INSIGHT ON HEALTHCARE
CONVERGENCE, COMMUNICATION
AND COLLABORATION
by Chuck Appleby
Healthcare is undergoing a transformation that is changing the way care is
delivered and paid for. Understanding the process of convergence can help
us navigate this change successfully.
INTRODUCTION
Technology convergence is a broad term more familiar to industries outside healthcare than within healthcare. Generally, technology
convergence is defined as the merging of existing technologies into new forms that bring together different types of media and applications.
The most obvious example is the smartphone, which has expanded beyond simple voice communications to become a personal music
player, digital camera, video player and text message system. The Internet is the most widespread example of technological convergence in
its aggregation of entertainment technologies such as video, TV, books and games.
Both examples are obviously impacting healthcare. A hospital-centric example of technology convergence is Unified Communications (UC),
which integrates real-time communications such as messaging, telephony, video, interactive whiteboards, presence information, voicemail
and email into a single platform that enables communication among multiple devices.
However, as the healthcare environment radically moves from a volume-based, fee-for-service model to one based on value, accountable
care and population-health management, the center of gravity is quickly shifting from the acute-care hospital to the outpatient sector, the
home and patients themselves.
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HEALTHCARE PROVIDERS ARE BECOMING THE COMMUNITY
As coordinated, team-based, patient-centered care replaces the old episodic care model,
the healthcare enterprise expands to encompass the community. Viewing healthcare within
this expanded framework makes it clear that convergence is occurring in more than just
technology.
The best IT strategy has always worked within a dynamic: people, process and technology.
Convergence is occurring in all three in healthcare. We hope this report, “Convergence,
Communications and Collaboration,” offers a framework for understanding the interplay
of factors occurring in the most exciting but also the most challenging time in healthcare.
This is not intended to be a comprehensive analysis of convergence in healthcare, but a
thoughtful starting point for a discussion throughout the year.
THE PRECAMBRIAN ERA OF HEALTHCARE TECHNOLOGY
“Technology convergence in healthcare is like all industries, there’s a natural progression,”
says Vishal Agrawal, MD, president of Harris Healthcare, a division of Harris Corp., a
$5 Billion global communications firm. “We’re in this Precambrian technology era,
characterized by market innovation and limited standards and are heading toward an
incredibly fertile Cambrian era with convergence on a common standard.”
That journey involves organizational self-interest.
“You begin by having a common set of standards. Look at the computer industry—
Atari, Commodore, Mac, TRS 80s. It converged on a couple of software platforms, Windows
and Mac. Now we’re finding desktop platforms are moving to mobile. From the 60s, 70s
and 80s, every organization has worked within that system. I don’t think healthcare is
different. It follows a natural progression. First, it was paper. Then, digitization on zeros and
ones, then convergence, whether for geospatial imaging or MRI. Then, comes insight. We’re
buying that industry-wide integration and interoperability are the next stage.”
A COIN BALANCED ON ITS EDGE
Rob Havasy, project specialist and operations manager for the Center for Connected Health
at Partners Healthcare in Boston, says healthcare is poised on the edge of a coin; with the
traditional enterprise on one side, and the customer -- who is increasingly on the hook for
the cost of care -- on the other.
If it’s a challenge to unify digital communications within the hospital, it requires a whole
other level of magnitude to unify communications between the hospital enterprise and the
consumer community.
Havasy poses a real-world technology example: “The hospital might be using Cisco or
PolyCom video conferencing over ISDN lines while the patient says, ‘I want to use Skype
or video chat.’ A traditional hospital UC strategy might incorporate Microsoft Lync, but
consumers may be using Cisco Jabber to communicate on multiple devices, making it
impossible to set up a secure digital meeting room between them.”
But these challenges also offer entrepreneurial possibilities.
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CRISIS EQUALS OPPORTUNITY
“That’s where the opportunity for convergence is—a UC strategy that links consumer
technology with enterprise technology in a HIPAA world,” says Havasy, who helped
develop the Center’s tele-psychiatry pilots, which enable virtual visits for returning military
veterans at Massachusetts General Hospital in Boston. “We’ve had to cobble together the
technology,” he says.
