The Barriers to Military Healthcare Technological Innovation and What We Can Do to Remove Them DoD & VA Electronic Health Records Symposium Washington, DC Shahid N. Shah, Chairman - OSEHRA Strategic Advisory Board

NETSPECTIVE www.netspective.com 2 Who is Shahid? • Serial healthcare IT entrepreneur, advisor to numerous startups, blogger, healthcare technology futurist • Chairman, OSEHRA Strategic Advisory Board • 23+ years of software engineering and multi-site healthcare system deployment experience in Fortune 50 and Government sectors. • 15+ years of healthcare IT and medical devices experience (blog at http://healthcareguy.com) • 15+ years of technology management experience (government, non-profit, commercial) • 10+ years as architect, engineer, and implementation manager on various EMR and EHR initiatives (commercial and non-profit) Author of Chapter 13, “You’re the CIO of your Own Office”

NETSPECTIVE www.netspective.com 3 What’s this talk about? Questions answered • Is disruptive innovation in military healthcare technology possible? • What does innovation in military healthcare mean? • Where are the major areas in military healthcare where innovation is required? Key takeaways • Go narrow, specialize, dive deep • Understand PBU: Payer vs. Benefiter vs. User • Understand why military healthcare agencies buy stuff so you can build the right thing

NETSPECTIVE www.netspective.com 4 What does “disrupting healthcare” mean? This is $1 Trillion and the Healthcare Market is about $3 Trillion MHS is about $50 billion ~10 million beneficiaries This is $1 Billion

www.netspective.com 5 No, your innovation will not disrupt military healthcare. I promise. The good news is that doesn’t have to.

www.netspective.com 6 No, your big data or mobile ideas will not disrupt military healthcare. But if you can use them to add or extract value from the existing system, you’ll do just fine.

www.netspective.com 7 No, your EHR/PHR or app will not be used by enough MHS doctors or patients to disrupt healthcare. But if you can get even a fraction of them to use your software, you’ll do just fine.

www.netspective.com 8 No, your innovation will not be easily accepted by permissions- oriented institutions. Find customers with a problem-solving culture willing to accept risks and reward failures.

www.netspective.com 9 No, your innovation will not be easily integrated into regulated device-focused clinical workflows. Incumbent vendors will not entertain the potential of new legal liabilities without someone to share it with or new competition without direct compensation.

NETSPECTIVE www.netspective.com 10 What I mean by “actionable innovation” You have made the job of identifying, diagnosing, treating, or curing diseases faster, better, or cheaper for clinicians through the use of information technology (IT) or business models. You have made the job of self-diagnosing, self- treating, or preventing diseases and improving overall wellness of patients through the use of new incentives, business models, or IT.

NETSPECTIVE www.netspective.com 11 How innovation in military healthcare is different Health IT Experience Single Payer System Information Sharing Data Interoperability Strong Program Management Significant Systems Engineering Capabilities As described by Dr. Paul Tibbits at the conference this morning “Improve tech and you save money, improve information sharing and you save lives”

NETSPECTIVE www.netspective.com 12 Top killers today Heart disease Cancer Chronic lower respiratory diseases Top killers in 1900 Pneumonia and influenza TB Diarrhea and enteritis Infectious diseases used to kill us… …but what’s left seem only to be “manageable” not easily “curable” Per 100k population, Historical Statistics of the United States, Millennial Edition

NETSPECTIVE www.netspective.com 13 Death by age group, 1900 Death by age group, Today From cures to management… …young people don’t dye of diseases often now http://siteresources.worldbank.org/INTHSD/Resources/topics/Health-Financing/HFRChap1.pdf

NETSPECTIVE www.netspective.com 14 What Is the business of military health care? • It's always better to define an organization by what beneficiaries want than by what you can produce or build – For example, whereas doctors and hospitals focus on producing health care, what people really want is health – What makes military health innovation different from non-military health? • In the future, successful doctors, hospitals, and health systems will shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health. What business are you in? The Emergence of Health as the Business of Health Care Source: http://www.nejm.org/doi/full/10.1056/NEJMp1206862

NETSPECTIVE www.netspective.com 15 PBU: Payer vs. Benefiter vs. User Payer Benefiter User If you don’t understand the exact interplay between PBU your product will fail The payer is the person/entity that writes the check for your product. The person or group that benefits most from the use of the product. The person or group that actually uses the product.

