Why Shouldn’t Dr. Halamka Be Optimistic? And Why Shouldn’t We All Be? Further Thoughts on HIMSS16

Oct. 4, 2016
Reflecting on Dr. John Halamka’s blog summarizing his perspectives around HIMSS16, it’s impossible not to endorse his core, gritty, realistic optimism about the future of healthcare and healthcare IT

It was fascinating to come across the blog of John Halamka, M.D., on Wednesday last week, as I was dashing through the Sands Expo Center in Las Vegas. Indeed, just the day before, I had run into Dr. Halamka in the crowded corridors of the convention center, and had a good chat with him about things. I had run into him just before he and Jonathan Bush, the founder and CEO of athenahealth, were to do their co-presentation, sharing their perspectives on data-sharing and other topics.

So when I came across Dr. Halamka’s Wednesday-written blog, entitled “Dispatch from HIMSS,” I was deeply intrigued. And his blog did not disappoint. I would encourage readers to go directly to the blog and read it in its entirety, but a few comments particularly stood out for me.

Surveying this year’s conference and its “buzz,” Dr. Halamka wrote, “In the recent past, big data, interoperability, personalized medicine, population health, and wearables were buzzwords in every booth. This year, the buzzwords were replaced by one overarching concept—providers and vendors must innovate or die.” He cited the advent of the MIPS (Merit-based Incentive Payment System) system, being ushered in by last year’s MACRA (Medicare Access and CHIP Reauthorization Act of 2015) legislation, noting that, in his view, “We will no longer be driven by compliance imperatives (Meaningful Use, HIPAA, Affordable Care Act, and ICD10), but instead will need to improve outcomes in order to survive financially.   No one is completely sure how to do that, but there are enablers.” And he cited several phenomena that he believes will help U.S. healthcare leaders forward, including the Surescripts National Record Locator Service, the CommonWell Health Alliance, DirectTrust, FHIR-based application program interfaces (APIs), and “agile,” cloud-hosted services.

Most pointedly, Dr. Halamka noted that “Providers will be responsible for the care that their patients receive throughout the community—inpatient, outpatient, urgent care, post-acute care and home care all contribute to total medical expense and wellness.  Some of the care may be delivered by people and organizations outside the control of primary care givers.  The only way they can succeed is by aggregating data from payers, providers, and patients/families in an attempt to provide ‘care traffic control.’” And, he noted, “Doing this requires tools for team-based care and communications, functions that may not be provided by the core EHR vendor.   Instead, an ecosystem of apps, services, and connectivity will surround the EHR to enhance usability and workflow.”

No one will disagree that any of these will be challenges; indeed, there is universal agreement that in some ways, CIOs and other healthcare IT leaders are challenged as never before in U.S. healthcare. But here’s the thing: Dr. Halamka ended all this on an upbeat note. As he emphasized, “In the View from the Top keynote I did with Jonathan Bush (the yin to my yang) we left the audience with a call to action. It is possible today to connect the healthcare ecosystem using the enablers listed above,” he said. “We do not need to wait for the perfect standard or the next round of prescriptive regulations. It’s happening now and companies that are early movers in telehealth, connectivity, and care management will out-compete the laggards.” And his very last paragraph was this: “I left HIMSS this year with great optimism.  Vendors, technologies, and incentives are aligned for positive change. 2016 will be a great year.”

I have to say, reading this blog was very validating for me. I also left HIMSS feeling optimism, of rather a similar sort to the kind that Dr. Halamka felt.

To begin with, after 25 HIMSS Conferences, I’ve never seen a more focused, aligned, determined group of industry leaders. There is huge contrast in comparing HIMSS16 to HIMSS Conferences in the mid-1990s, for example. Back then, there was no clear consensus on where healthcare was going, along the dimensions of policy, business evolution, or technology development. As a result, looking back now, there was a sense of tentativeness and even, some years, drifting. There were all sorts of competing narratives, battling theories of change. Sure, the very, very broadest outlines obtained some level of agreement among some observers: healthcare was becoming more expensive, healthcare consumers would eventually become empowered, electronic health records (EHRs) were inevitable.

But look back at, say, 1995, 1996, 1997, and those who were at the HIMSS Conference in those years will recall, as I do, EHR vendors boasting about how closed their core clinical systems were; provider leaders saw filling hospital beds as a core business objective in perpetuity; payers were absolutely seen as the enemy, or at least a profound adversary; and the concept of interoperability was openly scoffed at by many.

