2,061 Days in the Making

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Wow!

It has been 365 days since my last post on xchangehealth and so much has happened. I have been so focused on things at MINES that I haven’t been very active on Twitter or my blog so it’s probably about time for an update and a little taste of things to come at MINES.

As of July 3rd, 2017, MINES is now using a fully-CRM-based Electronic Health Record (EHR) system for patient management. I can’t even begin to explain how big of a deal this is for us, but to suffice it to say that there aren’t many others out there. Why is this so uncommon? Because rather than using the billing method to determine how to organize our records, we use the relationships that people actually have in their lives as our core operating assumption.

If that doesn’t make sense to you, let me put it another way: this was the result of over 5.6 years of planning, designing, and testing (several cycles, in fact) to create a system that would allow for this schema to be viable for a long-term records solution while minimally impacting daily operations and creating the opportunity for further development down the road.

“So what does that “down the road” really look like,” you might ask. I’d be happy to provide some examples!

Create your own (EH)Record!

Beginning in 2018, our clients will be able to submit all of the necessary information to get a referral for sessions and manage their own authorizations and provider interactions.

New provider value scores!

Our patient satisfaction data will be tied directly to patient and provider records, allowing real-time data regarding patient satisfaction for future referrals.

More in-depth reporting for HR!

Beginning in 2018, a new utilization report will be released for HR that provides greater insight into problems at the worksite and what interventions might help improve the operations of the company.

Better workflow for patient management!

Using the functionality that business development has been using for years means being able to apply the workflow of communication and client management to patient coordination.

Deeper insights into how patients actually work with their peers!

As early as 2019 we’ll see the implementation of a social media connection opportunity for those looking to leverage their social networks to improve their therapeutic performance. We’ll also be leveraging the growing relationship data to provide a basis for Social Network Analysis, giving us the opportunity to engage in a population health model at worksites.

A REAL app for an EAP!

Many EAPs have released limited versions of their website and/or online content, which is a start, but the app we will be releasing will allow clients to manage their account, see their appointments, share notes with their provider, and potentially launch an ad hoc telemedicine session.

The end of the traditional therapy model!

MINES will also be launching a new program model for purchase by employers to move away from the traditional “1-some number of sessions” model, allowing employees to call, video, text as they please. This allows for the EAP to work even more proactively with clients and to tailor clinical response to the particular need.

The team at MINES has been exceptionally open and excited about this critical difference in our record structure, and while we opened with a few glitches (as to be expected with any software roll-out) we’ve experienced no disruption in our regular processes.

Today marks the beginning of a new, more data-driven patient management era for the team at MINES and a new opportunity to “save lives and influence the course of human events.”

The Ashley Madison hack and healthcare

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I was really hesitant to write anything about this topic at all, but a recent article in Gizmodo convinced me that there is something really critical here to be discussed. Yes, I am talking about the Ashley Madison data hack and its implications for the healthcare industry.

What do we know so far? Well, we know that there were approximately 35 million records dumped onto the “dark web” and that within that data was quite a bit of information. In fact, I’ve recently seen a sampling of that data including addresses and names and it’s frankly startling to see someone you know show up on the list. I don’t recommend it.

What I don’t know is anything other than the limited data that I’ve seen and what is presented by what I hope are reputable sources. What I present here is not presently vetted as it would be quite an undertaking to do so on my own. I’m hoping by publishing through this medium (heh — get it!) that we might be able to get some clarification on this topic and to help me with my own thoughts about how this impacts the healthcare industry.

First, let’s talk about privacy versus security

There is a certain amount of privacy that one should expect when engaging with a site that purports to maintain a secret for you, or to help you evade telling the truth. Privacy is “the state or condition of being free from being observed or disturbed by other people.” In contrast, security is “ the state of being free from danger or threat.” There is a nuance to the interplay between these two, but they are absolutely distinct.

In the healthcare industry, we’re well aware of the difference between these two things — or at least we should be. But all too often we confuse the strictures of HIPAA as being about privacy. That’s not inherently true. HIPAA is the Health Insurance Portability and Accountability Act. It’s about security, not necessarily privacy. In fact, HIPAA even covers how healthcare entities should handle informing their patients on how things are handled with regards to privacy because HIPAA doesn’t specifically provide for them. The “P” throws everyone off.

In fact, your Private Health Information (PHI) likely moves around the system in all kinds of ways that you may not realize. When you are seen for a service, your information probably goes to a payer on a claim form. That claim form may be accompanied by clinical documentation that may go to a Managed Care company. Your data ends up going through all kinds of people that you don’t explicitly give your permission to. All KINDS of people.

But just because your information is being moved from company to company, person to person, doesn’t mean your information isn’t secure. Most of the time, the system works just fine. Other times, you run into a problem like Anthem had where a breach in their IT structures resulted in a massive data leak. In such cases, there are actual federal guidelines as to how that breach is handled that are clearly defined. And those breaches are very expensive to the healthcare company.

