Mature Market Experts Gem of The Day: $20B For Healthcare Information Technology

j0438865 mature market electronic medical records

Mature Market Experts: more mature market news and stats more often – $20B For Healthcare Information Technology – All politics are local, so the saying goes. So, it is worth noting that the amount of money being allocated in the new recovery and reinvestment law will affect all of us in some way on a local level—either for the good or the bad. Of particular interest to me is the roughly $20B allocation associated with healthcare information technology. As healthcare and its peripheral topics are of interest to me by education, training and profession, this particular expenditure carries with it both hope and caution. The expenditure carries hope from the perspective that the promise of universal electronic medical records can ultimately improve the quality of care for us all. The caution is that the devil is in the details and there is the possibility—and likelihood—that the challenges associated with implementing and administering such a technological advancement will not be resolved for many years to come.

Returning to the “politics are local” theme for a moment, the challenges with universal health records (note: NOT universal health care…I’ll leave that political debate alone for the time being) are in their implementation and acceptance across the U.S. It is not sufficient to simply supply each primary care provider with a laptop computer…there is the issue of the medical record software itself. Both Microsoft and Google have made large investments in personalized health records (I have one myself). But access to these data, the adoption of the medium across the country, identification of the patient, securing and protecting the information from unauthorized review, and many other challenges are before us.

These challenges will not be resolved by merely spending ~$20B on healthcare information technology initiatives. To address these challenges requires a unified effort across multiple fronts, including breaching technological and sociological boundaries. The basic tenets of restricted and assured access as well as accuracy of the data are so significant and are of such dire import that their mentioning cannot be overemphasized. From an academic perspective one might conclude that “of course” these items and more must be guaranteed. However, we in the U.S. have at present no common standard for enabling and ensuring these two most basic of operational items in this day and age. Certainly the technologies exist to meet the demands of these key requirements. But, their seamless, universal application is presently not available nor enforceable throughout the continuum of care nationwide. This is so for many reasons. Key among these reasons is the lack of enforced standardization for interoperability among the many, many standalone healthcare information technology systems. Many lone islands are available which cannot communicate among one another. The investment required to achieve this feat is in no way trivial. Furthermore, common standards for storing this information so that it may be retrieved at a hospital, say, in Orlando, Florida while I am away on business, have yet to be put into place.

So, how do we proceed? Well, in order to achieve the vision, all hospitals that acquire new or upgrade existing healthcare information technology systems (inclusive of electronic enterprise health records) should mandate that these systems interoperate with each other so that orders, medications, patient vital signs, laboratory results, imagery, and other information can be shared seamlessly among the many disparate systems that can coexist within a healthcare enterprise. This implies that such systems must support common data and information communication frameworks such as those proffered by Health Level 7 (HL7), DICOM, and others. Furthermore, such systems must provide the capability to support role-based user access to all stored information so that patient data will only be revealed to individuals with a need to know. Special care must be given to any information such as patient data for numerous reasons including safety and privacy. Additionally, repositories of patient information must be made available to clinicians anywhere at any time. Access must be reliable, assured, the data must be accurate and beyond question in terms of its integrity.

The aforementioned requirements are only a subset of those needed to support a truly universal form of electronic health record throughout the many thousands of enterprises worldwide. I have not made mention of the standards of care and how these can vary worldwide. Even if such a universal medium for storing and accessing patient information were confined to the United States alone this is a nontrivial challenge. However, I believe it is necessary to overcome given the even greater challenge of improving the quality of healthcare and reducing its ponderous costs in the years to come.

Note: more blog entries on electronic medical records can be found here.

Mature Market Experts Gem of The Day: Serving Aging Populations with Remote Monitoring Technologies

42-17073549 telehealth mature market experts

Mature Market Experts: more mature market news and stats more often – Serving Aging Populations with Remote Monitoring Technologies – Estimates by the U.S. Census Bureau expect the population of Americans aged 65 and older to increase by more than a factor of two between 2010 and 2050 [1]. At the same time estimates of healthcare expenditure increases between 2007 and 2017 show an increase to nearly 20% of GDP in this period [2]. These estimates were made prior to the recent financial crisis that began during the Fall of 2008. Further compounding this increasing demand and the concomitant increase in costs is the availability of allied healthcare professionals. Some studies [3] identify the likely decrease in the number of physicians entering any number of key specialty areas, including cardiology (20% decrease by 2020), geriatrics (35% of current demand met today), rheumatology (38 day average wait for a new appointment), and primary care (on the verge of collapse). Those of us who are baby boomers are on the leading edge of this demand and, in order to mitigate and minimize the cost impacts on our children, it is our challenge and responsibility to innovate and meet these challenges without passing along unnecessary burdens to our children and grandchildren.

