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

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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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”

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

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

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

Shahid N. Shah

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