The reason for that is that PHI can sometimes be more difficult to protect oneself in a breach than, say, your financial information. Because there is no national ID for the healthcare system, often a Social Security Number is used for transactions between systems. While an insurer might also provide you with an individual ID for their internal systems, for those data to move between entities, you have to use an SSN.

But even SSN can be protected against a breach with credit monitoring when it comes to your financial information. What is a little different about PHI is that it can contain deeply personal information about the individual such as diagnoses, current or past treatment, and even likelihood for future diagnoses when it comes to genetic information. Your genome can’t be changed like your SSN or bank account information. That’s all yours.

Let’s bring it back to Ashley Madison

What did Ashley Madison actually promise, then?

Ashley Madison is the most famous name in infidelity and married dating. As seen on Hannity, Howard Stern, TIME, BusinessWeek, Sports Illustrated, Maxim, USA Today. Ashley Madison is the most recognized and reputable married dating company. Our Married Dating Services for Married individuals Work. Ashley Madison is the most successful website for finding an affair and cheating partners. Have an Affair today on Ashley Madison. Thousands of cheating wivesand cheating husbands signup everyday looking for an affair. We are the most famous website for discreet encounters between married individuals. Married Dating has never been easier. With Our affair guarantee package we guarantee you will find the perfect affair partner. Sign up for Free today.

We can discuss the morality behind the purpose of the site all day long, but the site exists and people signed up for it. So let’s just move on past that topic and dig into how this is relevant to our purpose here.

After looking at the data from Annalee Newitz’s article, there’s clearly something else going on here. There are not a ton of married people who are successful in cheating on their spouses. There are a ton of married men who are flirting with the idea of cheating on their spouses.

The societal impact of the hack

Well, we know that Josh Duggar admitted to cheating on his wife andentering rehab after the hack was announced and that he was on the list. I haven’t seen that he successfully met anyone on the site, but looking at the numbers in the Gizmodo article, I’m going to guess not. And there arereports that there may be suicides that have been linked to the hack. And there has even been reporting on the pervasiveness of the use of the site by federal employees.

So, we’re seeing some significant potential impact of the site across many walks of life and affecting many groups throughout the world, in fact. But again, going back to the numbers, this probably isn’t nearly the situation that we think it is.

Let’s focus on the men that were probably brought to this site, since the Gizmodo article all but dismisses the women that were on the site — especially after highlighting that a number of those women could have been checking for cheating spouses, rather than looking to cheat.

There is the issue of Ashley Madison’s promise to its users. That it would allow for discretion in cheating. That’s a privacy promise in my opinion, and not necessarily a security one. Would one assume that their information was being secured as well? Maybe, but I don’t think that’s inherent to their brand promise. Again, I haven’t dug into the language of their policy yet — this is a working document — but there was going to be no protection when you moved from the online world to the offline world anyhow, so how one could have reasonably expected security is beyond me.

You’ll have to draw your own line as to what is considered cheating and what is not, but most of these individuals that were active on the site were more than likely talking to robots. Those that weren’t may have been casually flirting. And of those left, well, I’ll just say the proportions would show that likely if anyone was successful in cheating, they were probably 4th or 5th in line in their area.

For the first two categories, you were made a promise by Ashley Madison and you were either duped or you got exactly what you needed. If you expected you would actually find an affair, the first category; if you were looking for an outlet that let you flirt, you probably got a robot and received exactly what you needed from the site.

What this means for healthcare

Does or would the Ashley Madison hack have an effect on healthcare more broadly? I don’t know. There’s certainly a couple of considerations here.

Does this inherently decrease the public’s trust of the internet and data security generally? I hope not. You should absolutely be concerned about security, but let’s be honest — Ashley Madison is not the healthcare industry, it’s a site for people wanting to cheat. There’s an inherent, goal-oriented difference between the two, we’ll call them, “industries.”

Does the new data lessen the impact that the hack actually has on the greater societal opinion surrounding the fear of data integrity? Probably, but it really shouldn’t. This still highlights a critical misunderstanding that we have about our data and how it gets used. That’s no less true in the healthcare industry as I’ve pointed out above.

Will it change the way that healthcare handles data? I cannot imagine it would. Your data is being protected pretty well already, but this type of hack is the result of something far different than why someone would go after healthcare — that’s largely financial.

Is the Ashley Madison hack still relevant? You bet your sweet you know what it is! We’re entering a new phase in the healthcare industry’s development where you as a consumer are going to be able to make more decisions about the way in which you interface with that system. That means you have more control over who is getting your data initially, and within the new Health Information Exchange models set up in each state, maybe even after your initial input of data. Some systems are prepared to share data down to very granular levels. That means you will have to make some decisions about how you want your information to be shared.