For most of us, aging means more frequent and severe afflictions. Taking care of our health by improving diet, exercising, and maintaining an otherwise active lifestyle is essential to ensure a high quality life. Even with increased vigilance chronic ailments can affect us later in life, brought on both by our genetics and consequentially due to the lifestyles we’ve led in our youths. Ailments such as dementia, coronary artery disease, Alzheimer’s, myocardial infarction, congestive heart failure, macular degeneration, osteoporosis, hypertension, chronic obstructive pulmonary disease, diabetes, and others take their toll. Managing chronic diseases is costly from a logistical perspective in terms of time and money. However, even more to the point, effective and quality oversight of patients with chronic ailments requires regular review, screening, and monitoring of patients. This is further complicated by the need to serve patients who lack the means or are physically incapable of leaving their homes for extended periods. Telehealth and remote monitoring are a means by which a case manager—an individual assigned to oversee the care of chronically ill patients within a home-health setting—can review patient information on a regular basis (for example, daily) and support both the patient and the primary care provider. Furthermore, Intensive care units and emergency departments are becoming more crowded. Individuals with insurance are going to EDs because they cannot find satisfaction in terms of prompt scheduling with their gatekeepers (family practitioners). The quantity of individuals with chronic ailments is on the rise (stroke, CHF, diabetes, COPD, etc.) This is in part due to the fact that people are living longer. At the same time the Medicare and SS systems will not be able to sustain the growth in population over age 65. This means that working individuals will increasingly bear the financial burden for us “boomers.” As a result of increased longevity and the fiscal challenges, the retirement age will increase.

So, what do we do? Well, several things: first, technology in the form of remote data collection, reporting devices and software will become more prevalent: glucometers, BP cuffs, spirometers and associated software will be more readily available for direct communication with personalized electronic health records. If the purpose of a typical visit is to take BP and diabetic assessments, this can be handled most by collecting data at the point of care (home) and transmitting to the physician’s office for assessment. Such also applies to nursing and assisted living facilities. Next, the technical infrastructure required to transmit and store these data will be required. Paying for this infrastructure could come from a number of sources. One possibility: most everyone nowadays has access to cable television. Cable companies could offer devices that integrate with existing modems to collect and transmit data to the FP, together with complementary emails to next of kin (e.g. “Your mother’s BP as of 8:10 this morning was 145/89”). Other technologies that can be used to evaluate and monitor chronic ailments such as macular degeneration can further reduce costs by providing video cameras at point of care whereby ophthalmologists can review retinal changes without requiring an elderly individual to be transported at expense and time to a hospital or office. In addition, support for remote consults via VoIP and video can be supported over the same network. This empowers the remote provider with the ability to interact with the patient All of these technologies are in use in remote pockets around the world today. But, they will become more prevalent. These technology implementations will reduce costs and provide for more personalized care in comfortable settings (homes). Of course, nothing takes the place of the tactile hands-on. But, for routine visits the above will be invaluable. In terms of the software technologies, personalized medicine will become the norm (eventually). Telehealth will be key. But, also, support for automated workflow in the acute care environment will need to be augmented. This means fully integrating all data into the enterprise HIS.

 The U.S. Department of Health and Human Services through its Office of the National Coordinator for Health Information Technology published operational scenarios focused on providing key information to assist in harmonizing standards on the implementation, certification, and policy implications for robust remote patient monitoring [4]. Included in this assessment are requirements on interacting with personalized health records and enterprise health information systems. The approaches to advancing remote monitoring include both seamless communication from medical devices at the point of care (i.e., in a patient’s home setting) and with a case manager and primary care provider both through electronic transfer, storage, and display of health information and remote video and audio interaction with patients in the same home health setting.

 Technology is not the silver bullet, but those described above are key enablers for remote health monitoring. Of course, the use of technology carries with it the implication that sufficient underlying infrastructure exists. This is not always the case in remote areas of the country. Satellite, cable, and fiber optic technologies are fairly extensive within the continental United States, but pockets and regions exist in which this is not the case. Therefore, a combined effort to extend the communications infrastructure must continue together with a unified effort to standardize and train and “in-service” individual care providers on these technologies must occur. One of the best mechanisms for enabling this is through the local hospitals and their satellite clinics.

