly planted in this group of trend-spotters. It can’t be fully appreciated in the present.

Our “health care future is here, but it’s not evenly distributed,” as author William Gibson may have said.

From the perspective of current health care practitioners, the future that’s happening now looks like a distant planet, light years away. As evidence from some of the predictable early reviews of the book perhaps nowhere is the future less evenly distributed than health care. Physicians (and likely a lot of health technology vendors) don’t see or recognize many of the changes taking place. In health care, after all, there’s an often-cited 17-year adoption rate of new innovation.

If this were under normal circumstances it still may take a while to get dramatic industry-wide change, but this is not internal change. Change is coming from outside, from patients and digital innovators. At a time when big tech innovators like Google are investing in outer space, this kind of innovation seems overdue for health care.

The connectivity and democratization of health information – the prerequisites for Topol’s health care future – has already started. With this new information, patients and caregivers are, at the same time, driving significant improvements in care and care delivery as the medical establishment. Consumers don’t need 17 years to adopt new tools and to develop new solutions when they are both the developers and adopters. Topol cites several examples of people taking their data and their technology into their own hands, from the 3D-printing tumors of to help their physicians gain a better view, to Angelina Jolie’s very public BRCA saga and taking preventative actions in consultation with her physician.

The disruption Topol sees for health care is not unlike the disruption MacLuhan saw for media, and Topol leans appropriately on McLuhan’s work early on to set the tone for the remainder of the book. Tech innovation will change the fabric of medicine and society’s relationship to their health care in the same way it changed our relationship to media.

Topol’s latest is a must-read for anyone interested in the future of health care and what risks and opportunities are on the horizon. There are fundamental trends that will make this happen, although it’s admittedly hard to predict when it will occur. This is perhaps the first and best book to date about the dramatic social changes technology is driving in health care. The technologies are changing traditional relationship dynamics between various stakeholders in health care. We are entering the age of “Do It Yourself” health care, smart phone care, retail care and cloud-based care. These changes are as disruptive to medicine as eCommerce and MegaStores have been to retail.

If you have an interest in the technological, social, science and business futures of health care, go read #TPWSYN with an open mind and think about how value will be generated in this new world and our privacy and our ability to live freely can be protected while managing more and more of our own health. Putting these tools to use could save your life or the life of someone you love.

8 Key Takeaways

1. Medical costs are largely about location, time and people. Intelligent networks will allow place, time and people to become more distributed.

Tech will change how and where medical intelligence will live. It will become distributed in the cloud, within connected communities, and at our fingertips in evolving ecosystems of smart phones and sensors (IoMT or Internet of Medical Things, as Topol calls them). These networks will able to access and apply the knowledge in the world and at the bedside. Kevin Kelly is calling the act of putting intelligence into things “to cognify.” We’ll see much of our world become distributed and “medically cognified” in the years to come.

2. Democratization of medicine means the end to paternalism.

Democratization of health data, health information, and sensors means the democratization of care and an end to much medical paternalism, which has largely existed because of knowledge asymmetries. With the end of these asymmetries, the relationship will undergo a change from patient as kind of object to patient as COO. As Topol notes, just as the Gutenberg’s printing press upended many institutions of the time, so too will the spread of medical knowledge upend many current institutions.

3. Democratization will lead to more Peer-to-Peer (P2P) medicine.

Networks can connect people and devices in ways that make the whole smarter than the sum of it’s parts. Patients can connect to patients who have shared problems and can share solutions, such as with the FLHCC community Topol describes that worked with researchers to find the cause of this rare cancer. People can connect images to 3D printers and monitor their ECG from across the globe. These networks of P2Ps of many varieties will continue to shake up the medical community and find solutions to difficult problems, solutions that would otherwise be expensive, rare or underfunded.