Does this mean you shouldn’t share your data? I wouldn’t go that far. Your data, if properly secured, doesn’t need to be private from legitimate sources in the healthcare industry. That data can be very important for medical advancement for one. But there is also a possibility that your information can help providers make better decisions to help you in making decisions about your own healthcare.

Health inSite: Consumer-directed Healthcare Part IV

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This is part IV in a four part series. Links for Part I, Part II, and Part III

There are numerous components that the sharing economy and new applications have developed that will likely make an impact on healthcare moving forward.

Two-step verification

One major integration point that social networks have started to implement is that of two-step verification. This allows for identifying an entry-point for any given social network so that if someone attempts to access your profile from a device that is not recognized there is a second layer of security. In the age of mobile, this has been helpful in beginning to lock down the username/password issue of the past. But there is more needed from this methodology. One day, either through bio-markers or technology insertion, such two-step verification might further button down security related to social networks.

Social sign-on

There are a number of sites that are now beginning to rely on social sign-on where an OAuth call brings over the credentials of a particular user’s information from a major social network to bypass a number of the traditional sign-up information needed to create a new user, creating a “virtual passport.” This usually passes a limited amount of information between the two sites. Some sites, such as Tinder, might bring over your friend list and interests, where other sites may bring over only your identifying account from Facebook. This level of information sharing enables the user to activate the social network to act like a passport for accessing different sites across the web.

Credentialing

Once credentialing information has been brought into the secondary system such as through the ‘social sign-on’ system, it is combined with information related directly to the application into which you ported your ‘passport’ information. However, having a “passport” doesn’t guarantee two way communication, which is the goal. A passport gets you into a country but doesn’t necessarily allow for your travel itinerary to be shared with your country of origin. It affords access to local resources without necessarily communicating back to the issuing authority. As a result, your local identity can be managed locally, only. Which means that while those external credentials can be managed by the external authority, local, additional data (credentials) can be managed within the new authority.

Identity management

But, as a user accesses, and enables that passport to be used across the web, a composite identity can be realized through the passport. Similarly to the stamps that end up in your passport, a comprehensive view of the “travels” you acquire while moving through the social web can be realized. With secure technologies and stronger information security protocols through these passport services, a comprehensive yet protective identity can be managed across the social web.

Essentially, this allows for a deeper sense of security in identity. If you’ve ever tried to apply for a birth certificate, you know that an insane amount of information is collected by a host of agencies and coordinated to test for the authenticity of the person requesting the information. Similarly, a social footprint through the social web’s passport allows for a full, historical picture that can act in much the same way as a credit score or an issuing agency for birth certificates. So long as users can help to manage the information related to that social passport.

Social network analysis

Another opportunity that using these social platforms for credentialing affords is bringing over the social structure information from the network into another platform. Dating sites like Tinder and Hinge have already made strides in trying to develop ways of identifying social connections and even likelihood of compatibility of matches through their apps by analyzing this information. Deeper forms of social network analysis could make possible analysis into what that social network might do once it enters into a third-party application.

Friends of Friends

A study into Social Network Analysis (SNA) quite quickly reveals the possibility of using the information related to hubs, links, nodes, and clusters for the dissemination (or potential, thereof) information with a certain amount of predictability. We in healthcare should look at this as the Holy Grail for culture change and treatment adherence. By enabling that social network, inherent to an already existing system of networks like Facebook, means that information doesn’t have to be populated from the healthcare side. Attempts to do so in the past have been seriously lacking in critical mass. And looking at studies like the Framingham study point to how important our social networks really are in our health behaviors, so healthcare needs to identify a way of making this a reality.

Influencers, mavens, and hubs

But even without the nebulous interaction points and influences in any given social network, by processing the data from networks like Facebook as to link influence and the flow of information and influence, it would be possible with a fairly limited amount of that information coming into a third-party application to reasonably predict these patterns of influence and identify influencers, mavens, and hubs within geographic, familial, and even professional networks.

Social integration for experience-sharing

All of this social integration has value for both the system attempting to impact health behavior and outcomes, but also to increase the overall shared experience of the users as they are able to interact with one another around those behaviors, as well as their personal experience in a given system – such as the healthcare system. Further, those experiences would continue to impact the reevaluation of that experience by members as they share those experiences. Social integration is also becoming a necessary reality to create a consumer experience in competition with the rest of the world that patient is experiencing.

Mutual rating networks

Even further, by bringing the data from a social network into a third-party application for healthcare and allowing for that data to be combined with new data derived by the system’s application, a seemingly private interaction currency could allow for consumers to rate the outcome and behavior experiences they have, their connections have, and they have with their attending providers as well as other members of the healthcare system (the current other 2 Ps in the healthcare system – payer and purchaser). In the healthcare system, this means monitoring of transactions to identify opportunities for improved patient care.

