The system of caring for people — the chronically ill, the
elderly or even the fitness buff — is reactive, expensive and
cumbersome. But a new paradigm of care, called connected
health, promises to reduce costs and improve quality by
working with patients proactively. How? Patients monitor
their own health using electronic devices outside of the
provider setting. As a result, the number of visits to both
physicians' offices and inpatient hospital units can drop
significantly.
Modern Healthcare and PricewaterhouseCoopers
present Straight talk. The session on connected health was
held on May 1, 2007 at Modern Healthcare's Chicago
Headquarters. Fawn Lopez, the publisher of Modern
Healthcare, was the moderator.
Lopez: Let's start by talking about the challenges facing
healthcare today. What is your point of view on the problems that
healthcare is facing?
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McClure: There is a perfect storm growing. There are large
demand shifts in healthcare that are going on: the rapidly aging
population coupled with the rise in chronic disease, which is
more expensive and time consuming to care for than acute
interactions. Meanwhile, there is a supply constraint in
place. It is very widely publicized that there is a nursing
shortage, but less publicized that there is actually a physician
shortage as well. At Partners, we have fairly large-scale efforts
underway to figure out how to take care of people better without
necessarily dragging them through our hospitals or our clinics
every single time. Our primary goal is to help people do a better
job of taking care of themselves.
Whitlinger: There is a shift in the healthcare
system. That shift is from bringing the patient to the
institution for the delivery of healthcare to bringing that
healthcare to where the patient resides. The shift can sometimes
be described as personal telehealth or connected health. If you
look at the cost of the delivery of healthcare along a scale, on
one end you might have the ICU. The quality of life for that
individual in the ICU is probably pretty poor. If you slide down
to the other end of the scale, delivery of healthcare to the home
is probably much less costly and the quality of life for that
individual is going to be much higher.
Lopez: This is a new paradigm of care. Your vision is to
take healthcare to the home - or outside the provider
setting. You talked briefly about telehealth. How is it different
from the traditional telemedicine?
Whitlinger: Personal telehealth is a whole suite of
devices and services from many different vendors that can be used
to help monitor a person's health. Whether that is the health and
fitness athlete - who is monitoring their fitness or their weight
program and is able to interact with healthcare professionals -
or all the way over to the individual with chronic disease - who
is monitoring their glucose and is able to interact with
clinicians using connected devices. There is one aspect of this
that is another paradigm shift: taking healthcare from a reactive
model to a proactive mode. Using devices and connected services,
we can give individuals. whether they are patients or consumers
- tools to monitor their healthcare. They can monitor their
health when they are well and can monitor their health when they
are sick.
Ayyagari: We are where we were with the Internet in 1990.
These are early days. Things are going to change a lot. But at
the core of all of this are the technologies that have followed
the consumer. What it comes down to is a different way of looking
at health and care. The two dimensions: health and care.
Fisher: The key point is empowerment. If you think about
the three domains - chronic disease, the elderly and health and
wellness. empowerment means something different to the consumer
in each of these categories. What I find so fascinating about the
space is you define it in a way that is most meaningful to
you. As we create the ubiquitous environment with the
interoperability standards, the market will figure out creatively
what the right health services are for the different consumer
constituents. It will enable innovation in ways that we haven't
even thought of yet.
Lopez: Let's talk about the Continua Health Alliance. What
is the Continua Health Alliance? What is its mission?
Whitlinger: Continua Health Alliance is an open industry,
nonprofit alliance. It is a collaborative organization. We are
more than 110 companies that have come together to collaborate on
bringing this connected technology to the world. It comes down to
being able to empower patients, consumers and healthcare
providers in developing new methods to deliver healthcare.
McClure: The group I work in has done a fair amount of
telemedicine work. Connected health is different. It certainly
has a telemedicine component to it, but it is a logical extension
of telemedicine. There is a distinction between the two of
them. In telemedicine, you have a clinician sitting in the middle
for reimbursement reasons and for care-delivery reasons. In
connected health or telehealth, we can envision a system in which
we don't have to have a clinician sitting in the middle of every
transaction. We envision a better health system, which enables
care when it is needed but also enables self-care.
Lopez: What types of companies are members of Continua?