4. Because of the democratization of medical knowledge, innovation will come from all sorts of new places.

People with medical problems have the time, the resources and the incentives that the medical establishment doesn’t have. Jack Andraka is now famous ag a 16 year-old high school student that came up with a novel approach to detecting pancreatic cancer. Kim Goodsell and others are were able to diagnose complex medical conditions that their physicians could never have time to figure out. The surplus of open knowledge and information (including big data and open access) will soon combine to allow innovation to spring from new places. In fact, it already has.

5. The open health movement, patient-centered care, and value-based payments are inextricably linked.

Topol devotes an entire chapter in the book to the open movement. At the core of the issue is a whole new group of people, patients and caregivers, need to have access to information – code, data, research and more – to make the best decisions. Better decisions by all players will make value-based payments successful. As I write this, Bill Clinton just committed to “open source health care” and the White House has issued new goals and guidelines around value-based payments in Medicare. Want to accelerate better decisions and success under these new paradigms? Open more access to more information resources.

6. Medical education is near-turmoil.

Medical education and knowledge will also be democratized and upended. Massively Open Online Medical Education, MOOM, as Topol calls it, may be the answer, but medical education is in turmoil. There are few digital health courses or care delivery courses in medical schools in the United States. If physicians are to continue to stay relevant, they’ll need to become as adept with these tools, and in delivering care through them, as their patients soon will be.

7. Patients may ultimately be better at understanding risks than many physicians.

In a world where, as Topol notes, nearly everyone with elevated cholesterol gets Lipitor, and mammograms find 100x more false positives than tumors, we may need a reboot of our understanding of costs and risks. The ones bearing the risks and the costs may want to have a larger voice. It’s all too easy, even with good intentions, for physicians to say, “do more,” because the risks for physicians is almost always doing too little. For the patients, doing less may be a much lower risk option, and with more data and more democratization, we may get a better handle on those risks.

8. There are risks, of course.

Just as we have networks like Google and Facebook that are virtual monopoly on our online selves, we face the same risks in our health future where identity and computing power could be controlled by a small few. We’ll have to be vigilant to keep the whole system open and balanced with privacy and security for all.

All the right notes, but…

Overall, Topol hits on all the right notes. Just when I thought, “we need to bring social media into this conversation” or “we need to bring the open movement, or costs or security into this conversation,” I would inevitably find a passage or even a chapter on the topic and a great discussion on the next subject. “‘The Patient Will See You Now: The Future of Medicine is in Your Hands” is an extremely satisfying read, offering a phenomenal tour of possibilities.

If there a few things to add to the conversation, I’ll add two.

First, more on how user-experience-driven technology design (not just the design of facilities) will play a role in providing solutions people can actually use to their greatest benefit. These new tools won’t work for everyone. We’ll need technology designers to find solutions to displace bricks and mortar health care, including some stepping stones. Who can help those that can’t help themselves with new tools? Care coordinators, social networks, nurses? I am as convinced as Topol, but we need to recognize that self-care or P2P care won’t work for everyone right away. For others, due to price and geography, these new tools may be the only options.

Second, How policy might accelerate some of these changes? Topol touches on how existing players can adapt in the last chapter, but not much on how we can help deliver this better world. I suspect Dr. Topol sees the changes he describes as inevitable because of basic economics (we’ll get more, better outcomes for less). Still, security and privacy (which Topol discusses, but there are no easy solutions here) may be roadblocks. Also, there are many perverse incentives and difficult design challenges along the way that will keep us from getting to high-quality tech-enabled care at a reasonable price. In fact, the “Obamacare 2.0” as Vox recently put it, is a proposal to accelerate pay-for-quality reimbursements may be part of the solutions.

Still, this is not that kind of book. It’s not a design or policy book. It’s about potential, a catalytic substrate for what will happen very soon as patients become central to health care and the democratization of health data comes to fruition. As Topol points out at the end, each of us could have a role toward tipping medicine toward a much brighter future. Let’s each do our part to make it a better health care world.

January-27-2015

15:11
Allow Don't Allow

How will my “Personal Information” be used?