Big data

This all leads to the combination of social, physical, occupational, emotional, intellectual, financial, and possibly environmental and spiritual data for a composite view of the current, past, and future version of ourselves as we actively engage and interact with the healthcare system. This, folks, is what Big Data is all about. It’s not silos or collecting all the information into a repository, but the opportunities inherent in bringing together, ad hoc, the disparate pieces of data so that recombining that data results in insights into helping people. It’s why we get up in the morning at my company: “to save lives and influence the course of human events.”

Conclusion

What I’m suggesting is that there is a coming Uber-ification of healthcare that is the next step in the sharing economy’s development. It’s not certain to me how that shift is going to occur and certainly the healthcare system is significantly more regulated by government, more powerful than taxi companies, more necessary in the daily lives of individuals than most of the ways that the companies we identify as disrupting traditional markets. But I believe it’s coming regardless. We will see consumer-directed healthcare in the coming years become more commonplace with patients that are empowered to take control of their health and wellbeing. The question is only how, and how is the healthcare system preparing for the peak that we’re all approaching that is a consumer-directed healthcare system.

Health inSite: Consumer-directed Healthcare Part III

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This is part III in a four part series. Links for Part I, Part II, and Part IV

And now, we get to the purpose of this series. What does the sharing economy have to do with the consumer-directed healthcare system? First, let’s look at what is at the core of purchasing: economic offering.

Levels of economic offering

In their book The Experience Economy (I did a post on this too, forever ago!), Joe Pine and James Gilmore explain the value pyramid.

As products increase in differentiation (customization), a higher asking price for that product can generally be realized. In this way, value to the consumer comes in the ability to match the need with the offering and in healthcare, this means enabling smart, simple decisions.

In a consumer-directed healthcare system, shifting healthcare transactions to goods, rather than experience, and focusing the overall healthcare purchasing and maintenance up to that of an experience will be critical to success. This can be done when the exchange, for example, becomes broker, maintenance organization (think HMO), and coordinator of one’s health record (not an Electronic Health Record as we know them, but a coordinator of the health profile mentioned earlier). For such a situation to work, the exchange then will need to either build out, or partner with organizations with experience in guiding human behavior, to successfully engage those patient-consumers in maintaining their profile as well as actively pursuing greater levels of health.

Examples of how they work

The sharing economy is also making significant changes to the way that we engage as consumers. This economic shift allows for individuals to make transactions with little to no broker (for example, a bank) in order to make purchases. Most of the sharing economy relies heavily on technology to enable people to come together. A chart of examples is below:

 

Organization Primary offering Industry disrupted Innovation Description
Uber/Lyft Car service Taxis By allowing individuals to directly contact a driver, users interact with an app that can manage their payment and reservation.
AirBnB Housing Hotels Users submit their social network credentials as “proof of trust” for user-to-user reservations of rooms
Car-2-Go and many others Cars Every car company Cars placed around the city, can be “rented” for one-direction travel.
Bitcoin and other cryptocurrencies Currency Banks Distributed, “proof-of-work” based cryptocurrency which allows for peer-to-peer exchange of value.
Kiva Microfinance Lending companies Individuals can register their needs for financing and other members of the Kiva network can make those loans direct to the borrower without a traditional lender.
GoFundMe and other crowd-sourced finance platforms Project Funding Investors Individuals can create a project page with donation-level rewards for contributing to the financing of a project or product.

Considering these examples, I believe that there may be some interesting opportunities for alternative funding and insurance when it comes to healthcare. Consider this: what would it look like if traditional insurers were no longer the primary location to insure oneself. In the current healthcare system, some groups (usually smaller companies with less leverage than bigger companies) might choose to pool their collective employees into what’s called a captive insurance group. What if a similar model were to be contemplated where individuals were to select a captive group of similar patients, almost self-selecting to become a part of a patient-centered medical home model. Exchanges could do the same with their patient population by segmenting those patients into population groups.

Now, what if those groups could be funded by individuals wanting to bet on the success or failure of those groups. This allows for more direct funding for investors and patients that could result in dividends for the patients and investors when benchmarks are achieved or maintained. What other possibilities for alternate funding models might still be out there to be explored?

The core of the sharing economy

Trust

At the very core of the sharing economy is a redistribution of trust networks. By decentralizing trust models from institutional to peer-to-peer, the sharing economy refocuses and reinforces a community around the exchange of goods and services by moving brokerage to a fluid, and seemingly direct, brokerage for those exchanges.

Supply/Demand

The other side of this change to the sharing economy is supply and demand monitoring and coordination. Uber has the ability to simplify the exchange of need for transportation with the supply of excess time (and access to a vehicle) on the part of the driver all while it is in the process of cutting out the institutional (and very infrastructure-heavy) taxicab industry.

