Health Care of the Future: Interoperability

Today I had the honor of delivering the keynote speech at the Nashville Business Journal’s Health Care of the Future event at the Music City Center. It was a challenge to tackle this vast subject in just 15 minutes. Following is the text of my speech, which focuses on three of the many factors that define the future of healthcare, consumers, advanced data analytics and care coordination, and covers some of the exciting efforts underway at HCA Healthcare. I hope you find it interesting.

Thank you for the kind introduction. It’s a pleasure to be here with this esteemed group. I’d like to set the stage for today’s discussion by focusing on three main areas – the future of healthcare, the importance of interoperability and the opportunities that exist for Nashville.

Future of Healthcare

Some people say if you want to know the future of healthcare, just look at the present day state of being for any other industry. Now, while it may be true that healthcare has ample room to improve, as CEO of one of the largest healthcare companies in the U.S., I take issue with such a broad generalization. Yes it’s true that the industry has opportunity to improve how it leverages technology, meets evolving consumer demands, and conducts business to deliver the best results possible…in the shortest timeframe…at an affordable price. But I know the exciting developments taking place within this industry, and I can tell you from firsthand experience that not all providers are created equally. I’ll talk a little more about that in a minute, but let me just narrow our focus a bit. Many factors define the future of healthcare, some we can control, others we can’t – Washington, D.C. and genetics are the first that spring to mind. But since we can’t spend the week here discussing this, I’m going to focus on three that are particularly relevant to the interoperability dialogue – consumers, advanced data analytics and care coordination.

First, we all know that consumer expectations continue to rise and expand. We’re not just competing within the healthcare industry, but beyond it. The seamless, convenient, secure experiences enjoyed in other facets of life – like retail, finance and transportation – are now expected in healthcare. It’s no longer about Provider A versus Provider B; it’s about Provider A compared against Starbucks, Amazon and Uber. This holds especially true among younger generations, who have grown up with real-time, on demand access to information. It doesn’t matter whether it’s to answer a random question, pay a bill, listen to music or get directions – accurate information is readily available…and personal information is safeguarded. Grocery shopping and buying clothes no longer require a trip to the store. You can order online or on an app and have anything shipped to your house – shopping that’s convenient for you, conducted privately, securely and on your timeframe.  Consumers expect higher levels of service to get what they want, when they want it. They also expect greater value and transparency. They want to know how much something is going to cost (before buying it) and how it’s supposed to perform (or its quality). They’ll determine for themselves what constitutes value.

So what are the implications of this for healthcare? When we talk of healthcare consumers, we have to consider both the patient and those who provide the care. The tools and technologies we use to take care of people have to work well together in order to be useful to clinicians and other caregivers. The more cohesive the toolset, the better able we are to meet consumer expectations – and we all know that satisfaction has real implications for the bottom line.

Healthcare is often thought of in two contexts – one at the individual level and one at the population level. The need to deliver person-centered care for individuals and manage the health of populations will continue to grow in importance.  At HCA Healthcare, we have a 50-year tradition of providing patient-centered care, but the expectations for patients have changed. Traditionally when we have conducted consumer research about one of our facilities, satisfaction related to the overall outcome, and people tended to be generous in their assessments.  Well today, things are different.  Now patient-centric care means making my care about me. Timely care means not only when I need it, but when I want it. Convenience is about not just whether there is a hospital close enough to my home to make me feel safe, it’s about a network for multi-level care facilities that are available where and when I want to access that care. And, the care is tailored to my unique biological, genetic and social factors, as well as my cultural and language preferences. Consumers will continue to demand greater value and emphasize outcomes that are meaningful to them, especially as healthcare costs take up more of their household budgets. They will further embrace digital and social media platforms to share their experiences and increase transparency, so providers need to be prepared for growing scrutiny and readily respond to feedback. At HCA Healthcare, we have developed an extensive reputation management team whose sole purpose is to monitor and engage with consumers of care from our facilities, to ensure their experiences are satisfactory, and if we fall short of the mark, to intervene – real-time – and resolve whatever issues those patients or their caregivers may have.

Population health is about the distribution and determinants of health outcomes. It focuses on illness prevention and management of illness when it is present. Aspects of population health management include nutrition guidelines, encouragement and availability of appropriate physical activity, assistance with tobacco cessation and avoidance, and addressing vulnerabilities such as poverty, literacy and access to care. Healthy consumers at the individual level lead to healthier populations, so it’s imperative that we establish meaningful relationships with those we care for and engage them in managing their health. We also seek to proactively manage entire populations rather than being reactive and treating those who present at the hospital or office with symptoms. We are fortunate in Middle Tennessee to have the support and engagement of leaders like Mayor Berry and Governor Haslam, who have initiated and advanced programs at the community and state levels, to support and encourage wellness and access to care, particularly for some of our most vulnerable populations. All of this, of course, relies on data.