One of the most annoying emails in my inbox is from a digital address app. Emails come from people I do not know asking me, via the app, to “update my contact information”.

Let’s take a look at the app’s privacy policy. It says, “We may choose to buy or sell assets. In these types of transactions, customer information is typically one of the business assets that is transferred. Also, if we are acquired, or if we go out of business, enter bankruptcy, or go through some other change of control, Personal Information would be one of the assets transferred to or acquired by a third party.” (Emphasis mine.)

This clearly states that “Personal Information” can be given or sold to a third party, but emails from the app tout that information is private. I never directly shared my email information with the sender, although there are numerous ways the sender or the app may have gotten my email. But I do not have a relationship with the sender or the app.

Without a relationship, there can be no trust.

The Issue: We Need a Trust Revolution

At the 2015 World Economic Forum Annual Meeting in Davos, a session in the Future of the Internet track was, “In Tech We Trust”.

“The digital revolution needs a trust revolution. Huge shifts are occurring as the world moves towards comprehensive information sharing via social media, cloud computing and big data. Systems of record (such as email) have become systems of engagement (such as social media) and are now moving towards systems of intelligence (data analytics). However, this progress cannot occur unless customers trust how their data is used. The challenge: more than 90% of consumers feel they have lost control of their data.”

Recent Privacy Concerns in Healthcare

Before I write a post for HL7standards.com, I generally have read and collected quite a few articles on a particular topic. My “Consent of the User” list was overflowing. I am going to limit this post to three timely concerns in healthcare: Healthcare.gov, “matchbacks”, and 23andMe.

Healthcare.gov

In case you missed it, Healthcare.gov was saving personal health data in referrer URLs from people using the system. This personal health data was also being shared with “third parties”, at least 14, according to the Electronic Freedom Foundation:

EFF researchers have independently confirmed that healthcare.gov is sending personal health information to at least 14 third party domains, even if the user has enabled Do Not Track. The information is sent via the referrer header, which contains the URL of the page requesting a third party resource. The referrer header is an essential part of the HTTP protocol, and is sent for every request that is made on the web. The referrer header lets the requested resource know what URL the request came from. This would for example let a website know who else was linking to their pages. In this case however the referrer URL contains personal health information.

According to MEDCITYNews, “At first, the administration defended the current standing of privacy standards, but advocates and lawmakers became very vocal and demanded changes.”

Matchbacks

Matchbacks

 

According to Bloomberg News, “matchbacks” are a little known process of assigning patients unique codes based on their prescription drug records. Marketers can then send tailored Web ads to patients.  Federal regulators were not aware of this practice when contacted by Bloomberg News. It may be legal, but many do not consider it ethical. According to Bloomberg, matchbacks were also not addressed in privacy policies.

De-Identified, Anonymous and Confidential Have Different Meanings

Just because data are de-identified, that does not mean anonymous. Most people do not realize that de-identified, anonymous, and confidential all have different meanings, especially when it comes to research, which brings us to 23andMe.

23andMe

What could be more personal than your DNA? One of the most confusing and ever-changing privacy policies is 23andMe.  The company recently announced tens of millions of dollars in deals with pharmaceutical companies for research. In Medium, Dr. Eric Topol asks, “Who Should Have Access to your DNA?”  He says that critics are now questioning whether customers really understood what they were consenting to at the time of their saliva data collection, “We are moving into the big data-per individual era (with your very own ‘Google’ medical map), and we have not yet established any model for the rightful ownership of all this information.”

Opt-In vs. Opt-Out

Vendors and apps often say that you can always opt-out. However, most people prefer a choice to opt-in. If technology wants to build trust, opt-in will need to be the model.

opt-in-out-privacy-poll

A Set of Universal Principles for Data Protection

At the WEF Annual Meeting, a set of universal data protection principles was called for.

