Connecting Care Across the Healthcare Universe
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Connecting Care Across the Healthcare Universe Looking toward technology innovation and collaboration to achieve a healthier healthcare system Executive Summary For the healthcare industry, technology has become both a panacea and a challenge. Technology is one of the proposed cures for out-of-control costs, limited access to quality care, and lack of coordination and collaboration across the healthcare system. However, some believe that the solutions being implemented today may actually be exacerbating the very problems healthcare is striving to solve. A number of healthcare experts have publicly called for healthcare IT vendors to be more innovative and collaborative in order to solve this technology paradox. Widespread use of social networking, mobile devices, software as a service (SaaS), cloud computing, machine-to-machine (M2M) networking, and other revolutionary technologies make the timing right to look toward innovation in healthcare IT. This white paper examines the key challenges facing the industry and looks at how existing and emerging technologies may be used to enhance or replace current technologies in order to address and solve for those challenges.
Connecting Care Across the Healthcare Universe_______________________________________________________________________________________________ 2
The Staggering Costs of Chronic Disease Since the backlash from providers and patients against the “managed
All eyes in healthcare today are on containing costs while improving care” approach of the 1980s and 1990s – a more volume-driven
patient outcomes, two monumental challenges that are inextricably approach focused primarily on cost management and efficiency
linked. Rigorous and public debate over healthcare reform, and the over delivery – healthcare systems have acknowledged that they
passage of the Patient Protection and Affordable Care Act (PPACA) must address quality of care and patient outcomes with integrated,
in 2010, once again pushed the staggering and rapidly growing collaborative systems in order to have an impact on healthcare’s
cost of healthcare into the national spotlight. In fact, U.S. healthcare enormous costs. Through the emergence of accountable care
spending reached $2.5 trillion in 2009, comprising 17.6% of GDP and organizations (ACOs), hospitals, physicians and payers are seeking a
representing the highest level of spending on healthcare in the world.1 more “value-driven” system by aligning their goals to deliver better
care for patients across a broad community or system, sharing
But it is where these costs are largely centered that is particularly responsibility for patient outcomes as well as the financial impact of
alarming. Healthcare spending is highly concentrated among a very those outcomes.7
small percentage of high-cost patients – 5% of the U.S. population
represents almost 50% of all healthcare spend – and people with at However, some industry watchers have expressed concern about the
least one chronic health condition are two to four times more likely future of ACOs and similar initiatives to achieve more coordinated and
to fall within that concentrated population.2 Additionally, patients with collaborative care. One reason is the lack of infrastructure in place
multiple chronic conditions cost up to seven times as much as patients to support dependable, accurate and fast information access, sharing
with only one chronic condition.3 and management8 – essentially, the information technology that can
support widespread integration of reliable data to help providers make
With diabetes, hypertension, high cholesterol and other conditions that informed treatment decisions nimbly and support their patients across
are linked to obesity on the rise, the healthcare system is turning its multiple settings.
attention to lifestyle and health behavior as the key factor in fighting
this epidemic of rising healthcare costs. One report propositioned that Consequently, in the past few years, the healthcare industry has
encouraging obese, pre-diabetic baby boomers to lose 7% of their been focused on attempting to resolve the fundamental challenge
body weight and maintain that loss could save $7 billion to $15 billion of building technology infrastructure to support coordinated and
in lifetime Medicare spend.4 collaborative care. With the passage of the Health Information
Technology for Economic and Clinical Health Act (HITECH) provision
of the American Reinvestment and Recovery Act (ARRA) in 2009, the
industry finally became acutely focused on deploying and using health
Healthcare Spending 2009 information technology (HIT) in a meaningful manner to improve
health information exchange, care collaboration and patient outcomes.
Professional Care Provider organizations also understand that they must not only select,
21%
Hospital Care 29% implement and adopt technology in time to reap the financial benefits
Administrative Expenses of HITECH, or face financial penalties down the road for not doing so.
Prescription Drugs 9%
The Uphill Battle of Healthcare IT
Other
More than two years after HITECH’s passage, a large percentage of
14%
27% hospitals and physicians’ groups have plans in place to adopt and
achieve “meaningful use” of certified electronic health records (EHRs).