This brings us to the second factor in the future of healthcare, advanced data analytics. Advanced data analytics fuels growth and competition, serves as a primary driver of both patient-centered care and population health management, and enables data-driven quality improvement and scientific discovery. It’s predicated on the ability to move from capturing data to creating knowledge and applying wisdom.

The term big data has become commonplace in healthcare. Its role is to help us see and understand the relationships within and among pieces of information. These include hidden patterns, unknown correlations, trends, preferences and other information useful to clinical care and operations. Big data are defined by the three V’s – volume, variety and velocity. Volume refers to the amount of data. HCA Healthcare, for example, has generated over 120 petabytes – that’s enough to fill the planet Jupiter with data. The scale at which we can learn and make discoveries is tremendous. Variety refers to the different types of data. We have to be able to learn from both structured data, like lab results and electronic medication orders, and the more complicated unstructured data, like images and doctor’s notes. I recently returned from a healthcare study mission in London with the Nashville Health Care Council, and during one session we were given a presentation by a duo of researchers whose company was acquired by Google. When I asked them about their experiences with unstructured data, they indicated this was a challenging area, one that is difficult to mine for useful information.  But I will tell you that HCA Healthcare is applying big data analysis in unstructured spaces, to glean information in the clinical, communications and billing spaces. We have the ability to identify lung cancer tumors that might otherwise have gone undetected because their presence in a scan was noted as a secondary care issue; we can identify the appropriate ways in which to address the concerns of patients based on stated cultural reference points that are important to them; and we can use language in billing disputes with payors that creates a greater opportunity for success.  All of these advancements stem from analysis of unstructured big data.

Velocity refers to the speed of data processing, which has been drastically reduced by advances in computing power. Our aim is to achieve consistent, real-time analytics to assist clinicians at the point of decision. You can add a fourth V for veracity, which refers to the quality of the data and our ability to trust their accuracy.

Analytics is a never-ending realm of discovery. Efforts to build the collective body of wisdom pertaining to the human condition, precisely diagnose conditions, and develop targeted treatments will continue to grow. It was groundbreaking when the human genome was sequenced in 2003. Today, researchers have expanded beyond genomics (study of the genome) to include the study of proteins, the study of metabolism, and the study of microbes. The more detailed our knowledge, the more precise the person-centered care will be.

The broader our knowledge of individuals, the better we can help them as well. Healthcare would benefit from greater integration of nontraditional sources of data that account for environmental and socio-economic factors affecting the people for whom we care. Your doctor doesn’t know how often you eat hot chicken and ice cream, but your credit card does. This type of information could aid, for example, in predicting which of our patients are more likely to be readmitted after surgery. It might not be the individual with the least favorable clinical metrics; rather, it’s the person with the low credit score, which could indicate they don’t have the necessary support network to aid in their recovery. If we have a more complete picture of what is going on with an individual, we can better cater to his or her needs. We also can better understand the decision tree linking care choices to outcomes.

Advanced data analytics also further our goal of providing the safest, most efficient care possible. Real-time monitoring that integrates diverse clinical data points enables us to detect problems before a patient experiences decompensation. Consider the example of sepsis, a life-threatening bloodstream infection. Detecting its onset so that early intervention can be initiated can be the difference between life and death. The symptoms on their own – quickened breathing, accelerated heart rate, unusually high or low core temperature, and abnormally high or low white blood cell count – may not trigger concern as stand-alone data points. However, when taken together, we see a different picture – one that an algorithm is better suited to detect than a busy clinician. HCA Healthcare is piloting a project that assists our caregivers with detection of sepsis in patients, a capability that is offering earlier detection of as much as 24 hours, and can be a critical advantage in fighting the deadly effects of sepsis.

Let’s turn to our third factor, care coordination. The National Academy of Medicine identifies care coordination as a key strategy with the potential to improve the effectiveness, safety, and efficiency of the U.S. healthcare system. Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care. The patient’s needs and preferences are known ahead of time and securely communicated at the right time to the right people. Well-designed, targeted care coordination can improve outcomes for everyone – patients, providers and payors. It’s essential that coordination reach across all aspects of the care continuum – hospitals, physician offices, pharmacies, first responders, long-term care facilities, home health, palliative care, community-based services, and payors. The length of this list speaks to the complexity of care coordination.