What that means for institutional healthcare

So WHAT DOES this mean for institutional healthcare? Great question! It could mean realignment around roles within the healthcare system. It could mean small market-share loss if the idea doesn’t take off easily. It could mean more competitive models. I’m interested to hear your thoughts.

The Conclusion: Part IV

Health inSite: Consumer-directed Healthcare Part II

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This is part II in a four part series. Links for Part I, Part III, and Part IV

Behavioral economics

The complexity of the healthcare system as it currently is already embroils patients in the very difficult position of having to make decisions with imperfect, nonexistent, and unintelligible data. When individuals are forced to make a decision in a situation where these factors are present, depending on the cognitive capacity of the individual (complexity of thought, for one – see Thinking, Fast and Slow), sometimes results in fast thinking that may include cognitive bias (errors). When this occurs, decisions are poorly conceived and may result in catastrophic results. For that reason, we need a single, comprehensive, coordinated, and collaborative profile.

A personal profile/avatar

Which brings us to the core of a consumer-directed healthcare system’s BIG need. A longitudinal profile. The fantastic Jenn Dennard replied to a question posted on twitter recently

to which I say, Yay! There is a need, in a consumer-directed healthcare system, for the individual to be empowered in their decision-making by having the data on their past, present, and future outlook in the same way that we have the ability to understand our financial wellbeing over time. Organizing this information in a comprehensive, yet easily summarized way can help the consumer make determinations about what works for their short- and long-term investment in their healthcare options. While I’m tempted to refer here to the SAMHSA model of wellbeing to outline the information that should be collected in this profile, I’ll speak briefly on a few that I think are critical to the goal and then finally how they might work in tandem to help with decision-making.

Physical

Obviously, if we’re going to talk about a profile related to healthcare decisions, a comprehensive health record, complete with genetic profile, risk-factors, behaviors, and the like should be consolidated and coordinated. Something that looks along the lines of the EHR that is contemplated in this TED talk by Thomas Goetz comes to mind.

Financial

I’ve long said that healthcare is as much a financial decision as about providing care, but in more than just from the payer perspective. The provider’s ability to understand the financial impact in concert with the patient’s needs should be coordinated through this profile. But in a consumer-directed healthcare system, this also means empowering the patient with projections based on their health record that helps to estimate the financial burden that they may experience based on their health reality.

Social

If you’ve not read any of my previous posts, I recommend checking the various postings on the importance of ‘social’ in shaping our health reality (I’ll point you to the latest here). The way we interact with our friends, family, neighbors, co-workers, etc. all shape our health reality. Incorporating and ‘animating’ those connections – really analyzing and understanding them – is a key element to making significant changes in our behavior as well as helping to alter the health reality of each consumer.

Psychological

The psychological aspects of healthcare range from simple awareness (or lack thereof) to the complex co-occurring conditions to their interactions as the patient tackles their health reality. Further, the interpersonal experiences available to the consumer through their social network is sometimes limited by the psychological reality of the consumer – the functions or dysfunctions of cognition, personality, etc.

Game-state evaluation

In all of these components, it’s important to keep in mind that we are not static over the entire course of our lives and rarely so even when looking at only one factor. While research points to potential for adjustments in things like resiliency, literature also shows that we have hard-coded tendencies such as temperament. For more on game-state evaluation and other related topics, see my post on Decision Support, Games, and Making People Healthier.

Why tracking is important

A method for tracking those changes and dynamically responding to those changes along all axes can provide context for how the consumer should, and can, act on their purchasing, but also their locus of control and potential efficacy in using the system through the plan they intend to use/purchase.

Part III

Health inSite: Consumer Directed Healthcare Part I

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Intro

I was recently invited to participate in an interview for Stride (on twitter), a developing local Health Information Technology ecosystem that is the first of its kind in scope and vision. I’ll let you check out their site for details and spare them here, but I was excited to participate in helping to promote this project as a local member of the Health IT community in Colorado. While reading through the questions that had been prepared, I was thinking about the way in which Stride is poised (intentionally) to disrupt our current healthcare delivery model by bringing together stakeholders from startups and the institutional healthcare system. As a company that’s been around for 35 years, MINES & Associates is certainly in that latter category in many respects; however, one of the reasons that I have decided to make MINES my home is that, as a company, we have embraced technology as a tool to reach our organization mantra: to “save lives, and influence the course of human events.”

This is part I in a four part series. Links for Part II, Part III, and Part IV

A shifting landscape

The Affordable Care Act has caused a seismic shift in our healthcare landscape and some are preparing for the fault lines’ impact on what were once the prairielands of the healthcare system. The new mountain ahead of us consists of layers of changes that I will attempt to outline as I see them. These are the result of following some very bright people that I will try to mention as I go. Follow these people! They are making huge steps toward preparing for these changes.