A January 2011 survey by the Department of Health and Human
Deloitte: March 2011
Services (HHS) reported that four-fifths of U.S. hospitals and 41% of
office-based physicians say they intend to implement EHRs in time to
take advantage of federal incentive payments by 2015.9
Spending on inpatient hospital care, the most expensive setting for
delivering care, is far and away the biggest contributor to healthcare However, it remains to be seen whether these providers will be able
costs: by one estimate, 27% of healthcare spending in 2009 was on to achieve the meaningful use milestone in time. Various research
hospital care.5 The spending is due in large part to high readmission shows that U.S. hospitals and physician groups are starting late and
rates for people whose conditions sent them back to the hospital have a long way to go before they get there. A 2010 report in Health
not long after they had been discharged. The Agency for Healthcare Affairs notes only 2% of hospitals had EHR systems in place that would
Research and Quality (AHRQ) found that in 2008, 11% of privately actually meet meaningful use criteria.10 The HHS report showed 50%
insured adults ages 18-64 and 24% of Medicare-insured adults in growth in primary care practices’ adoption of “basic” EHRs between
the same age range were readmitted within 30 days after their first 2008 and 2010, from 19.8% to 29.6% of all practices. But, the report
hospital stay.6 also stated that “most physicians would need to further upgrade their
EHR systems or their use of systems in order to qualify for meaningful
A Movement Toward Accountable and Coordinated Care use incentive payments.”11
Recognizing the drivers behind these trends, the healthcare system is
focused full-tilt on designing new ways to help increase the quality of Meaningful use requirements were established to facilitate more
healthcare and support patients’ proactive, ongoing management of connected care. However, connectivity at the level stipulated by
their chronic conditions while driving down costs. meaningful use rules is the often elusive missing link for successful
implementation of many EHRs. Even when an EHR system is certifiedConnecting Care Across the Healthcare Universe_______________________________________________________________________________________________ 3
by the Certification Commission for Health Information Technology In work done … interviewing clinicians in emergency department
(CCHIT), signaling it is capable of supporting meaningful use, and primary care settings, receipt of a care summary in the ED
organizations must still be able to implement it in a way that enables occurs unreliably, if at all. While many EDs and increasing numbers
them to share data seamlessly among the care team. They of primary care practices have EHRs, they are rarely interoperable
must also be able to measure and report quality metrics using so providers most often communicate by auto-fax that often fails
that data. These goals are still very much out of reach for many to transmit or gets lost in busy EDs, potentially placing patients
healthcare organizations. at risk. Stage 1 meaningful use measures began to address the
need for data exchange with the 50% requirement for electronic
The healthcare industry faces multiple challenges in achieving the level transfer of the summary of care record for care transitions, and
of connectivity needed to meet meaningful use requirements. One tests of certified records capacity to electronically exchange clinical
of the toughest challenges is actually implementing the information information. However, given that practices are only required to send
technology that organizations are tasked with adopting. Some of the it 50% of the time, practices may elect (and not unreasonably given
major reasons include: their resource limitations and time constraints) to have their staff
• Cost – By some measures, U.S. hospitals will need to spend send this information for their more straightforward, scheduled
approximately $120 billion (about $80,000 to $100,000 per bed) to outpatient referrals. As a result, when a provider is seeing a
fully implement an EHR that meets meaningful use requirements. patient with unscheduled acute care needs, the summary may
That cost includes project planning and consulting, software not be available.14
investments, hardware investments, implementation and training. • Unwieldy Volumes of Complex Data – At the same time that
Financial incentives through ARRA will fund only part of that organizations are struggling to interface and integrate the complex
investment. While hospitals and practices will see a long-term data generated by their disparate systems, they are grappling with
payoff in labor savings, high quality and a reduction of adverse drug enormous volumes of healthcare data. It has been estimated that
events that will offset these costs, the upfront financial investment one patient’s electronic medical record by 2010 would be the
may be too steep for many organizations.12 equivalent of 12 billion novels15 – and the volume and complexity
of this data are growing rapidly each year. As they consider their
IT strategy and how to achieve connected and intelligent care,
Average start-up costs per bed
healthcare organizations are simultaneously challenged with how
$ thousand to store and manage these vast volumes of data, as well as how
External IT consulting 27-30 to deliver it quickly and securely in useful, meaningful ways that
provide actionable information – whether for managing a single
Hardware 15-25
patient or an entire population. From the physician perspective,
Clinical-software licenses 20-22 information overload and frustration with slow speeds and
External training services 10-12 incomplete information can hinder the usefulness of technology.