Whitlinger: We have providers and payers as well as
companies specializing in medical devices, fitness devices,
consumer electronics, telecommunications, computing technologies
and electronic health records. For example some of the
representative member companies include:
- Sharp
- The Tunstall Group
- GE Healthcare
- Samsung Electronics
- Motorola
- Medtronic
- Cisco Systems
- Welch Allyn
- Intel
- Royal Philips Electronics
Lopez: One of the goals of Continua is
interoperability. How is this going to make health care more
efficient and cost effective?
Ayyagari: I would like to make a few statements about what
interoperability really means. You have policy makers talking
about interoperability as the panacea for all that ails the
healthcare system. Obviously, interoperability is something that
is both very complicated and hard to do. Otherwise, it would be
something that we would just do naturally. If you look back at
industries, like telecommunications, that have addressed the
problem, you will notice that achieving interoperability was
actually like a trapeze artist walking on a rope that was
swinging like a pendulum. It is a really difficult balancing
act. On one hand, you want to enable true interoperability to
create a marketplace big enough to have a lot of companies coming
in and having a fighting chance of making a viable business. On
the other end of the spectrum, you want people who can
differentiate their products through innovation. To win, you
need to innovate. If you have a lot of players in the market,
costs come down and technology becomes commoditized. But perfect
interoperability reduces the playing field to the lowest common
denominator, which stymies innovation. In healthcare, what will
interoperability do? A larger marketplace with more players will
naturally drive costs down. We, at this point in the healthcare
space, can certainly benefit from that the most. We don't have
to worry so much about staunching innovation as yet. Right now,
you want to break down monopolistic barriers and create big open
markets with common rules and interfaces that bring people in,
giving all technology companies a real chance at succeeding by
building innovative medical products.
McClure: What interoperability does is enable a set of
process changes that will allow us to get data and make it part
of our electronic medical record. In doing that, we will do a
better job of helping people take care of themselves. Diabetes is
one example. There is type 1 and there is type 2 and there is
the pre-diabetic and there is the out-of-control diabetic. When
we think about pre-diabetic patients, for example, we.d love to
catch people before they actually become diabetic. The
conversation is: If you don't change your behaviors, in five
years, you will become a type 2 diabetic and then you will really
have to worry about your blood sugar. You've got to lose a little
weight, you've got to change your diet, and you've got to get
more active. We can actually get paid to coach people to do
that. The payer side of the universe is really interested in us
catching people before they really have diabetes. The cost of
care is much less. You might do this through activity monitoring.
Lopez: This brings me back to the role Continua plays. Are
you making recommendations? Creating guidelines? If so, can you
elaborate on your initiatives?
Whitlinger: We started back in the middle of last year
collecting use cases. Uses cases are what the member companies of
Continua believe are going to be the user experiences that we
want to enable. We took those use cases, collected them, removed
redundancy and then had the industry.the members of Continua.vote
on the highest priorities for establishing interoperability. We
now have that set of use cases that we have turned over to
technical working groups. The output from technical working
groups will be a set of guidelines, which we will publish this
year. What those guidelines are is a collection of the standards
necessary to enable strict out-of-the-box interoperability. As a
consumer or healthcare provider, you can have a product from any
one of the member companies and it will be interoperable with the
products and services of the other companies. You don't need a
technician to glue this stuff together. It is a consumer
electronics level of interoperability. There will be a
certification and logo program. Consumers and healthcare
providers will be able to look for a Continua logo on the device
and services in this marketplace. If they see a Continua logo on
a blood pressure cuff and a Continua logo on a cell phone, they
know that the two are going to talk together. They will be able
to exchange data. Our promise to the provider and the consumer
is that it is out-ofthe- box simple. We expect to have our
certification and logo program in place at the end of the year,
and certified products in the marketplace in Q1 and Q2 of 2008.
Lopez: Partners is one of a handful of providers in
Continua. Can you give us some specific programs that you have
pilot tested in the telehealth space?
McClure: I work for the Center for Connected Health, which
is part of Partners HealthCare. It is about 35 people and has
been around for 10 or 11 years. It started out doing very
traditional telemedicine. What we have created is a model and a
methodology for how we can take ideas like that and put it in a
research and development environment to figure out the clinical
and economic outcomes that we might get. For example, four-plus
years ago, we began work on remote monitoring of congestive heart
failure in the homecare environment. We were trying to figure out
if we could get the clinical and economic outcomes. We now have
about 100 patients in service at any given time. The homecare
managers think they have about 500-plus patients at any given
time that might be eligible to be monitored remotely. They plan
on scaling to that number. The ROI turned out to be about how
Medicare pays for us to take care of those patents. Medicare
created a prospective payment system where they pay us the same
amount to take care of somebody in 60 days whether we see that
patient a lot of times or very few times. If we hold the quality
level and we figure out how to do it in a more cost effective
way, there is a win. Unfortunately, that doesn't work for Blue
Cross and Blue Shield [of Massachusetts, Inc.]. They actually pay
us each time we go see one of their patients in the home. Now we
have an incentive alignment problem.
