David McCallie, MD, is Senior Vice President for Medical Informatics at Cerner, where his research team is examining potential applications for semantic content extracted from EHR systems. In addition, he is a co-founder of the CommonWell Health Alliance and a founder of the Argonaut Project, both of which are multi-vendor efforts to promote interoperability standards. At Convergence, Dr. McCallie will discuss new approaches to application development and integration that can promote more fluid data sharing than today’s systems typically allow.
Why is it important for the healthcare industry to take the emergence of payer-provider convergence seriously? What do you see in your work that makes this important to you?
The obvious driver is the shift toward risk-sharing approaches in managing care, away from fee-for-service (FFS). You have to have cooperation between providers and risk holders. The big question is how fast we will move in this direction – and the uncertainty with the new administration and future of ACA has slowed things down – but it’s inevitable that we will get there. The FFS model doesn’t make sense in the long run.
We need to put in place systems that facilitate this sharing of risk. There are many different organizational structures that could do this. Payers and providers may be less distinguishable in the future. When providers are sharing risk for the actions they take in supporting their patients, it’s a different ballgame.
Which stakeholders need to be at the table when strategic conversations about convergence take place?
There’s a critical need to share lots of data. Despite the fact that we are making progress toward interoperability, the kinds of data sharing for understanding what it means to take on risk go beyond the type of interoperability that’s easy and commonplace. When we implement HealtheIntent, our population health management (PHM) product, there could be upwards of 50 interfaces into our system that we have to build. Some of these interfaces are becoming routine enough to knock them off quickly, but each deal has a few that we’ve never seen before.
One would hope emergence of the Fast Healthcare Interoperability Resources (FHIR) specification will make this easier in the future, but I don’t think this is going to happen overnight. FHIR is moving fast for a standard, but it’s still very young.
A lot of people say, you need an interface to move data back and forth. But you also need to move interactions back and forth. SMART apps can facilitate that. A care manager needs to push information into a workflow to have a conversation about where we stand with this patient. You could get the vendor to parse out where to put that data on the screen – or you could plug in a SMART app and see the data without having to do deep data integration. That approach can yield a lot of collaboration without requiring that every single piece of data be integrated.
Say we’re friends on Facebook, and you want to share a photo with me. Facebook could push the photo to my phone’s photo app – or I could open the Facebook app and see the photos there. It’s easier to build an app that plugs into the phone than push a bunch of photos to the native phone photo viewer.
At Cerner, we assemble a longitudinal patient record (LPR) based on all the data feeds that come into the PHM service. We could push all that data out to the providers – but it’s easier to publish a SMART app that serves up the LPR. The recipient can sift through the data without having to build a whole interface, and with FHIR support, they will eventually be able to import key data elements into their local EHR record.
Do you think the roadblocks to broader acceptance of convergence are more strategic, tactical, operational, or cultural in nature?
There are issues at all of those levels. The ones that I naturally focus on, with my works on standards, are the technical barriers. SMART on FHIR will obviate some of those barriers. But, clearly, if you don’t have a strategic agreement about how risk sharing will work, and if you don’t have operational agreements on how to do the work, all the tech in the world won’t help you.
The first hurdle is just the decision to go at-risk. Then you have to figure out what kind of risk-sharing, and then all the gory details about how you transition from predominantly FFS to a risk-sharing model without upsetting the people you want to participate. And how do you get the patient / consumer to buy in to be a participant in this? Much of the belief in PHM is predicated on changing behaviors to improve outcomes, which is a challenge in and of itself. Engaging and motivating customers is a new challenge, beyond the provider vs. payer stresses.
Back to the technology side, I think we’ll see, in the future, that PHM is mediated through apps that patients have on their phones, helping them manage their condition, as much as something that you push into the provider workflow. Why wouldn’t you expect to have app help you with diabetes or congestive heart failure any more than you have an app to help you find a restaurant? Whether they come from payers or providers is an open question, as both sides have the incentive to deploy those apps. Both sides have something to gain.
Convergence and value-based care are closely linked. What will it take for the industry to accelerate the shift toward value-based care?
We have an unsustainably expensive system. We will reinvent medicine over the next decade; there’s no other choice than for it to move in this direction. The cost pressures will drive us there more than anything.
Today, everybody operates independently – and we get the mess we’re in. We need to better align the needs of the decision maker, the risk holder, and the person who behaves in the world so that they can make the best possible choices.
There will be a pause as the new administration tries to figure out how to address payment models, but interest will pick up. Medicaid programs are progressively moving to managed care, just for cost control. Medicare is moving toward accountable care and bundled payments. Together, they cover half of Americans.
As Medicare and Medicaid move in that direction, the industry’s going to follow. How fast it goes is the big question. No one wants to take a big risk if they don’t know what will happen next.
Who do you consider to be leading voices in convergence?
I pay a lot of attention to what former National Coordinator for Health IT Dr. Farzad Mostashari (now CEO of Aledade) is up to. I respect his intelligence and willingness to try new things. He’s a role model for changing the way we do things.
I also pay attention to former Centers for Medicare & Medicaid Services Administrator Andy Slavitt (now senior advisor of Avia). He’s become a prolific spokesperson for a lot of these thoughts – and he’s gaining an audience now that he’s free to share his opinions outside of CMS.
Former U.S. CTO Aneesh Chopra (now president of CareJourney) is pushing hard on notion of consumer directed exchange, where consumers could empower organizations to use data beyond the understanding of what a traditional PHM company does. It’s complicated, because the data movement occurs outside HIPAA. Consumers could get taken advantage of and not have any recourse. On the other hand, there could be a whole new generation of companies that go DTC.
What are some of the key approaches to application development that will help providers and payers see each other’s data?
There’s FHIR as an emerging application programming interface (API) standard. We need agreement on data that moves back and forth; what are the acceptable data standards? SMART apps let you interject outside conversations into a heterogeneous environment. Doctors in the community are using eClinicalWorks, Allscripts, Epic, and Cerner, and you have to be able to tap into all of them.
Also, making better use of the smartphones. There are lot of “mHealth” apps, but they’re not connected to payers or providers. There’s a use case for smartphone apps that connect everything together, so you have the input of the provider but also the constraints of the payer as you navigate the system with the complex disease you have. We haven’t seen it yet, but it’s absolutely going happen. It could be “prescription model” where it’s paid for by the risk-holder, deployed by the provider, and used by the consumer. Apps on smart phones are the way that we run the rest of our lives. Why would we expect these expensive and complicated care decisions to be any different?