Other software licenses 5-6
Bridging the Healthcare Digital Divide
Internal IT support 3-5
The federal government and healthcare leaders consider technology
to be the remedy to many of healthcare’s inefficiencies and
Source: “Reforming hospitals with IT investment.” McKinsey Quarterly, August 2010. quality challenges. Yet the substantial challenges associated with
acquiring, implementing and adopting traditional technology may
• Inflexibility of Proprietary EHRs – Many organizations may be be exacerbating the problem, especially when it comes to serving
investing in sophisticated EHR systems that may ultimately make it underserved or chronically ill populations.
difficult to share data outside the core network. Proprietary, non-
interoperable software can be a significant roadblock for healthcare Many experts have warned that the substantial financial investment
organizations that need to share information with physicians’ required to implement EHRs may lead to a “digital divide” in
groups, partner hospitals or even internal departments operating healthcare. In other words, hospitals and physicians’ practices that
on different software. Organizations may need to invest significant serve poor communities, patient populations of color, or immigrant
money and time to build interfaces between different vendors’ communities, are less likely to implement EHRs and other technologies
EHRs in order to share data successfully. that can increase patient safety and improve coordinated, high-
quality care. This undermines industry-wide efforts for increased
•P
roductivity Disruption and User Frustration – Physicians efficiency and cost savings, as these populations tend to include
recognize the long-term benefits of technology, but they still more uninsured patients without access to preventive care, as well as
express frustration and even resistance to adopting a new people disproportionately affected by chronic disease. For example, all
technology-based workflow that slows them down or is unintuitive minorities except for Native Americans are two to six times more likely
for the way they need to work.13 Downtime, poor usability, slow than whites to develop type 2 diabetes.16
speed, distractions in the exam room and other barriers may slow
user adoption of new software, even if a health system has decided Healthcare experts have publicly called for a coordinated effort
at the executive level to universally implement the EHR. among healthcare IT vendors to address and begin to close this
digital divide,17 innovating and collaborating to find ways to foster
• Limited
Usefulness as Communication Tools – While ARRA faster, more widespread adoption of EHRs and other healthcare
emphasizes the need of EHRs to facilitate better provider-provider technologies – including emerging innovations in mobile and cloud
and provider-patient communication, many EHRs are limited in their technologies – that can begin to move healthcare closer toward its
ability to serve as communication tools. Take for instance this case collective goal: healthier patients and less costly healthcare delivery.
documented by the Center for Studying Health System Change:Connecting Care Across the Healthcare Universe_______________________________________________________________________________________________ 4
Collaborative Innovation: Setting Healthcare Technology Free collaboration, exchanging data and gathering intelligence. The
It is time for healthcare to answer this call. As the stewards of the healthcare industry is quickly moving toward leveraging “the cloud”
healthcare system ponder reform, our industry must adopt a spirit of and software-as-a-service (SaaS) applications as opportunities for
innovation and collaboration. As it faces unprecedented costs and out- developing and accessing technology that supports its goals. Cloud
of-control disease rates, healthcare must move away from proprietary, services can provide:
highly structured, rigid systems and towards technologies that can free
up healthcare providers to deliver more agile and insightful care, while • Scalability and Flexibility – Cloud services enable healthcare
bridging the divide to support patients in behavior change and self- organizations to store, manage and access vast and rapidly growing
management of disease. volumes of data with flexibility and agility.