Lopez: Do you have another example?
McClure: We are working to set up a series of research and
development experiments to figure out how to make the coaching
process more automated. Can we create an avatar that has
programming behind it that does most of the coaching? We have to
help clinicians figure out how to take care of more patients in
the same amount of time. A lot of that has to be automated
messaging. The programs we might think about are ways to help
strengthen the care-delivery process around diabetes or asthma.
Partners. Center for Connected health is very much engaged in
building out a set of programs. We have to prove this
intervention has the value.
Lopez: What are some of the barriers?
McClure: Deepak would tell me that there is nothing
special about the remote monitoring that we use. It is not high
tech. The hard part is the process change. The homecare nurse is
on the front lines in charge of the care for that patient. It is
hard to make fewer visits and instead rely on nurses to monitor
data remotely. It can be very hard work and it can be quite
murky sometimes about what the payoff is going to be. To this
day, nobody pays us to put a unit in the home. We have to take
the bet as an organization that we can provide better care and
get the payment with this technology. So far that bet has paid
off. But how much will the technology and the process change cost
us and will it be worth the money that is on the table? That is
where we will rely on our consumer electronics friends to help
drive the cost out of this. Home monitoring today is really
pretty expensive.
Lopez: You have a couple of payers in Continua. What is
their perspective?
Whitlinger: The private payers are starting to see that
there is something there. The private payers are getting
engaged. The first major activity at Continua is to put together
a landmark, baseline study for remote patient monitoring. We have
contracted out to a research organization and pooled together all
of the remote patient-monitoring trials that have occurred in the
U.S. and Europe over the last five years. We are going to take
that study and look at it objectively and say, "Here is all the
data that proves quality and outcomes." We are not likely to get
ROI data. What we would like to do with that study then is go
over to the payer community and say, "OK, Here is what the data
now says. We know that the data is probably insufficient. We
don't expect it to prove our point this year, but tell us,
payers, what is the data that is now necessary?" We hope that
dialogue will happen this fall. From there, we can decide in 2008
what to do.
Lopez: What is the next step? What will move telehealth
forward?
Fisher: One of the things that is going to be necessary,
we think, is a common language that describes the value
proposition to the various stakeholders. We think the IOM's
[Institute of Medicine] six quality aims is potentially the way
to frame that value proposition. You had talked about the dollar
ROI, but part of the value is around access and part of the value
is around quality and part of the value is around these things
that are really hard to quantify. So the comprehensive value
proposition includes more than just the direct ROI. It is
imperative, but it is not all that has to be figured out and
communicated to all kinds of different people.
McClure: Providers have an incentive to do it because they
will provide better quality of care; payers have an incentive to
do it because they will save money (they are losing quite a bit
right now on chronic disease patients); technology companies have
an incentive because they will tap into a huge market; and
consumers have an incentive because they will get better care.
Want to learn more about connected health, or the Continua Health
Alliance? Contact PricewaterhouseCoopers: James Fisher at (317)
453-4100 or click here to send him an email.
You also can visit PricewaterhouseCoopers on the web at pwc.com/healthcare or
via telephone at 800-211-5131.
Participants:
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David Whitlinger
President and Chairman of the Board,
Continua Health Alliance,
Beaverton, OR
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Deepak Ayyagari, PhD.
Principal scientist,
Personal Healthcare Technologies,
Sharp Laboratories of America, Inc.,
Camas, WA
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Douglas McClure
Corporate Manager,
Center for Connected Health,
Partners HealthCare,
Boston, MA
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James Fisher
Director,
PricewaterhouseCoopers,
Indianapolis, IN
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Fawn Lopez
Publisher
Modern Healthcare
Chicago, IL
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The views expressed by Straight talk participants are not
necessarily the views of Modern Healthcare, Crain
Communications Inc. or PricewaterhouseCoopers. Special
advertising supplement and educational session provided by
PricewaterhouseCoopers.
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