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The Barriers to Military Healthcare Technology Innovation and What We Can Do to Remove Them

Shahid N. Shah
September 30, 2013

The Barriers to Military Healthcare Technology Innovation and What We Can Do to Remove Them

This briefing was presented at the Military Electronic Healthcare Records Symposium in Washington DC. It answers the following questions:
* 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?

Shahid N. Shah

September 30, 2013
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  1. 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

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    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”

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    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

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    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

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

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    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.

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    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.

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    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.

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    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.

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    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.

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    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”

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    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

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    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

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    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

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    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.

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    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

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    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

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    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

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    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

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    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

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

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    When does data matter?
    Only when we use it.

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    When will we use the data?
    When we can trust it.
    When we can access it.

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

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    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.).

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

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    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

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    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

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    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.”

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    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.

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    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

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    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

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    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

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    The myth of mobility in healthcare
    Sexy but wrong: Device-centric closed systems Dull but right: Workflow-centric open solutions

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    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

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    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

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    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

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    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

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    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

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    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

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    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

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    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.

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    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

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    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

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    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

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    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”

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

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