[1] Source: Population Division, U.S. Census Bureau, August 14th, 2008; Table 12: “Projections of the population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12)”

[2] Cinda Becker, “Slow: Budget Danger Ahead,” Modern Healthcare, March 3rd 2008.

[3] “Recent Studies and Reports on Physician Shortages in the U.S.,” Center for Workforce Studies, Association of American Medical Colleges, August 2007.

[4] “Remote Monitoring Detailed Use Case,” U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, March 21st, 2008.

So, how long do we have? Well, the sooner the better. Successful telehealth and remote monitoring programs exist throughout the United States and worldwide today. We should ensure that our elected representatives direct healthcare expenditures towards several specific areas to promote growth and alignment to meet the objectives of remote monitoring. These include continuing alignment on electronic personalized health records, expansion of our underlying communications infrastructure, and promoting common standards of communication among these records so that, regardless of location, a patient can communicate his or her information to any physician and allied health professional within the country. In summary: common storage, homogeneous communication, standardized formats.



Mature Market Experts Stat of The Day: Nanotechnology in Medical Diagnosis and Treatment

j0438738 mature market cancer

Mature Market Experts: more mature market news and stats more often – Nanotechnology in Medical Diagnosis and Treatment- The average size of the avian influenza virus is on the order of 100 nanometers, or 0.1 microns. That a virus so small can wreak such havoc on the human body is a testament to the complex mechanisms associated with these infections. The ability to ward off such infections is also a testament to the awesome nature of the human immune system. By comparison, the width of a typical human hair is on the order of 100,000 nanometers (estimates put the range at 50,000 – 150,000, depending on the specific type of hair).

Now, consider the field of nanotechnology which focuses on the manufacture and fielding of mechanical and electronic devices of microscopic size, typically on the order of 100 nanometers or smaller. The National Cancer Institute (NCI) provides a fairly detailed overview of the use of nanotechnology in cancer treatment, and the NCI Alliance for Nanotechnology in Cancer is an initiative that provides a focal point for public and private investigation for the application of nanotechnology to the treatment of cancer. Researchers and companies have been investigating the manufacture of devices of this order of magnitude and smaller for application in the treatment of disease. A major focus for nanotechnology in healthcare is, not surprisingly, the treatment of cancer. Specific methods and modes of delivery vary. Examples include outfitting little “robots” with markers that will burrow into and attach themselves to cancerous cells for the purpose of enabling treatment and destruction of malignant cells. A major benefit of this approach versus traditional methods of radiation and chemotherapy is that the malignancies can be targeted directly without attacking or otherwise molesting healthy cells. This is a major advancement, since many of the current therapies that attack cells indiscriminately will kill both healthy as well as malignant cell material. When battling this terrible disease the last thing needed is to destroy those healthy cells upon which the individual depends for sustenance and survival. Thus, nanotechnology provides a mechanism for delivering targeted, customized, tailored therapy.

 While we are on the cutting edge of the application of these technologies, the vision is real, and it is extremely promising. Treatment is only one aspect of nanotechnology use. Diagnosis is another area, in which nanoparticles can be used to assist in imaging of potential malignancies.

 While almost a cliché, the aging of the baby-boomer population will drive a number of these new technologies, applications, and initiatives. It is almost a tautology that early diagnosis of disease translates into a higher likelihood of survival. Technologies that support early diagnosis are, therefore, of great value and will enable better, more efficient, and more accurate treatment of disease going forward. As a member of this generation (albeit, at the tail end), I am very encouraged and supportive of this research. I recall some 17 years ago when my mother passed away from breast cancer that the use of exotic technologies such as nanotechnology was barely an inkling. Indeed, the three oft-used mechanisms for treating cancer have remained surgery, irradiation, or poisoning (chemotherapy). It has only been within the past 10 years or so in which alternative therapies have been devised and discovered that are not simply variants of these three. Research into the targeted treatment of cancer by destroying the genetic material within malignant cells so that they cannot reproduce or cannot receive nourishment is an astonishing advancement and offers great future promise—a testament to human ingenuity, talent, innovation, and creativity. As in vitro and in vivo medicine evolve, such future-looking technologies will be essential in terms of early diagnoses and intervention.

Mature Market Experts Gem of The Day: Healthcare Delivery is a Systems Integration Challenge

Mature Market Experts: more mature market news and stats more often – Healthcare Delivery is a Systems Intergration Challenge – There’s an old saying: if you want a new idea, read an old book. There’s another saying: those who do not learn from history are doomed to repeat it. Keep these two thoughts in mind as you proceed through this piece.