“Now I can use my iPad at home. Can I use my mobile please? We’re not prepared to set up
those cells in a more secure environment.”
Given that the vast majority of healthcare costs are driven by lifestyle choices, a
convergence on consumer devices is necessary to reduce costs and achieve better
healthcare outcomes. As the healthcare market changes and health systems like Partners
assume more risk for patient care, these organizations suddenly become more in tune with
the cost of having a patient come in -- because they’ll receive a lump-sum care payment
whatever the patient’s condition.
“What we want to do is help people make better choices. That requires the combination of
information and measurement on any number of devices like FitBit Trackers, Smartphones
and smart scales connected to the Web. Then it’s a matter of feedback and guidance.”
MY IPHONE, MYSELF
It’s also a matter of consumer convenience and access to care. “No elderly person in
Boston wants to take two hours to get to the doctor by public transportation when it’s 12
degrees and snowing,” says Havasy. He argues that consumer technology can actually
make healthcare more convenient and more personal. “We’ve already turned most routine
medicine into an impersonal experience. Most people have a warmer relationship to their
iPhone than their provider, especially in a hospital setting.”
Consumers of all ages seem to enthusiastically embrace personal mobile devices in their
own care. In a pilot by the Center using a tablet-based home-healthcare solution, a number
of elderly patients used an iPad Mini as a hub device with Verizon data connection. “We
were getting messages from Verizon that the data connections were tapping out. All the
elderly people were using the devices to download videos and setting up Facebook,” says
Havasy.
“They were much more engaged in their healthcare when they got the iPad Minis. If
someone can marry that together you get a higher patient activation score. Rent two free
movies if you comply with your therapy. That’s crying out for a company to fill a gap in the
marketplace in partnership with local providers. It’s going to converge. It’s forcing us to
converge.”
INTELLIGENT MEDICAL HOME
The Intelligent Medical Home exhibit at HIMSS14 in Orlando showed how disruptive
consumer technology and more can be smartly blended today to enable coordinated care
under value-based accountable care. New this year as an extension of HIMSS’ traditional
Intelligent Hospital Exhibit, the IMH drew a continual stream of tours -- including
seven international delegations and a group of top executives from Microsoft -- to the
1,800-square-foot fully furnished demo home. Visitors watched actors play an elderly
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woman with dementia and prone to falls, her middle-aged son recovering from a heart attack
and a caregiver whose presence signified that the acute-care setting had just made a house
call.
“This is all about what happens when the patient goes home,” says Alan Snell, MD, chair
of the IMH Advisory Council and former CMIO at St. Vincent’s Health (Ascension Health)
in Indianapolis. “The emphasis is on reducing hospital readmissions. How can we take the
higher acuity patient and make it work at home? This wouldn’t work well in a fee-for-service
environment. It works well in a capitated environment,” says Snell, whose experience helping
lead the Central Indiana Beacon Community demonstrated the power of similar (though less
extensive) consumer technology for patient care at home.
BRINGING THE HOSPITAL HOME
The IMH featured about 30 technology “use cases,” a few of which we highlight:
LIVING ROOM:
• CareNavigator, an at-home, web-based (computer, tablet, smartphone, television) and IVR
(telephone) application supporting pre-admission and post-discharge patient engagement.
This tool delivers patient/procedure/condition-specific health education, sends
appointment and medication reminders, alerts patients to tasks—weight, blood pressure,
blood glucose—complete functional outcome and pain surveys, and keeps the patient
connected to the care team. Using the TV, patients and their families can get real-time
information directly to their living rooms while the TV is in operation.
• Smart Wrist Watch helps the patient function in daily activities and reports results back to
the caregiver (see Kitchen) but can also ID potential safety issues, such as when a patient
has not moved for an hour. It also uses a risk-prediction algorithm to continually calculate
the risk of falls using data from the home, and detecting when walking becomes erratic or
less linear.
KITCHEN
• Smart Behavior Monitoring programs detect if a patient unintentionally puts herself at
risk and will disable dangerous home appliances when she approaches. The Smart Wrist
Watch automatically feeds data about patient identity and location to an intelligent
tracking system that electronically enables devices only if an authorized user attempts to
use them.