  • First, “consent” must always be requested and granted.
  • Second, how personal data is used must be fully “transparent.”
  • Third, heightened “accountability” must accompany higher levels of data access.

Is the Enterprise Cloud a  Model for the Consumer Cloud?

Marc Benioff of Salesforce believes the enterprise cloud should be a model for the consumer cloud. Healthcare is said to be Salesforce’s next billion dollar initiative. Here’s what Marc shared at WEF in Davos:
“We all have to step up to another level of transparency, especially the vendors. So whether you are an enterprise vendor or a consumer vendor, we all need to open up a lot more to be able to say exactly where is the data, what’s going on with the data, who has the data, and if there’s a problem with the data – a security problem or some other issue with the data – immediate disclosure, complete and total transparency. No secrets. Because only through that transparency are we going to get to a higher level of trust. That is not where we are today.
“We’re the enterprise cloud. Our customers are the GEs, the Philips, the BMWs, it’s their data. We can’t do anything without our customers saying what we can do. It’s their data. They tell where they want it, how they want to use it, what applications are using it. We can’t see it, the data is black to us, it’s encrypted. But that very much is a model from where the consumer companies are going to have to go. Enterprise companies can’t do anything without their customers saying it’s okay. That’s our agreement with our customers that we sign with them. In the consumer world, you don’t know what’s going on, and that is going to have to change. Total disclosure is critical.”

Trade-Offs

Marissa Mayer was also part of the WEF panel. (Yahoo’s privacy policy was criticized by Bloomberg News regarding matchups in the above-mentioned story.) Here’s what she had to say from Davos:
Trust is about weighing trade-offs – how much privacy do I have, how secure do I feel – what are the benefits I get, in exchange for that? You need to afford the individual trace and control. The user’s own their data. They should be able to examine it, take it with them, bring it to other sites, bring it to other vendors that they trust more. Basically, have a system and a market that helps people make these trade-offs and these decisions. But they should have control over how they use the system, or whether they use the system at all. People have trouble making some of these trade-offs because the vendors are not being transparent enough, not providing enough controls and choice.”

Beneficent Apps

Tim Berners-Lee said that at MIT they are working on a new architecture for how we store data, and proposed “Beneficent Apps.”

Is what I am doing beneficent? Basically, is it good for users? Suppose we have a brand, this is a beneficent app, that means while I am writing the app, you are going to pay me for the app, and I am going to think about what you want. That’s the business model we are going to see.

Terms of Service, Privacy Policies

The moderator of the WEF panel, Nick Gowing, said the that Terms and Conditions are not the small print, “Terms and Conditions, No, that’s the Big Print.”

Terms of service and privacy policies may not identify what third parties can do with data. So even if you trust an app or service, you may not know what a third party can do with your data. This will become increasing important with the growth in consumer health data that is not necessarily patient data. In a world of convergence, the Internet of Things, wearable technologies and integrated health app platforms, we need to build with consent of the user.

Consent means, we won’t use your data for any other purpose, unless you approve it.

January-22-2015

11:01

In a recent blog, the opinions of the JASON Report Part II with regards to CDA were analyzed. The review of CDA was lukewarm at best. However, the report did spend a significant amount of time talking about future possibilities. The main focus of the future possibilities was HL7 FHIR.

FHIR was discussed extensively in the report because JASON thought it lends itself well to the health IT vision which was stated as:

Focus on the health of individuals rather than the care of individuals.

Key to this vision is the establishment of a robust health data infrastructure that could also be used to enable a Learning Health System. But one major impediment that remains is the critical need for open APIs for EHR connectivity and to stimulate entrepreneurial ideas. One solution to this impediment is seen as the FHIR standard, which JASON sees as a “significant improvement over CDA.”

The JASON report describes CDA as a container for information. The problem with the container is that it is hard to sort out all the data in the container into usable chunks. FHIR solves this by organizing the data into smaller usable chunks called resources. These resources standardize the exchange of information as modular components.