Of course, that was before the Affordable Care Act, the HITECH Act and the meaningful use program, and a host of other policy and payment mandates compelling providers forward to make healthcare more efficient, cost-effective, accountable, transparent, and of higher care quality and patient safety. It was before the readmissions reduction mandate in the ACA ended forever the notion that U.S. hospital executives could ignore federal officials’ collective command to eliminate avoidable readmissions. It was before participation in value-based payment became required of hospitals and physicians under Medicare. And it was before last year’s passage by Congress of the MACRA (Medicare Access and CHIP Reauthorization Act of 2015), with its requirement that physicians accepting Medicare payment either participate in an alternative payment program or in the new MIPS (Merit-based Incentive Payment System) payment system, beginning in 2017. And it was before the legislation requiring that physicians ordering diagnostic imaging exams make use of clinical decision support and appropriateness criteria tools, beginning in 2017.

And it was before the ACA’s provisions also stimulated the development of accountable care organizations (ACOs), bundled payments, and other new-ish delivery and payment models, and before the Medicare program’s hosting of all those models further stimulated private insurers’ ACO and population health-driven programs, programs which had begun prior to the passage of the ACA, but which rapidly gained steam once the federal government had strongly endorsed such models.

These days, the policy and payment landscape is clearer than ever before—on both the public and private payer sides. Simply put, the public and private purchasers and payers of healthcare, facing a plunge over a massive national cost cliff, have put their huge, collective foot down, and made it clear that old-style, unaccountable, untransparent fee-for-service healthcare delivery and payment are on their way out (over time, of course).

This is why I was able to write last Monday, speaking of the Business of Healthcare Pre-Conference Symposium at HIMSS16, “Ten years ago, it would have been virtually unthinkable to have a provider leader (not to mention a physician executive at an academic health system) and a health plan senior executive, follow one another on a symposium program, and say essentially the same kinds of things—from the provider and payer perspectives of course—about payment incentives and collaboration. And yet these were exactly the kinds of presentations that took place at the Business of Healthcare Symposium on Monday. Indeed, the subtitle of the symposium, or its tagline, was this: ‘New Payment Models: Are You Ready?’”

I spoke of payer-provider convergence last week, and that convergence was only further validated and affirmed throughout the course of HIMSS16. It’s not just that everyone was talking so much about population health, care management, accountable care, and value-based purchasing—it was that payer and provider leaders were looking at essentially the same landscape, in not-dissimilar ways. And that would have been unthinkable 20 years ago.

Meanwhile, as we all know, the information technology in 2016 is simply much, much better than it was in healthcare in 1996, for example. Twenty years later, clinicians and others in healthcare have a variety of effective tools with which to risk-stratify their patient populations, apply analytics to their care management, participate in deep-dive, authentic care management, engage front-line physicians, nurses, and others, and participate in both internal and external benchmarking and value-based programs, in ways that were impossible back then. Indeed, it’s so much more focused and “real,” as well, meaning, so much more aligned with the true, long-term, needs of providers and payers. So in short, we’ve got alignment along a few different dimensions going on these days.

And while it’s absolutely true that a lack of deep semantic interoperability remains a stumbling block, I agree wholeheartedly with Dr. Halamka that the coarse tools are now there to practically overcome some of the core barriers. Direct-facilitated messaging, FHIR-based APIs, and other phenomena are—when combined with the OpenNotes movement and physician documentation reform, shifting the landscape around which clinical data-sharing is taking place. Within a few years, the ability to share the most vital pieces of information about patients in real time will be widespread; and that ability, along with the very broad diffusion of genuine population health and care management, and aided by true patient/consumer engagement, will change U.S. healthcare profoundly.

As I wrote last Thursday, it was exciting to hear a presentation showcasing a consumer engagement initiative taking place at Denver’s Centura Health, in collaboration with Welltok and the IBM Watson of IBM. The cognitive computing aspect of that initiative speaks to the real progress that pioneers are making in moving the needle on ways to engage patients/consumers in their daily lives, and affect health status outside the walls of the hospital stay and the physician visit.

So yes: I believe that Dr. Halamka is not only justified in his optimism, but right in it. There’s no question about it: this is a challenging time in healthcare. And healthcare IT leaders are under pressure as never before. But with policy and payment clarity, increasing payer-provider convergence, newer care delivery and payment models, growing patient/consumer engagement, and far better healthcare information technology, we really are in a different world from ten years ago, and certainly from twenty years ago.

And what HIMSS16 felt like, really, was this: a group of really, really smart, innovative, clever, hardworking, and determined industry leaders, talking not about whether they should move forward to completely re-vision and re-work our U.S. healthcare system, but rather, talking about how they should move forward to do so (specific strategies and tactics, not conceptual resistance). And that—that—is cause for real optimism. Because if so many smart, determined people are focused on remaking our healthcare system, can ultimate success really be prevented?

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