The healthcare “system” is really a system of systems. Enterprise health information systems (eHIS) are but one component of this system of systems. The integrated whole of the healthcare environment involves the technology, the people providing the care, the people managing the enterprise, the payers, and the workflow peculiarities of the environment in general.

Herein lies the old book. Those working in the aerospace industry are, perhaps, those most familiar with the system of systems integration concept. Systems integration has been a discipline employed by those working in the aerospace and defense fields. In these fields, large-scale systems need to be combined, coexist, and cooperate harmoniously within a larger context or framework. These frameworks, sometimes referred to as system-of-systems (SoS) architecture, are typically used to achieve component and interface commonality to promote reuse across separate and potentially disparate subsystems and components. The Department of Defense (DoD) published a framework [1] for establishing a coordinated approach for Command, Control, Communications, Computers, Intelligence, Surveillance, and Reconnaissance (C4ISR), whose principal objective was to ensure that architectures created and systems developed by various branches of the DoD would be synergistic and standardized across operational, technical, and organizational boundaries. Chen & Clothier [2] discussed the maintenance of sustainable and controlled SoS evolution. However, their application related to the concept of SoS with respect to military applications, as does the C4ISR, being chartered by the DoD.

Attempts to apply the C4ISR framework to commercial industry abound. Systems Engineering processes and Systems Integration as disciplines are being discussed and applied outside of the DoD domain in telecommunications and healthcare, to name two specific instances. However, even in these industries the main focus of SoS has been on the integration of a single product (that is, the product’s architectural components). This is somewhat different from large-scale, multi-system SoS architecture, in which separate stakeholders and developers, quite possibly outside of the integrating organization, must also participate in the overall solution.

So, what are the parallels to healthcare? Healthcare delivery involves wide-ranging, disparate, seemingly autonomous enterprises: hospitals around the country and around the world. Commonality exists in the form of (fairly) consistent clinical training: medical treatment protocols are the same regardless of where you go in the United States. Basic medicine and its teaching are consistent and uniform worldwide. Yet, the infrastructure to support patients and providers in the delivery of that care can vary from hospital to hospital; enterprise to enterprise; region to region; and country to country. For instance, take any emergency department (ED) in the U.S., and you will see basic medicine being practiced consistently (for the most part). But, depending on the sophistication, financial health, population, and training of the providers and supporting staff, the tools with which care is delivered and managed can be quite different. One ED may have a computerized tracking board for managing patients. Another may have a white board and no computers; yet another may record patients on a simple clipboard. The methods of management are different, but the approaches to care are the same. The benefits derived from more efficient management can be astonishing: lower mortality rates, higher throughput, and higher customer satisfaction.

Standardization across the healthcare enterprise is the subject of efforts by many standards and oversight organizations. One example includes the HL7 standard for healthcare data communication and interoperability standards related to medical device integration with electronic health information systems. But, where healthcare could benefit is by recognizing that this truly represents system of systems integration: each separate healthcare enterprise represents a separate system. The ability to communicate, interoperate, and exchange information among these separate enterprises is the subject and the goal of the system of systems: each autonomous enterprise can interact with its sister enterprise.

So, what are the benefits of achieving this result? One that resonates most closely to home is described in the following scenario. Consider falling ill in a foreign city—regardless of whether in country or globally—and being able to go to the local hospital and have all of your medical records displayed in a format consistent with that display in your home town. The benefit to you is any remote or foreign healthcare enterprise can have the complete detailed record of you. This mitigates errors, reduces the time required to provide treatment, and ensures that your entire history is accurately presented to any clinical user to provide the capability to manage your health better.

This is where history can teach us a lesson: those in the aerospace industry have understood this need for decades. However, the pace of progress has been much slower in healthcare than in the aerospace field. Yet, consider the benefits to patient, provider, insurer. Sometimes the cost of proliferating the not-invented-here attitude can have vast implications which complicate basic care. Healthcare would do well to think outside of its own “box” and draw upon the tools and stride the well-worn paths traversed by others in fields remote to medicine.

[1] C4ISR Architecture Framework, Version 2.0: Report of the C4ISR Architecture Working Group (AWG); 18 December 1997.

[2] Pin Chen, Jennie Clothier, “Advancing systems engineering for systems-of-systems challenges,” pp170-183, Systems Engineering Journal, Volume 6, Issue 3.