Resources contain basic pieces of information and can be extended to fulfill specialized requirements. Resources can also be bundled together to satisfy the same messaging and document workflows that the health IT industry uses today. In a previous post, I detailed the interoperability paradigms of FHIR, including REST, messaging, documents, and services.  Examples of resources include Patient, Medication, and CarePlan to name a few. Like CDA, each resource has a human readable element as well as coded entries.

Because these resources are simple in structure and clearly defined, they are viewed as something that is easy to parse and extract the data. Not to mention, it is always possible to extract the human readable portion. The resources, which can be encoded in XML or JSON (not to be confused with JASON – the organization writing the report), are lightweight and easily adaptable to web applications which is something that has not existed in health IT to this point.

According to the report, of even greater importance than the lightweight and clearly defined resources is the ability to support representation state transfer (REST). There are several design features listed in the report which give evidence to REST being such a good choice:

  • Separation of concerns about the storage of data and the interface to the data
  • The communication is essentially stateless between requests
  • Load balancing can easily be employed on the server side
  • Client caching can be enabled for efficiency
  • Servers can send code to clients to extend functionality
  • Applications present a uniform interface, with four guiding principles:
    • Resources are identified via URLs
    • Clients, with permission, can modify the resources on the server
    • Messages are self-descriptive
    • Transitions of the data are performed using hyperlinks

With REST in place as a paradigm for interoperability, along with the simple modular structure of resources, JASON believes that FHIR sets the stage for a major shift in the way healthcare data is exchanged, and make data more readily available when and where it is needed to support the future vision of healthcare.

January-21-2015

11:23

This is part II of my interview with Proteus Duxbury, CTO of the Colorado Health Insurance Marketplace, Connect for Health Colorado . I also encourage  you to read Part I.

As Colorado runs its own exchange, and has had what most consider a successful rollout, we’ll discuss what is next and how the exchange works to improve the long-term health of the people of Colorado. In this chat we discuss choice architectures and how to build an exchange that is really, truly consumer-centric – a great vision for health in any state, and I’m glad to see it emerging here in Colorado.

LK: Have you looked into behavioral economics and what are called choice architectures like what they describe in Nudge? Nudge has a pretty long section on creating a framework for effective decisions based on the goals of the user.

PD: Absolutely. Our marketplace solution is a good traditional transactional system, but it’s not been designed as a true engagement platform, utilizing choice/behavioral best practices, so we’ll likely need to append our architecture with some niche solutions. These could come from the startup community and non-traditional sources of innovation in the local community, and that’s very exciting.

LK: You and I have talked the opportunity for the exchange to be more of a platform, presumably with APIs that would allow outside developers to come in and build new solutions and applications using data supplied via the API combined with other outside sources. What can you share with us about that?

PD: We are implementing an API into various parts of our marketplace, hopefully in the next year or so.

Digital engagement is very important to us. We are going to move forward with a hackathon so that we can engage the local digital health community to bring innovative new ideas that could be leveraged in the long term to create an engaging, transparent experience. As CTO however, there is a balance between being innovative and having an enterprise scalable architecture. Anything that we put into production has to be robust, it has to scale well. We have recently engaged with a startup, CodeBaby, who are based here in Colorado Springs. They helped us go live today with Kyla our avatar who helps people navigate our website. For now this is limited, but we hope to integrate this further into our key, core portal marketplace screens and into our streamlined eligibility application.

LK: That’s great to see, and I can’t wait to see what comes next. I think that this kind of opportunity will be very exciting for entrepreneurs because health care is something that literally everyone has a stake, and it’s great to have these kinds of opportunities in Colorado to get more people involved in improving it, with code.

PD: Denver is a really exciting place to be in the development of new health technologies and new innovations given the work that Mike Biselli is doing (creating Stride, an emerging digital health campus with some big soon-to-be-named digital health tenants) to establish Denver as a hub.