• Medication Management programs prompt the patient, via the Smart Wrist Watch, to take
a medication and then measures compliance through location change -- such as when the
patient is near the medication dispenser. The patient then views video of assigned tasks
and checks off each task when completed.
ACUTE BEDROOM
• A Medication Management system that verifies a patient removed the proper medications
from a dispenser at the proper time, picked up a water bottle and then exhibited the
proper hand-to-mouth movement via Microsoft Kinect-based tracking. If the patient failed
to take the prescriptions on time, the system prompts her via text message or audiovisual
message on an Android tablet. The patient does not need to wear anything special to do
this.
• A Non-contact Sensor monitors a patient’s heart and respiration rates, motion and presence
while in a bed or chair. Caregivers and family members can access this information
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remotely through a cloud server to a simple web or mobile device so the patient’s
condition can be monitored real-time from anywhere. Can provide bed-exit and extended
out-of-bed alarms.
BATHROOM
• Fall Detection System uses Kinect to detect sudden movement and falls and can alert EMS
if there is no response from patient.
MASTER BEDROOM
• Smart Body Analyzer enables a weight scale to take a comprehensive health snapshot by
measuring weight, BMI, body fat, heart rate and air quality of the room. Data can be sent
directly to be visualized on the TV.
WELLNESS/EXERCISE ROOM
• Orthopedic Rehab Solution can observe a patient exercising while she is watching a video
and matching movements using Microsoft Kinect. Displays range of motion, number of
repetitions and achievement of therapy goals.
BEACONS OF INNOVATION
The beauty of the IMH was that it brought many different consumer and mobile devices
together in an integrated, holistic approach that supported the high-acuity patient at home.
Elements of this approach have been demonstrated in programs like the Beacon Communities.
Under the program, at-home patients received video consults from trained nurses via a mobile
device seven times a month, enabling providers to communicate at high levels with the
patient, observe their movement and provide them with educational videos to watch.
With similar aging, high-acuity patients with multiple chronic conditions at risk for readmission as the IMH, Snell (who wrote the script for the IMH) estimates the cost of such
monitoring was $400-$500 a month. “We didn’t do 24x7 monitoring, which would cost more.
In most home monitoring it’s not necessary. It can be integrated with an emergency call center
the patient can contact any time of the day or night.”
Pieces of the intelligent medical home concept are already being deployed by health systems
as they address preventable hospital readmissions and shift to greater risk sharing under
accountable care.
HIGH RISK FOR READMISSION
In an example that is becoming more and more common, Texas Health Resources (THR), an
Arlington, Texas-based, 26-hospital integrated health system, uses predictive analytics to
identify the patients they discharge who are high-risk for readmission within 30 days.
“I’ll send those patients home with a bunch of technology like a blood-glucose monitor, weight
scale and a pulse oximeter,” says Ed Marx, VP and CIO at THR. “The key is to do it remotely.”
Extending the eICU model to the community, THR employs a nurse to electronically monitor
six patients in their homes daily using technology that converges a half-dozen vital signs into
a single monitor. The result has been dramatic: a 30-percent reduction in readmissions, which
translates into savings of $40,000 to $50,000 each.
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“More importantly, no one wants to be in a hospital,” he says, adding that the next step is
to broaden coverage to a larger population.
CONVERGENCE
Russ Branzell, president and CEO of the College of Healthcare Information Management
Executives (CHIME), says a technology convergence is occurring between consumer and
commercial sectors that is extending into healthcare.
“The shift has been occurring in the home for years. I can be in rural China and get
my emails. What’s happening now is the never-ending loop between consumer and
commercial as in home and healthcare.”
Branzell’s daughter recently became ill at school and was sent home with, well,
technology. “Her life wasn’t disrupted. She stayed at home talking with her friends,
communicating with her school and teacher. The patient experience becomes integral
to the consumer portion of her life. You can monitor blood pressure and medications at
home.”
The explosion of consumer-based devices such as smartphones, tablets and even the
PC has blurred the lines between consumer and commercial. “Every healthcare CIO and
health system needs to have a mobile health and consumer integration strategy even if
you’re in a rural area,” Branzell says.