One of the opportunities (or threats, depending on your viewpoint) of consumer-directed healthcare may be the collapsing of the system within which the decisions in healthcare are made at an administrative level. Those changes could result in significant, down-stream implications for how the future healthcare consumer engages with their health. As a fellow Health 2.0 Denver/Boulder chapter member of mine, Sumanth, mentioned while on a panel regarding open-innovation models in healthcare, ‘We have a sickcare system, we’re working toward a healthcare system, but I’m interested in a health system.’ When we begin empowering people by giving them purchasing power, we also saddle them with the responsibility of that decision and we need systems in place to make those decisions reasonable.

Institutional vs. startups

If there is one person that I’ve heard that captures this coming change the most succinctly from the institutional perspective, it’s Aetna CEO, Mark Bertolini. A keynote at HIMSS 2014, Mr. Bertolini explained how Aetna is preparing for a more engaged, consumer-like patient in the Aetna model. If you don’t believe it, simply look at their acquisition of iTriage (among other advances, led by Michael Palmer, Chief Innovation and Digital Officer) that put the power of access and empowerment in the hands of their future patient.

Aetna made the right move by acquiring iTriage. By purchasing tech, rather than trying to build it out themselves, Aetna’s model is to scout and engage experts trying to help quell the shift in the landscape by harnessing technology. This means that rather than developing that internally, at a potential loss to the organization if it’s unable to deliver, Aetna can focus on its core offering. It also highlights a bigger shift in the healthcare ecosystem – one that Stride is very interested in nurturing – coopetition. Because these lean startup organizations have the ability to make changes quickly and bring in top talent to tackle tough, smaller issues – issues that can then be used in many different arenas. In my opinion, that nature of coopetition is a critical element to the new model of healthcare delivery, as I hope to illustrate in this blog series.

This is what disruption looks like

Telemedicine

There’s no question that telemedicine is becoming a more regular part of the healthcare industry with companies like CirrusMD, Call-a-Doc Plus, and AccessCare Technologies’ Aveo platform and many others (disclosure: MINES currently has business relationships with CADR+ and AccessCare Technology) making strides to disrupt the traditional delivery model for healthcare by enabling secure text messaging, prescriptions by phone, and HIPAA-compliant video telemedicine, respectively – this isn’t an exhaustive list of what these platforms do, but just a couple of examples. This enables asynchronous, non-geographically-specific, and convenient communication between a provider and patient. While our current model of on-site care is relatively new compared to the entire history of medicine where patients go to the provider, the bigger disruption here is in the fact that the premises is moving away entirely.

Retail health

The weekly #HITsm chat had a great discussion on January 24th (transcript) regarding retail healthcare – the movement of retail organizations into the healthcare space. Companies like CVS, Walgreens, and Target are making movements to put clinics in their retail locations to decrease barriers to accessing care for routine events like physicals and non-urgent medical needs. If you want to check out a really cool aspect of this, Theranos is partnering with Walgreens to make onsite blood testing a realistic part of this system.

Wearables

If you’ve not heard of wearable tech or the Internet of Things (of which wearables are only a part), you soon will. While Nike took early steps in tracking the efforts by athletes with the Nike+ system, this sub-industry has exploded with newcomers like Jawbone UP, Misfit Shine, FitBit, and even a tracker that will shock you into behavior change. While these various tracking devices are great at providing data to the person using them, efforts to make them usable in healthcare have been lacking. That said, there are efforts between Apple, the Mayo Clinic, and Epic EHR to solve this problem through Apple’s HealthKit. However, this change is only helpful to those that are on the iOS ecosystem. As you probably know, Google’s Android continues to gain ground in market share and as these devices continue to become more customizable and cheaper, iOS will either need to adapt or face staying in an ever-growing, niche market.

These are only the first step in a long development cycle of devices (and even things that don’t look like devices) that will someday be a part of our daily lives. In fact, watch the sequence a few minutes after Ewan McGregor’s character wakes up in the movie The Island, and you’ll get a sense for how this might play out in our daily lives. Actually, while trying to find that toilet scene where the character’s urine is tested while he is excreting, I found this article on a real-life example! Which now has my mind wandering on sample integrity…

Other major tech innovations

In fact, there are A LOT of people – very smart people – working on a number of innovations related to healthcare. Look no further than the IBM 5-in-5 if you’re ever wondering what some of those things might be. But we are quickly moving into a world where the things that are imagined in movies and TV are becoming reality – or are being worked on now to become reality. If you want a great example, check out the Tricorder X-prize. If you’re not familiar with what a tricorder is, here ya go!

A word on purchasers

The purchasers of the past are slowly slipping into the fog of a system going the way of dinosaurs. While our current healthcare system relies on someone purchasing insurance on behalf of a group of people, the new model of consumer-directed healthcare would include patients insuring themselves in a similar way to most other insurances – life insurance, car insurance, etc. In this model, the purchaser is correctly aligned with the responsibilities for maintenance. During deliberation of the Affordable Care Act, the Supreme Court actually highlighted how insurance could be mandated because cars can be mandated to be insured by the state. To ensure protection for all others in the pool of “drivers,” in much the same way that maintenance of one’s health and insurance for that health is a responsible act for the pool of citizens.