LK: Yes, the Prime Health Collaborative and Stride and Health 2.0 Denver do seem to have started something special in the community here. It seems like a great fit because people do come here to be active, and the active, consumer-centricity has started to show with the startups that have formed here. It’s a great confluence of forces around digital health and consumer-focused solutions.

So let’s talk a little about what makes this environment unique and how we’re going to sustain it. Connect for Health Colorado is a non-profit that will need to be self-sustaining. What are the opportunities for extending the business model?

PD: We do need to be self-sustaining in January of 2015 and we do have a plan to do so based on a broad market assessment and our carrier-fee billing for plans that we offer on the marketplace.  In the future however there may also be opportunities for monetizing our (anonymized) information assets and our technologies thereby funneling additional resources back into the exchange to support our ongoing vision and mission. Perhaps to other, newer exchanges.

LK: What improvements are you going looking to roll out in the near future?

PD: In addition to what we’ve already discussed, a key focus area for us will be the utilization of user preferences to identify the important decision-making criteria for individuals.

We’re also putting in an out-of-pocket calculator so people can understand what kind of plan they should choose given their predicted healthcare expenditures for the year.

We do have a provider search tool, so people can see which providers are in-network for individual plans. However there are opportunities to make these searches broader and more inclusive, with real-time information on which providers are taking new patients and the exact services they are providing. For example so someone could find a child ABA (Applied Behavioral Analysis) provider in Denver that also has current openings within their practice. That’s just not possible using the provider search tools in use.

We have recently gone live with a formulary tool to help people find out which medications are covered by individual plans. In the future I would like to see the development of richer decision-support tools around formulary, linking in efficacy and safety information for particular drugs, given the genetic pre-disposition of the individual. Quality ratings for plans, carriers and providers are also areas that exchanges are looking to move into in the future. Amazon-like consumer-driven payer/provider ratings. The ACA has driven a number of initiatives to introduce more transparency in the marketplace. We’ve discussed a little about the All Payer Claims Database, or APCD, here in Colorado, which was driven by the ACA. Transparency and quality metrics is an area (CMS) will be providing guidance on in 2016. The establishment of the health insurance exchanges themselves is, in and of itself, a broad move toward applying more transparency to the marketplace by creating a common benefit package for qualified health plans. So, it’s easier for the consumer to compare plans like they are comparing apples to apples. CMS and ACA are playing a large role in helping to make the healthcare marketplace more transparent.

LK: Despite the hype to the contrary, it really is a free-market approach, and for the free market to work, you need transparency. If we want to fix health care, we need to make all of it more transparent and that creates a lot of opportunity for health IT that can facilitate that transparency.

PD: Reflecting on the success of PatientsLikeMe, that builds communities of patients to share information. There’s no reason we couldn’t explore providing similar communities for people in Colorado.

LK: So more of building a community and helping people connect with others in the state? That sounds great.

PD: In parallel the development of storefronts for the provision of direct to provider services including Telehealth and concierge medicine seem like a natural future evolution for exchanges.

LK: Seems like there are a lot of niches that could be provided and make this more of a communications system between patients, providers, payers and between many different stakeholders in the system, as well as a face to the health care system in Colorado.

One other thing I wanted to ask about is, have you received any interesting demographic trends about who is signing up for insurance on the exchange?

PD: Some interesting facts from our last open enrollment period (2013-14) was that 38% were in 0-34 age range. 35% were in the 35-54 age range. More than 73% of our consumers were under 55. Only about 26% were in the 55-64 age range. The other surprising thing was that 40% of those who enrolled received no financial assistance (tax credits or cost sharing reductions) indicating that people are choosing us as a trusted place to shop for their insurance.

LK: I see a lot of entrepreneurs have been getting their insurance through the exchange, so we’ll look forward to seeing how having this kind of access has improved the labor market, as people no longer need to be tied to a traditional job to qualify for affordable insurance.

PD: And, of course, the other big benefit is that people with pre-existing conditions can no longer be discriminated against, and a lot of people have come to us for that reason.