CLINICAL CONVERGENCE
Convergence in healthcare comes in many forms. Clinical decision support (CDS) is a case
in point. CDS is a highly-specialized yet critical tool in supporting patient safety, quality
and efficiency of care, its broadest definition is anything that brings intelligence to the
point of care. It is best framed by Five Rights of CDS: The right information delivered to
the right person in the right intervention format through the right channel at the right time
in workflow.
Technologically, CDS involves rules and alerts that are triggered when a clinician writes
an order like a prescription for a patient into an electronic medical record (EMR). If the
patient is allergic to the medication or might suffer an adverse reaction with another
medication she is taking, an alert will pop up.
For hospitals and health systems to successfully design and implement CDS programs
requires tremendous resources, including a physician chief medical informatics officer
(CMIO) and a medical informatics department as well as a sophisticated EMR with
computerized physician order entry (CPOE) and clinical data warehouse.
A Consortium sponsored by the federal Agency for Healthcare Research and Quality
(AHRQ) showed how it’s possible for health systems to collaborate in a way that enables
building CDS across multiple organizations.
CLOUD OF KNOWING
“Everyone is talking about cloud computing, which is access to servers and high-powered
computing by being able to store data in the cloud and send data to the cloud,” says Dean
F. Sittig, PhD, professor at the University of Texas School of Biomedical Informatics at
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Houston, which participated in the project. “In this project, we showed how the cloud
could help us run CDS and support CDS from the same computer system for different
health systems.”
The CDS Consortium centralized the ability to build knowledge, test it and maintain it
using services-oriented architecture (SOA).
“The convergence is using the cloud to support widespread CDS for people. It takes a
huge amount of communication,” he says. “Sending data out of our system, computer-tocomputer communication over the Internet to where they populate the CDS.”
SOCIO-TECHNICALLY SPEAKING
Furthering the convergence idea, says Sittig, is the concept of “taking things that used to
be retrospective and making them real-time. Doing stuff in real time that previously relied
on store-and-forward. We didn’t used to be able to have access to high-powered computing
in real time. Such convergence has made it possible for four sites to use the same CDS
rules at Partners Healthcare in Boston.”
The project showed that it was possible to share CDS tools with different EMRs at
different organizations. “We had to overcome both technology issues and people issues,”
he says. “Clinical informatics is socio-technical. We would normally do this locally with
our data warehouse with reports at the end of the quarter. But the data could be three
weeks old and the patient dead by then. It’s the convergence of network speed, fast
processors and the ability to aggregate and analyze the quickly to be able to get those
reports in real-time. You can identify errors in real time. So we’re building a lot of realtime dashboards in the organization.”
CONVERGENCE LEADS TO COLLABORATION
Stanford Children’s Health in northern California has taken those dashboards and made
them real time using a web-based CDS application built upon an SOA platform developed
by industry group smartplatforms.org. For healthcare, this is technology convergence on a
single, open-systems platform upon which apps can be built to be shared.
“We don’t want everybody recreating the same whole set of CDS rules,” says Natalie
Pageler, MD, associate medical director of clinical decision support for pediatric critical
care medicine at Lucile Packard Children’s Hospital in Palo Alto, CA, the hospital for
Stanford Children’s Health. By deploying sharable apps, it eliminates duplicative work
and makes it possible for resource-constrained hospitals and health systems to adopt the
best CDS available to ensure patient safety and quality care.
Pageler uses a CDS tool that helps guide pediatricians to assess the very important level
of bilirubin in a newborn’s blood, which can indicate diseases like jaundice. Easy to use,
secure and accessible on the web to any physician using an EMR, the BiliTool requires
just a few pieces of non-HIPAA information such as patient age and bilirubin level to
assess the patient’s risk based on American Academy of Pediatrics guidelines. “Multiple
institutions have built the link into their EMR,” says Pageler.
Again, using the cloud makes it possible to maintain all the logic of the CDS rule in the
tool that the pediatrician “borrows” at the point of care. That eliminates the need for every
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hospital or health system to pour resources into developing and maintaining a tool which
likely would fail at achieving the same level of quality.