A culture of collaboration among healthcare IT developers will avoid • Resource and Cost Efficiency – IT departments can scale without
time-wasting “reinvention of the wheel,” tap a collective brainpower adding hardware and staff and, in some cases, can extend the life
to develop completely new ideas, and encourage “smart” connected of existing technology investments.
products made available rapidly to a wide audience of users. • Integrated Data Sharing and Aggregation – Providers across
In recent years, a number of new trends have emerged in support departments, organizations and geographies can exchange
of IT vendors working more collaboratively for the common good. dynamic and diverse information in the cloud, without the need to
For example, software development across all industries has been build point-to-point interfaces between systems. Cloud applications
revolutionized over the past several years, moving away from rigid, also foster efficient data gathering and analysis that can promote
proprietary products to open source, software as a service (SaaS), better insight and decision-making.
mobile apps, and social networks dedicated to promoting widespread • Security and Business Continuity – Cloud services typically feature
information-sharing. Fostering this change has been a new mindset in built-in disaster recovery backups and security to protect data from
information technology. Today, developers come together with great outages, hackers and other dangers.
ideas to continue to make products better; software has become
inexpensive to develop and to consume, especially as software Health Information Exchange in the Cloud
applications and hardware become more independent of each other. Experts have called health information exchanges (HIEs)
The healthcare industry is following closely on the heels of this “indispensable” to the success of accountable care organizations
revolution, discovering ways to tap into this spirit of innovation to (ACOs), because of the tremendous data exchange and reporting
foster the connectivity and communication that the healthcare requirements set forth by the Centers of Medicare and Medicaid.18
industry and government envisioned as they looked to technology Yet while HIEs are emerging across the country and demonstrating
adoption to address costs, efficiency and quality. As healthcare leaders significant results, the numbers of HIE organizations still remain
explore how this new wave of “unbound” technology can work in relatively low. KLAS reports that there were 67 active public HIE
health environments, they do so with a vision of the future in which: organizations in 2010 (up from 37 the previous year) and 160 private
HIEs (up from 52). Among the live HIEs, only 43% were delivering
• Complete, accurate patient data can be easily accessed wherever patient data directly into physicians’ EHRs, indicating that physician
a provider needs to see it and shared seamlessly among adoption is still relatively low.19
departments, organizations and communities.
Taking HIE to the cloud opens up a number of new possibilities
• Providers can easily and securely communicate and share for healthcare organizations. Cloud-based platforms can bring
information with each other and patients. together data from multiple applications into a single, secure
online interface. Building HIEs in the cloud helps organizations
• Technology promotes time-savings and is useful and helpful in a save money and optimize resources as well; for example, real-time
provider’s work, rather than a hindrance. mirroring of data in the cloud prevents the need to build a central
• Patients can effectively begin to take control of their own health data repository.20 Cloud-based HIEs also provide access to more Web
and manage their conditions, with ongoing support from providers 2.0-like collaboration among stakeholders, promoting more connected
managed efficiently and cost-effectively. care by better-informed providers.
Similar to the ways that other industries have virtually reinvented Cloud-based EHRs
themselves through innovation – the way that banking has changed While standalone EHRs often have inherent problems achieving
because of ATMs or the travel industry because of online booking the kind of interoperability and communication called for by ARRA,
– innovative technology has the opportunity to not just improve new cloud-based EHRs are being designed to seamlessly interface
healthcare, but to transform it. and aggregate data from multiple locations and platforms. Providers
can access this single view from anywhere, securely, over the Internet,
Many healthcare technology companies and organizations in making it easier for healthcare organizations to roll out systems and
partnership with them are leveraging emerging technologies to foster provider adoption, regardless of their existing level
reexamine everything from how healthcare is delivered to how data of technology.
is accessed, stored, managed and shared. Cloud computing and Saas,
mobile technologies and telehealth are some of the most significant For organizations grappling with the upfront financial investment
game-changing trends that promise to transform healthcare. Let’s take for an EHR system, plus the substantial cost of implementation
a closer look at why. and IT management, a cloud-based EHR offers many advantages.