NETSPECTIVE www.netspective.com 16 What kinds of military users are you targeting? Go narrow and deep not wide and shallow • Obesity Management • Wellness Management • Assessment – HRA • Stratification • Dietary • Physical Activity • Physician Coordination • Social Network • Behavior Modification • Education • Health Promotions • Healthy Lifestyle Choices • Health Risk Assessment • Diabetes • COPD • CHF • Stratification & Enrollment • Disease Management • Care Coordination • MD Pay-for-Performance • Patient Coaching • Physicians Office • Hospital • Other sites • Pharmacology • Catastrophic Case Management • Utilization Management • Care Coordination • Co-morbidities Prevention Management 26% of Population 4% of Costs 35% of Population 22% of Costs 35% of Population 37% of Costs 4% of Population 36% of Costs Source: Amir Jafri, PrescribeWell

NETSPECTIVE www.netspective.com 17 Defining your military PBU participants is really hard Target military health sector? Number of staff or participants? Annual agency spend? Geography? Number of hospital beds? Number of patients? Type of patients? The list goes on and on…be specific! Don’t focus on market segmentation, but do try to figure out who your customer is

NETSPECTIVE www.netspective.com 18 How will your customer pay for your innovation? Direct Payment • Your best option • Very few truly disruptive technologies can be directly paid for by providers within the USA • Limited adoption of ‘traditional’ pay for service reimbursement for next generation technology Direct Reimbursement • Second best option • Improvements in technology are outpacing payer adoption • Reimbursement will come but its time consuming and difficult Indirect Reimbursement • Emerging option • Payer requirements for improved quality and efficiency are creating indirect incentives to adopt innovative solutions • Solutions targeting new value-based reimbursement incentives are highly useful to medical providers If you haven’t figured it out for them, customers will not figure it out for themselves

NETSPECTIVE www.netspective.com 19 Where does your innovation fit? Therapies Therapeutic Tools Diagnostic Tools Patient Administration Patient Education Target the right market so you understand the regulatory impacts Most Regulation Least Regulation Be aware of regulations, don’t fear them, use them as a competitive advantage

NETSPECTIVE www.netspective.com 20 What problem will you be solving? Improve medical science? Improve access to care? Reduce costs? Improve therapies? Improve diagnostics? Improve drug design? Improve drug delivery? Create better payment models? Focus on jobs that need to be done, not what you want to build

Data for health or cost reductions Identifying opportunities in military health ecosystem

www.netspective.com 22 When does data matter? Only when we use it.

www.netspective.com 23 When will we use the data? When we can trust it. When we can access it.

www.netspective.com 24 When will we trust the data? When it doesn’t “suck”. 

www.netspective.com 25 How do we know data doesn’t “suck”? When it’s “actionable” – or probably when we can use it to make decisions based on it (e.g. for jobs to be done, workflow, etc.).

www.netspective.com 26 Unused data never gets better. Fix broken windows. Iterate your way to better data by forcing its use.

NETSPECTIVE www.netspective.com 27 Application focus is biggest mistake Application-focused IT instead of Data-focused IT is causing business problems. Healthcare Provider Systems Clinical Apps Patient Apps Billing Apps Lab Apps Other Apps Partner Systems Silos of information exist across groups (duplication, little sharing) Poor data integration across application bases

NETSPECTIVE www.netspective.com 28 NEJM believes doctors are trapped It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life. New England Journal of Medicine “Escaping the EHR Trap - The Future of Health IT”, June 2012

NETSPECTIVE www.netspective.com 29 Real world requirement: Reduce heart failure readmissions Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study http://qualitysafety.bmj.com/content/early/2013/07/31/bmjqs-2013-001901.full “This study provides preliminary evidence that technology platforms that allow for automated EMR data extraction, case identification and risk stratification may help potentiate the effect of known readmission reduction strategies, in particular those that emphasize intensive and early post-discharge outpatient contact.”

NETSPECTIVE www.netspective.com 30 NCI App NEI App NHLBI App Healthcare Provider Systems Clinical Apps Patient Apps Billing Apps Lab Apps Other Apps Master Data Management, Entity Resolution, and Data Integration Partner Systems Improved integration by services that can communicate between applications The Strategy: Modernize Integration Need to get existing applications to share data through modern integration techniques including minimal meta data.

NETSPECTIVE www.netspective.com 31 Common approach, low data interop Application A Data Functionality Presentation Feature Y Feature X Application B Data Functionality Presentation Feature Y Feature X Feature Z Copy features and enhance (everything is separate) Application A Data Functionality Presentation Feature Z Feature X Application B Data Functionality Presentation Feature Y Feature X Feature Z Connect to directly to existing data, but copy features and enhance

NETSPECTIVE www.netspective.com 32 Services Sophisticated, better data interop Application A Data Functionality Presentation Feature Y Feature X Application B Data Functionality Presentation Feature Y Feature X Feature Z Create API between applications, integrate data, create new data Application A Data Functionality Presentation Feature Z Feature X Application B Data Functionality Presentation Feature Y Feature X Feature Z Create common services and have all applications use them REST SOAP, RMI SOA APIs WOA