LK: Well thanks for the interview and all the great work that you’ve done. We are fortunate to live in a pretty progressive state in terms of health care and have some really great people working to improve things in Colorado.

Read Part 1 of this Q&A.

January-20-2015

9:16

I had the opportunity to chat with Proteus Duxbury, the CTO of our Connect for Health Colorado (the Colorado health insurance marketplace) just after the start of open enrollment this year (a very busy time for CTOs of state health insurance exchanges). We are headed for a very exciting time here in Colorado. A lot of innovation will be headed our way around health, wealth and wellness in Colorado, and a central part of that is the Colorado health insurance marketplace. We are fortunate to have some great minds working to come up with new solutions and applying appropriate technologies to payment reform and populations health.

LK: Proteus, tell us a little bit about your background and how you came to be CTO of Connect for Health Colorado.

PD: I was a consultant for an international management consulting firm PA Consulting, operating across a broad spectrum of areas including IT strategy, program management, and enterprise architecture. Primarily for healthcare clients. Over that time, I worked for large payer, provider and life science organizations so had the opportunity to gain a holistic view across the industry of some of the important health care emerging trends and how they can be supported by new technology.

LK: It sounds like you have a good background then to see, and potentially bring together, a lot of different data types into this more holistic view and create a pretty different perspective of the health care industry.

PD: Yes, for example, I’ve helped small regional hospitals implement EHR, and worked with the largest pharmaceutical company in the world to integrate a new clinical/real-world data hub. So I’ve been exposed across the entire end-to-end spectrum.

LK: And you were also at Catholic Health Initiatives (CHI), headquartered here in Denver.

PD: I was director of IT for their virtual health services group, owning all technology for a division within CHI, which was promoting the use of telehealth, telepharmacy and telepsychiatry to provide care remotely, in rural areas, and developing new ways to engage consumers in actively managing their health. To help keep them out of the ER and reduce readmissions. That gave me an in-depth appreciation of consumer health care needs. I started this new role here at Connect for Health Colorado in January where I am heading up all technology initiatives. I’m responsible for providing a stable and robust platform for people to enroll and engage with us, reduce technology spend for our sustainability goals and protect the security or our data and technology assets.

LK: It strikes me that you have a really great background then in consumer-focused care, do you see your role with the Colorado Exchange as an extension of that? Certainly it’s a consumer-focused site, but how do you see this extending further into the healthcare value chain and providing better value care, better outcomes at lower cost?

PD: I think the health care provider has a central role of ownership around the introduction of new digital platforms for engagement. But I’m beginning to think that with the introduction of the health insurance exchanges, Connect for Health Colorado is starting to have a bigger role in developing relationships with a large set of consumers that have not had health insurance before or those who need extra help in navigating this complex market. These are quite often high-risk populations and consumers that we can really help to shepherd through the complex health care decisions they have to make on a daily basis. That includes selecting the right plan, helping to manage their health care and ensuring they are not surprised with unplanned high co-pays and deductibles. So, yes, I think it’s a natural progression for an entity like the exchange to be a trusted healthcare partner and be more involved in digital engagement.

LK: So let’s talk a bit about establishing that trust. Colorado has been ranked as one of the top rollouts of the state exchanges. All-in-all, things went pretty smoothly here and now you’ve just gone into open enrollment. What’s the secret to the success here?

PD: It’s a lot of things really: leadership, a solid technology product, and a hard-working set of partners. The exchange really had an excellent leader in (former Connect for Health Colorado CEO) Patty Fontneau. She and her management team were empowered to be agile and make decisions quickly. They were really successful in creating a vision and uniting a small team of highly-focused experts to get this deployed very quickly. Also, very early on there was a decision made to invest in a packaged solution called hCentive that turned out to be a very robust platform that we were able to implement in just 15 months. We also had a great partner in CGI who were very flexible in meeting our needs and working as a collaborative partner, pulling out all the stops to deliver at 110% in order for us to go live on time.