TIP OF THE ICEBERG
That’s just one very specific pediatric tool. Every medical specialist, from family
practitioner to cardiologist, requires the same kind of highly-specific CDS tools that could
be built and maintained by the leading experts in the field and approved as best practice
by the particular medical association that oversees it. That’s the value of convergence: It
offers the technological means to radically communicate and collaborate around the best
practices, protocols and guidelines as promulgated by the professional associations and
national certifying boards.
By “converging” on an open SOA platform, such apps also overcome one of the bugaboos
of healthcare IT—lack of interoperability among EHR vendors. Technology convergence
enables vendor-agnostic apps to overcome that gap, which is a major impediment to
coordinated care and population health management under emerging accountable care
models.
Pageler says the benefits of the CDS tool are obvious in terms of patient safety because it
helps providers do the right thing. It also saves providers a lot of time, she says, because it
eliminates the old method of having to track down old paper charts, copy the information
and input it to the EHR.
“It’s the convergence of the EMR with web-based CDS with non-technical clinical
guidelines into a single seamless tool for providers,” she says.
CHECKLIST DASHBOARD
In yet another example of convergence, Lucile Packard’s pediatric intensive care unit
(PICU) has adopted a patient safety and quality dashboard that converges technical and
non-technical tools. The dashboard relies partly on the work of Peter Provonost, MD, at
Johns Hopkins Medicine in Baltimore, and Atul Gawande, MD, at Brigham and Women’s
Hospital in Boston, using simple but effective checklists to improve patient safety and
care quality.
Those checklists were inspired by ones used in “high-reliability” industries like aviation to
ensure safety. “The checklist is beautiful in its simplicity. Does the human mind need to
go through all that complexity?” asks Pageler.
Based on “best-practice bundles” for catheter care to prevent central-line-associated
bloodstream infections (CLABSI), the PICU dashboard is embedded in the EMR and
uses color-coded buttons—red for action required, green if no action is required—next to
important tasks like, “Has the dressing been changed?” and “Has the port needle been
changed?”
Use of the checklist, an easy-to-read graphical display on the computer monitor, has
resulted in a decrease in CLABSI rates from 2.6 per 1,000 line-days to 0.7per 1,000 line
days—a drop of nearly 75 percent.
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Says Pageler of the automated checklist: “This not the primary work of providers. Let the
machine do some of the background work.”
TAKEAWAYS
The topic of “Convergence, Communication and Collaboration” aims to provide a
framework for understanding the transformation healthcare is undergoing as it moves
from a volume-based, fee-for-service system to one based on value, accountable care and
population health. Here are key takeaways for health systems to consider:
1. Healthcare CIOs must shift from a mentality of building big proprietary systems to
becoming more integrated with the network of existing consumer devices and social
media. Despite the investment in patient portals, for example, there’s little evidence
of their use by patients outside of prescription refills and appointment changes.
G-Chat with Google Hangouts, Google iChat, iPads and Skype are all examples of
communications tools outside the health system.
2. Closely related to No. 1, every healthcare CIO must, if they haven’t already done
so, develop a strategy for mobile or connected health. Security is paramount.
Physicians are bringing personal tablets and smartphones into the healthcare
enterprise. Consumers are already there and expect to be able to communicate with
providers like they do with everybody else. The coordinated care required under
Accountable Care Organizations (ACOs) requires going to where the patient is and
that means mobile devices.
3. Recognize we are already in the post-EMR era. Interoperability and open
systems built upon open platforms like services-oriented architecture (SOA) offer
vendor-agnostic, standards-based opportunities for flexible, scalable and secure
communication across the continuum of care, which is now the community.
Investigate these open architectures and consider joining one of the consortiums
supporting them.
Author: Chuck Appleby
Chuck Appleby, a Partner with C-Suite Resources, has 25 years of experience in the healthcare industry as a
journalist, writer, media relations expert and marketing communications consultant. Focusing on healthcare
and IT, he has written and consulted for some of the most prominent healthcare experts, visionaries and
organizations in the country. Chuck can be reached at [email protected].
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