Care coordination is further exacerbated by the complexity of the needs facing an aging population with a higher prevalence of chronic disease and co-morbidities. We need robust coordination to improve their outcomes and care experience. Yet, these individuals are treated in a multitude of care settings that vary in their ability to coordinate care.

Importance of Interoperability

The common thread to satisfying consumers and enabling advanced data analytics and seamless care coordination is interoperability. Interoperability is the ability of devices and systems to exchange and use electronic information from other devices and systems without special effort on the part of the user. In healthcare, this speaks to the capability of our technical underpinnings to support data liquidity – when patient information moves freely and securely from the point of care — be that a hospital bed, doctor’s office or someone’s home– to wherever it is needed, from a clinical decision-making app or electronic health record to an analytics engine, clinical trial repository or public health registry. Interoperability of the technologies used in patient care enables the liquidity of data, without which it is more difficult to meet our goals of providing individualized care and managing the health of populations.

Unfortunately, healthcare is the only major industry that lacks an agreed-upon architecture for connecting the technologies and applications used across the continuum of care. This leaves the vast majority of medical devices, electronic health records and other IT systems unable to exchange information with ease at an affordable cost. Various systems and equipment typically are purchased from different manufacturers and each comes with its own proprietary interface technology. This means hospitals have to spend scarce time and money setting up each technology in a different way, instead of being able to rely on a consistent means for connectivity. Furthermore, hospitals usually have to invest in separate “middleware” systems to pull together all the disparate pieces of technology to feed data from bedside devices to EHRs, data warehouses and other applications that aid in clinical decision-making, research, analytics and consumer engagement. Many, especially older, devices don’t even connect; they require manual reading and data entry. As a nation, we employ hundreds of thousands of people to deal with this inefficiency.

The current lack of interoperability can compromise patient safety, undermine care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year. In fact, one study found that the lack of medical device interoperability costs the U.S. health system over $30 billion a year. As you would expect, it also impedes innovation, which may be the biggest missed opportunity for healthcare. Innovators in healthcare face significant obstacles accessing data, validating solutions, integrating into highly-configured environments, and scaling implementations across varied settings. As a result, the innovation community often steers clear of the healthcare market because navigating it simply is too difficult.  So the entrenched, proprietary interests we need to disrupt for advancement become further entrenched.

By contrast, the seamless exchange of information would improve care, increase operational efficiency and lower costs. It would facilitate care coordination, enable informatics and advanced analytics, reduce clinician workload and increase the return on existing technologies. To realize these benefits, we must rethink how to connect the disparate pieces involved in end-to-end patient care both within and across care settings. We need to repair the technical architecture supporting healthcare so we have a solid foundation upon which to innovate and develop solutions that will transform care for our nation.

Opportunity for Nashville

This leads us to the opportunity for Nashville. Our unparalleled expertise in how to deliver care positions us to disrupt the status quo. We have the leverage of a $78 billion healthcare industry to compel change and drive innovation. The time is ripe to make ourselves known for the number of lives we improve, not just the number of beds we manage. Our healthcare community encompasses the entire continuum of care, and we can demonstrate how to make end-to-end interoperability a reality, reaping its benefits for our citizens and businesses alike.

We are fortunate that the Center for Medical Interoperability chose Nashville as its headquarters. For those less familiar with the Center, it’s a nonprofit cooperative research and development lab founded by health systems to simplify and advance data-sharing among medical technologies and systems. The Center provides a centralized, vendor-neutral approach to performing technical work that enables person-centered care, testing and certifying devices and systems, and promoting the adoption of scalable solutions. I have the privilege of serving on the board of directors alongside several Nashville healthcare leaders, including Dr. Mike Schatzlein, who chairs the board.

Nashville can be a living lab for data liquidity. Our collaborative culture, coupled with the depth and breadth of our healthcare community, enable us to better integrate the many determinants of health – genetic, biological, environmental, socio-economic, lifestyle and wellness. We can forge private-public partnerships that innovate approaches to freely and securely sharing data in service of patient-centered care and population health.

So what does this all mean?  In short, future healthcare will be guided by consumer expectations, informed by advanced data analytics, and supported by robust care coordination. To ensure data liquidity and the best possible outcomes, we must achieve end-to-end interoperability across the continuum of care. Nashville has unique advantages to emerge as a true leader in driving healthcare transformation, and we cannot let this window of opportunity close. Thank you.

Milton Johnson

Chairman and Chief Executive Officer, HCA Healthcare