Consumers

Consumers make this sort of decision regularly. When purchasing electronics, for example, there are often options for insuring the item from damage and even loss. When confronted with this decision there is, in the mind of the consumer, a cost:benefit decision to be made. When making a decision regarding level of coverage to insure one’s vehicle, a similar cost:benefit decision must be made for the consumer regarding their risk tolerance related to the value and potential loss in value of the vehicle. But in these situations, consumers are aware of their role as a consumer; that same level of awareness needs to be at the core of a consumer-directed healthcare system if we expect those decisions to be more straight-forward and realistic.

Millenials

Millenials are fast becoming the largest part of the consumer segment of the economy; and they do things a little differently than their predecessors. As the CTO of Connect for Health Colorado (the health insurance exchange in Colorado), Proteus Duxbury, mentioned in a Prime Health Collaborative event that Millenials are soon to make up as much as 50% of the purchasers through the exchange in Colorado and they are preparing for this group which prefers peer-reviews to authoritarian ones. When I asked him about this posting, he shared this report from the White House on Millenials that you might find interesting for more details. Keeping an eye on the factors that make up this group is going to be important for their continued planning and development and healthcare organizations from insurance to consumer-facing wearables should take heed to the particulars of this shifting landscape. Community-focused, socially-aware, technology-forward, and averse to traditional signals of “growing” up like marriage and purchasing a home are all key differentiating factors. As those factors become more pronounced, healthcare will need to be aware of, and respond to, the way that these individuals view themselves and the world. Further, the section on a personal profile below will become even more pronounced and necessary to keep these individuals engaged and aware.

Is 4PHealth going away?

If you’re not familiar with my concept of 4PHealth, check out my earlier blog post for details (secretly hoping I can stop linking to this post at some point!) but the long and short of it is that there are four P’s in the healthcare system: payer, patient, provider, and the patient’s peers. Truthfully, there’s actually a fifth P that was not originally contemplated in that post but comes to light when you consider a consumer-directed healthcare model: purchaser. For most people in the US, the purchaser is an employer, or in the case of labor organizations, a trust into which employers contribute along with the dues from the members. But now that is shifting as smaller organizations are actually sending their employees to the health insurance exchange. Increasingly, I expect this to grow; and that’s a good thing. When the purchaser and the patient are the same, there is a shift in the financial onus for having a particular benefit plan; which means we need more informed consumers (patient-purchasers). But it also creates an opportunity for further collapsing of our very tiered silo. If the consumer could then also become the payer (see more in shared-economy model, below), we could very well see a one-to-one relationship between the provider and the consumer (patient-purchaser-payer). Hold on to your seats, kiddos. It could happen.

Part II

Health inSite: The Sharing Economy in HealthIT

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This is a draft of Part III in a three-part series on the current, and potential future, of healthcare delivery economic models. The full series will be available on xchangehealth.wordpress.com in the next week. A quick synopsis of parts I and II are extracted as an introduction.

Intro

I was recently invited to participate in a Storyvine for Stride (on twitter). While reading through the questions that had been prepared, I was thinking about the way in which Stride is poised (intentionally) to disrupt our current healthcare delivery model by bringing together stakeholders from startups and the institutional healthcare system.

As a company that’s been around for 35 years, MINES & Associates is certainly in that latter category in many respects; however, one of the reasons that I have decided to make MINES my home is that, as a company, we have embraced technology as a tool to reach our organization mantra: to “save lives, and influence the course of human events.”

There may be a shift to consumer-directed healthcare in the very near future. One of the opportunities (or threats, depending on your viewpoint) of consumer-directed healthcare may be the collapsing of the system within which the decisions in healthcare are made at an administrative level. As a fellow Health 2.0 Denver/Boulder chapter member of mine, Sumanth, mentioned while on a panel regarding open-innovation models in healthcare, ‘We have a sickcare system, we’re working toward a healthcare system, but I’m interested in a health system.’ When we begin empowering people by giving them purchasing power, we also saddle them with the responsibility of that decision and we need systems in place to make those decisions reasonable.

Is 4PHealth going away?

If you’re not familiar with my concept of 4PHealth, check out my earlier blog post for details (secretly hoping I can stop linking to this post at some point!) but the long and short of it is that there are four P’s in the healthcare system: payer, patient, provider, and the patient’s peers. Truthfully, there’s actually a fifth P that was not originally contemplated in that post but comes to light when you consider a consumer-directed healthcare model: purchaser.