LK: And how many different plans are available on the exchange right now, I recall it’s over 100.

PD: Yes, there are 176 plans available right now.

LK: Through how many different insurers?

PD: 15

LK: So that’s a lot of complexity, integrating with a wide variety of information sources. Did those come prepackaged at all or how did that all come together?

PD: That’s the work that CGI did, they took the hCentive platform and used middleware to integrate it with our best of breed systems including CRM, financial management, noticing and external partners, like OIT, Healthcare policy and the division of insurance. None of this was 100% prepackaged and it took great collaboration with CGI to build out this architecture.

LK: Let’s talk about CRM as a basis for this kind of platform, do you see this kind of CRM becoming the basis for a communication management system between people and their care?

PD: We use a packaged Oracle CRM system that’s in the cloud and it’s pretty rich, but it’s very transactional. In order to really outreach and engage with consumers, particularly with Millennial consumers, who will comprise more than 50% of the market in the next 10 years, we need to look to innovative digital tools that we won’t get from a traditional CRM solution. For example the new mobile app tool that Deloitte has built for HCPF. It’s not just for displaying static information, but is exposing key interactive functionality from their benefits management system and makes it available in a really intuitive way. As an initial step, we’ll want to look at providing that kind of access.

LK: So it really will be more like a platform for innovation and outreach?

PD: Yes.

LK: You and I are participated in a panel recently on “Transparent Consumer Markets in Health Care” at the Colorado Capital Conference. Of course, that’s one of the driver’s for exchanges, to promote transparency, but long term, how do you see the role of the exchange in making healthcare more transparent and help people plan and make better decisions around health care?

PD: As an exchange, transparency is built into our mission and vision statement. Part of our mission is to increase affordability and choice. Our core purpose is to help people be healthier and secure, including financial security.

Transparency for us is critical and needed if you’re going to have true engagement because our consumers often make suboptimal choices when selecting plans. People tend to take shortcuts, or they’ll assume the one at the top of the list is the right one or assume the Gold one is the right one for them. We have a need to educate users very quickly and help them make trade-offs. Choice and information overload does happen very quickly, in about 10 seconds in newly-introduced choice dimensions. We need to provide transparent information about plans, carriers and the providers that are within those plans and cost and quality.

The cost dimension is critical because what a lot of newly-insured people don’t understand, and even what people who have had insurance their whole lives don’t always understand is all of the hidden costs. We know that these hidden costs are increasing dramatically. I referenced the Deloitte study of $672 billion dollars in hidden costs that are in the market. So, as much transparency as we can provide to help people make good decisions, it enables them to make the right health decisions, and financially they’ll be better off if they select the right plan, that has the right balance between out of pocket costs, deductibles, and premiums. And they can only make those decisions effectively if they have the right information on what it’s really going to cost them. That’s why we’re looking to partners like The Center for Improving Health Value, or CIVHC, and the all-payer claims database here in Colorado.

The next challenge will be how we implement the quality information and provider, carrier and plan consumer ratings to provide something that is not overly complex. The more transparency and tools you provide, the quickly it can become complex visually and people can get overloaded, so we need to find the best way to do that, but also provide as much information as possible.

And one final point, we’re doing this because the insurance marketplace is definitely changing with the prevalence of HSAs coming with high deductibles, and companies moving from defined benefit to defined contribution. More than ever before, consumers are having to make their own healthcare benefit decisions, and so what we do is going to affect not just their health, but their finances as well. Those are two core parts of our mission, and I think we’re in a good place to help people navigate those decisions because we are motivated only by our mission. We’re not financially motivated. I think that’s unique and powerful in addition to our unique focus on people who live in Colorado.

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Stay tuned for Part II of my Interview with with Proteus Duxbury, CTO of the Colorado Health Insurance Exchange, Connect for Health Colorado.

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