The software as a service (SaaS) model makes it less prohibitive for
Cloud Technology and SaaS providers to adopt EHRs and more quickly reap the benefits. By their
Cloud services are transforming virtually every area of technology, very nature, cloud-based systems enable online communication
and healthcare is beginning to recognize their advantage for fostering and collaboration, and also offer more flexibility in the way data canConnecting Care Across the Healthcare Universe_______________________________________________________________________________________________ 5
be delivered to providers. Additionally, cloud-based applications are smartphone, and 27 percent owning a tablet, according to one
more easily available on mobile devices and eliminate the need for study.23 Delivering healthcare apps on these devices makes their
installation, upgrades and maintenance by hospital IT staff. Healthcare use more convenient and affordable for users, and may help to
organizations spend less on hardware and staff, plus get the advantage drive adoption.
of ongoing vendor support. Most cloud-based EHR vendors have
stringent security infrastructure in place. • Flexibility – Mobile technology can help to bridge many of the
gaps that today may be preventing timely, efficient, quality patient
EHRs connected via the cloud also provide public health benefits. By care – especially factors such as geography, limited physicians’
aggregating de-identified patient data from the thousands of healthcare time, and language barriers.
users of the system, public health researchers can identify trends and
proactively address healthcare risks and challenges. This data may be Mobile may be the missing link to help healthcare providers improve
used to understand correlations between behavior or socioeconomic patient outcomes, as it uses technology already in the hands of patients
status and disease, identify at-risk patients in the case of epidemics, or and physicians to foster more connected and coordinated care. Mobile
track prescribing patterns over very large populations of patients.21 also can empower patients to manage their own health with ongoing
support from healthcare professionals.
Cloud-based Medical Imaging
With the volume of medical images growing by 20% to 40% each year22, Mobile phones and M2M
healthcare organizations are increasingly struggling with high costs, The 2010 market for wireless technologies in healthcare alone was
staffing, and maintaining the agility needed to manage data storage $4.4 billion, three times bigger than it was in 2005,24 driven by the
and access. Healthcare is beginning to look to cloud services growth of mobile technology adoption in the United States. A 2011
for the scalability and agility necessary to manage this “tsunami of data” study showed that 83% of Americans own a cell phone, 35% own a
while still meeting the legal and regulatory requirements of keeping the smartphone, and 8% own a tablet. Among smartphone owners,
data secure and private. one-quarter say their mobile phone is their primary source of
Internet connectivity.25
As with EHRs in the cloud, cloud-based medical imaging can
address many of the interoperability challenges that organizations The numbers are even encouraging among baby boomers, who
face as they generate and try to derive value out of medical data. represent the majority of U.S. patients who have growing rates of
Whereas standalone picture archiving and communication systems chronic disease. According to one study, twice as many people over
(PACS) often have a proprietary nature, making image exchange and 55 have visited a social media website using a mobile phone in 2011
sharing a challenge, cloud-based medical imaging can be designed to than they did the year before, demonstrating an increase in usage and
be vendor-neutral. Organizations can access, view, annotate, manage comfort with mobile devices.26
and store their medical images in one central location, using their Thousands of mobile apps and mobile websites are beginning to
PACS of choice to do the work but without the limitations they might emerge – so many that the Food and Drug Administration (FDA)
experience when trying to communicate between disparate PACS. acknowledged the relevance of mHealth in mid-2011 when it issued
draft guidelines for mobile medical applications. Patients can download
mHealth their choice of dietary guidelines and food diaries, glucose and heart
Mobile technology is revolutionizing the world, and it can do the same rate trackers, exercise apps and many other health behavior apps.
for healthcare. Healthcare organizations continue to ponder how to
become more connected, collaborative, insightful and proactive in Now the key is using these devices to connect patients and providers –
healthcare delivery using existing technology in which they might and even to move beyond mere connectivity toward true intelligence,
already have invested, but which may not be inherently designed to enabling predictive and preventive interventions that can begin to
support interoperability and communication. Now, many are beginning influence patient behavior. Machine-to-machine (M2M) technology
to look to mobile and telehealth technologies as a way to take allows wireless devices to talk to each other – opening up endless
healthcare into a new era of smarter, more effective care. opportunities for innovation:
The possibilities are truly exciting. Many companies in the mobile • A person wearing a wireless monitor can send heart rate data to his
space are investigating ways to leverage mobile technology’s inherent mobile phone, which in turn transmits data to the patient’s physician
advantages to have a direct impact on healthcare challenges. Among or nurse – who can then call the patient if the heart rate seems
the characteristics of mobile technology that make it ripe as an abnormally high.