For most people in the US, the purchaser is an employer. But now that is shifting as organizations are actually sending their employees to the health insurance exchange. Increasingly, I expect this to grow; and that’s a good thing. When the purchaser and the patient are the same, there is a shift in the financial onus for having a particular benefit plan; which means we need more informed consumers (patient-purchasers). But it also creates an opportunity for further collapsing of our very-tiered silo. If the consumer could then also become the payer, we could very well see a one-to-one relationship between the provider and the consumer (patient-purchaser-payer).

Part III: The sharing economy

What does the sharing economy have to do with the consumer-directed healthcare system? First, let’s look at what is at the core of purchasing: economic offering.

Levels of economic offering

In their book The Experience Economy (I did a post on this too, forever ago!), Joe Pine and James Gilmore explain the value pyramid.

From Pine and Gilmore’s “The Experience Economy”

As products increase in differentiation (customization), a higher asking price for that product can generally be realized. In this way, value to the consumer comes in the ability to match the need with the offering and in healthcare, this means enabling smart, simple decisions.

In a consumer-directed healthcare system, shifting healthcare transactions to goods, rather than experience, and focusing the overall healthcare purchasing and maintenance up to that of an experience will be critical to success. Again, an awareness of this intentional effort to differentiate based on total experience. This can be done when the exchange, for example, becomes broker, maintenance organization (think HMO), and coordinator of one’s health record (not an Electronic Health Record as we know them, but a coordinator of the health profile mentioned earlier).

For such a situation to work, the exchange then will need to either build out, or partner with organizations with experience in guiding human behavior, to successfully engage those patient-consumers in maintaining their profile as well as actively pursuing greater levels of health.

Examples that work

The sharing economy is also making significant changes to the way that we engage as consumers. This economic shift allows for individuals to make transactions with little to no broker (for example, a bank) in order to make purchases. Most of the sharing economy relies heavily on technology to enable people to come together. A chart of examples is below:

Organization Primary offering Industry disrupted Innovation Description
Uber/Lyft Car service Taxis By allowing individuals to directly contact a driver, users interact with an app that can manage their payment and reservation.
AirBnB Housing Hotels Users submit their social network credentials as “proof of trust” for user-to-user reservations of rooms
Car-2-Go and many others Cars Every car company Cars placed around the city, can be “rented” for one-direction travel.
Bitcoin and other cryptocurrencies Currency Banks Distributed, “proof-of-work” based cryptocurrency which allows for peer-to-peer exchange of value.
Kiva Microfinance Lending companies Individuals can register their needs for financing and other members of the Kiva network can make those loans direct to the borrower without a traditional lender.
GoFundMe and other crowd-sourced finance platforms Project Funding Investors Individuals can create a project page with donation-level rewards for contributing to the financing of a project or product.

Considering these examples, I believe that there may be some interesting opportunities for alternative funding and insurance when it comes to healthcare. Consider this: what would it look like if traditional insurers were no longer the primary location to insure oneself. In the current healthcare system, some groups (usually smaller companies with less leverage than bigger companies) might choose to pool their collective employees into what’s called a captive insurance group.

What if a similar model were to be contemplated where individuals were to select a captive group of similar patients, almost self-selecting to become a part of a patient-centered medical home model. Exchanges could do the same with their patient population by segmenting those patients into population groups.

Now, what if those groups could be funded by individuals wanting to bet on the success or failure of those groups. This allows for more direct funding for investors and patients that could result in dividends for the patients and investors when benchmarks are achieved or maintained. What other possibilities for alternate funding models might still be out there to be explored?

The core of the sharing economy

Trust

At the very core of the sharing economy is a redistribution of trust networks. By decentralizing trust models from institutional to peer-to-peer, the sharing economy refocuses and reinforces a community around the exchange of goods and services by moving brokerage to a fluid, and seemingly direct brokerage for those exchanges.

Supply/Demand

The other side of this change to the sharing economy is supply and demand monitoring and connection. Uber has the ability to simplify the exchange of need for transportation with the supply of excess time (and access to a vehicle) on the part of the driver all while it is in the process of cutting out the institutional (and very infrastructure heavy) taxicab industry.

What that means for institutional healthcare

So WHAT DOES this mean for institutional healthcare? Great question! It could mean realignment around roles within the healthcare system. It could mean small market-share loss if the idea doesn’t take off easily. It could mean more competitive models. I’m interested to hear your thoughts.

Questions for Health IT

#HITsm T1: Is a sharing economy model realistic for the healthcare industry, in whole or in part? Where? How?

#HITsm T2: What should a sharing economy model prepare for with the current status of #HealthIT and #Healthcare?

#HITsm T3: If a sharing economy model were to come about, who wins and who loses in #HealthIT and #healthcare generally?

#HITsm T4: What other technology models are out there that #HealthIT can borrow from to enable those changes?

#HITsm T5: Any other thoughts on #healthcare economic models and how #healthIT can help?