NETSPECTIVE www.netspective.com 33 What’s being offered to users What users really want What users want vs. what they’re offered Data visualization requires integration and aggregation and then homogenization

NETSPECTIVE www.netspective.com 34 The myth of mobility in healthcare Sexy but wrong: Device-centric closed systems Dull but right: Workflow-centric open solutions

NETSPECTIVE www.netspective.com 35 The myth of med device data interop Device Serial Converter USB Converter Concentrator Local Network Gateway to EHR Cloud EHR DDS MQTT REST SOAP AMQP XMPP WCTP SNMP SMTP MLLP

NETSPECTIVE www.netspective.com 36 Architecture transition opportunities Mainframes Client/Server Web 1.0 Service-oriented Architecture (SOA) Web 2.0 & APIs Web-oriented Architecture (WOA) Event-driven Architecture (EDA) Data-driven Architecture (DDA) Prevalent healthcare industry architectures EDI HL7 X.12 MLLP DDS MQTT SOAP AMQP XMPP WCTP SNMP REST SMTP MLLP

NETSPECTIVE www.netspective.com 39 How to identify the best opportunities Circumstance • The specific problems a customer cares about • The way they assess solutions Context • Find a way to be with the customer when they encounter a problem and • Watch how they try to solve it Constraints • Develop an innovative means around a barrier constraining consumption Compensating behaviors • Determining whether a job is important enough to consider targeting • One clear sign is a customer spending money trying to solve a problem Criteria • Customers look at jobs through functional, emotional, and social lenses From “Jobs to be Done” to the “Five Cs of Opportunity Identification” Source: http://blogs.hbr.org/anthony/2012/10/the_five_cs_of_opportunity_identi.html

NETSPECTIVE www.netspective.com 40 The business needs • Quality and performance metrics • Patient stratification • Care coordination • Population management • Surveys and other direct- from-patient data collection • Evidence-based surveillance The technology strategy • Aggregated patient registries • Data warehouse / repository • Rules engines • Expert systems • Reporting tools • Dashboarding engines • Remote monitoring • Social engagement portal for patient/family Do you have ideas in payment design? Payment models going fee for service to outcomes-driven care

NETSPECTIVE www.netspective.com 41 Can you repurpose or enhance health data? Proteomics Genomics Biochemical Behavioral Phenotypics Economics Try to use existing data to create new diagnostics or therapeutic solutions IOT sensors Administrative

NETSPECTIVE www.netspective.com 42 Some stuff not to focus on • Don’t go for simple incremental technology innovation if you can be bold and incrementally improve workflow; but make it look like you fit into the existing ecosystem nicely • Don’t look at mHealth, look at mobility in healthcare • Don’t look at apps, look at entire systems Incremental tech innovation is easier, incremental workflow innovation is probably more useful

NETSPECTIVE www.netspective.com 43 Forget mobile apps, focus on health IOT • With all the attention being paid to mHealth there’s been an useless focus on mobile apps • For the mobile apps, instead focus on mobility in healthcare through “health internet of things (IOT)” and self-care technologies

NETSPECTIVE www.netspective.com 44 Healthcare Industry Fallacies • Healthcare folks are neither technically challenged nor simple techno-phobes (they’re busy saving lives) • Most product decisions are no longer made by clinical folks alone, CIOs are fully involved • Complex, full-featured, products are not easier to sell than simple, stand alone tools that have the capability of interoperating with other solutions are • Hospitals will not buy unless one proves value. • Selling into doctors offices is not easy.

NETSPECTIVE www.netspective.com 45 What makes your products successful • Easy to explain • Defendable and differentiated • Attractive partnership opportunities • Word of mouth opportunity • Potential for PR • Scaleable staff and systems • Scaleable product — build once, sell many times • Uncomplicated • Focused • Sales model is scaleable and predictable • Own relationship with and information about customers

NETSPECTIVE www.netspective.com 46 Why military healthcare organizations buy stuff Increase revenue (topline) Maintain capabilities Reduce costs (bottomline) Attract new patients Increase staff productivity Find your reason Healthcare agencies have complex buying processes – figure out why and what they buy

NETSPECTIVE www.netspective.com 47 The Customer Relationship Customer Gives You Get • Money • Time • Energy • Commitment • Referrals • Past experience • Expectations • Knowledge You Give Customer Gets • Product • Price • Value • Convenience • Selection • Service • Warranty • Brand If you can’t figure out why they buy, see if any of the things below make sense

NETSPECTIVE www.netspective.com 48 Health technology sector has many ups and downs Make sure you understand where your product fits in the hypecycle Source: Gartner; “Hype Cycle for Healthcare Provider Applications and Systems, 2010”

Thank You Visit http://www.netspective.com http://www.healthcareguy.com E-mail [email protected] Follow @ShahidNShah Call 202-713-5409