innovative space for healthcare:
• Prescription pill bottles can light up when it is time for a patient to
• L ower Development Costs – Software development costs in general take medication. If she forgets, the networked bottle can trigger a
have come down dramatically over the past several years, thanks to text message or phone call.
open source code, offshore development and other trends. Common
mobile enable developers to create new apps or mobile websites • Patients can use their mobile phones to record blood sugar levels,
quickly, flexibly and often less expensively. Delivery platforms for carbohydrate intake and other data points. An app automatically
apps are also established, which means users can easily access and delivers suggestions about how patients can make changes, and
pay for software using familiar online marketplaces. a live nurse, caseworker or physician receives the information and
follows up with more personal coaching.
•W
idespread Adoption of Technology – Although they haven’t been
on the market that long relative to other technologies, smartphones One report considers that some 300 million people in Europe and the
and tablets are seeing rapid adoption among consumers, and the United States have one or more diseases for which home monitoring
rate is even higher among physicians, with 64 percent owning a may be a treatment option. Of these patients, one-quarter wouldConnecting Care Across the Healthcare Universe_______________________________________________________________________________________________ 6
benefit from existing wireless home monitoring solutions, while
another 50% would benefit from integrating their mobile handsets AT&T ForHealthSM: At the Forefront of Healthcare Innovation
with existing medical devices.27 By this report’s estimates, some
225 million people would be able to more effectively manage their AT&T has embraced the spirit of innovation and collaboration,
conditions using mobile and wireless devices, by extension helping prescribed as the remedy for enabling healthcare to improve
to prevent hospitalizations and readmissions, improving outcomes and care quality and reduce costs, with its AT&T ForHealth practice
helping to reduce system costs. area. The company is focused on accelerating the delivery
of innovative wireless, cloud-based and networking services
Telehealth and Videoconferencing and applications that have direct and immediate impact on
The term “telehealth” encompasses various healthcare services care outcomes.
delivered virtually via telecommunications and information
technologies, including videoconferencing, remote monitoring, email
and digital diagnostic instruments. Telehealth can simulate in-person However, as the U.S. healthcare industry continues to face growing
care with secure, two-way videoconferencing over smart networks, challenges, the industry must explore how to empower sweeping
using high-definition video and audio and devices that deliver data to change – and this must involve not only new ideas, but the ability
providers in real time. to rapidly roll out those ideas to the end users who can turn ideas
into impact. By unleashing technology to enable this, the healthcare
Patients can gain broader access to healthcare services – particularly
industry can begin to achieve a healthier system for all.
impactful for patients in underserved communities. For health
professionals, telehealth enables virtual consultation and collaboration New ideas take shape at AT&T Labs, our innovation center where
with specialists across geographies, as well as remote monitoring technologists work to discover and develop solutions to widespread
of patients with chronic conditions. It is a flexible and cost-effective healthcare challenges. Critical to developing, improving upon and
way to deliver care on the spot exactly when a patient needs it – deploying these ideas is a commitment to global collaboration
connecting to specialists remotely from the ED, for example – while with other companies and organizations, and the belief that
delivering regular and proactive care to patients who cannot access collectively organizations can make great ideas a reality. Working
it otherwise. One report predicts that telehealth used to promote with best-of-breed technology companies, as well as leading
preventive care, early intervention and effective information-sharing institutions and agencies, AT&T ForHealth has begun to pilot a
could save the United States $3.61 billion annually.28 number of innovative new solutions for remote monitoring, telehealth,
and disease management across the country.
Today telehealth is becoming more and more mainstream, as it can be
customized to support many different uses in a wide variety of settings, AT&T ForHealth is developing and delivering advanced IT solutions
from individual clinics to regional hospital networks. Use is increasing in four areas: mHealth, telehealth, cloud-based healthcare solutions
as networks become faster, more secure and more powerful. that include medical imaging in the cloud and health information
exchange (HIE) platforms for coordinated care. The company is utilizing
Unleashing Technology for Healthcare Transformation its network, scale and technological expertise to collaborate with the
Stopping the course of runaway costs and high disease rates in healthcare industry to address and solve its challenges.
the United States requires a new way of thinking. Technology may
indeed be part of the answer, but it must be technology that is widely Endnotes
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