SESSION #4Changing the Digital Trajectory of Healthcare

Dale SandersPresident, Technology

Health Catalyst

For the record…

• I will frequently refer to Health Catalyst’s strategy and products in this lecture, but only by necessity to emphasize the concepts

• I’m not selling products

• I’m advocating concepts and principles that everyone-- all vendors-- should follow

• Just like these fine young men…

The story in today’s discussion

• Why do we need to change the current digital trajectory?

• What’s the business case for a Data Operating System

• What is a Data Operating System and how did we get here?

• What difference will DOS make?

• What should we do with it and what should we expect?

But the military has changed, adapted and transformed itself

Advice to C-levels about a digital health future

1. For better or worse, faster or slower, your company runs at the speed of software now

2. Everything you want and need to do is either helped or hindered by software and data

3. All C-levels now need to be a little bit Chief Information Officer and Chief Digital Officer

Thank you, Russel Reynolds Associates for the graphic

Raise your digital IQ, or else…If you choose not to be informed, good luck

“Healthcare CEO, what is your organization’s Digital Quotient?”

Healthcare is one of the least digital sectors, and it shows in profit margin growth.

Source: McKinsey Corporate Performance Analysis Tool

DQ = Data Assets x Data Usage x Data Skilled Labor

Digital disruption is already happening

• The world’s largest taxi company… owns no taxis

• The world’s largest voice/video communications companies… own no telco

• The most popular media company… owns no content

• The largest lodging company… owns no property

• The world’s most valuable retailer… owns no inventory

• The world’s largest software vendors… don’t write the apps

Thanks for the inspiration, Ron Kalifa of Worldpay; and IBM

The world’s largest and most successful healthcare and health management companies,

will own no hospitals

In the digital future of healthcare…

10

Two fundamental requirements to be “digitized”1. Digitize the thing or things you

are trying to manage and optimize

2. Digitize your process of managing the thing you are trying to manage and optimize

Airplanes

Air traffic control,baggage handling, ticketing,maintenance, manufacturing

Patients

Registration, scheduling, encounters, diagnosis, orders, billing, claims

Outside the ICU, we haven’t digitized the patient and we’ve done a crappy job of digitizing our processes

Digitization of the patient and healthcare processWe’re collecting data on the backs of physicians and nurses, and that won’t scaleLots of great ideas for applications and machine learning, but where’s the data?We need to invest significantly in diagnostic and process of care sensors

PwC, 2015

The parallels between health and car maintenanceAn ounce of prevention is worth a pound of cure

• Every 10 hours, Tesla collects 1 million miles of driving data

• 25Gbytes per car per hour• We collect 100Mbytes per patient per

year, on average

• “We can fix problems in your car and make it safer, long before you know you need it.”

• ”10,000 fatalities and 500,000 injuries per year will be prevented.”

• Ram Ramachander, Chief Commercial Officer, Social Innovation Business at Hitachi

80% of Factors Affecting Health Outcomes Fall Outside Traditional Healthcare Delivery

But we have an EMR…

• Only 8% of data required for a population health and precision medicine initiative resides in today’s EMR/EHR

Alberta Innovates Health Solutions, Secondary Data Use Project, March 2016

This is my life This is healthcare’s digital view of my life

Humans gravitate towards freedom of choice6 billion smart phones by 2020 in a world population of 8 billion

Evolution of healthcare IT

In the meantime, this is what’s possible…• 103 applications on my iPhone

• 89 different vendors

• They build on a common platform with open software standards

• I wouldn’t expect nor hope for a single vendor to meet all my needs

20

Modern software concepts & designs• Analytics are embedded… it’s ambient to the user interface experience

From a blog I wrote in 2010

“What if Facebook built an EHR?”• Patient’s evolving health story at the

center of the record• Embedded video and images• Integrated text and discrete data• Secure messaging• Social support from family & friends• Flexible security, defined by the

patient

EMR screen shot

In traditional healthcare datawarehousing, this curve takes too long—hours, days

Silicon Valley gives us a good role model for compressing the curve

Find The Truth

Tell The Truth

Face The Truth

• Nebulous in healthcare• Relative to point of view• Tribalism trumps facts

• Presentation matters• Diplomacy, sensitivity• Mastery, Autonomy, Purpose

• Humility• Openness• Community vs Individual

If you miss the soft side of humanity on the data and digital journey, it’s going to backfire on you

The Nebraska Cornhuskers story with Brent Musberger

Poll Question #1

At $35B in US government incentives and $105B from the budgets of healthcare systems and physician offices, how would you describe the return on investment in Electronic Medical Records, in terms of their total benefits to US healthcare?

a) Terrible

b) Poor

c) Mediocre

d) Positive

e) Superb

So, what’s a Data Operating System?

Using related concepts…DOS is a combination of the following, but enabled by modern technology, designs, and software…

1. HIE

2. Clinical Data Repository

3. Enterprise Data Warehouse

DOS is a platform of constantly updated raw and organized data, within a domain such as healthcare, that enables

rapid development and changes to the software applications built upon it.

DOS is a Hybrid ArchitectureGartner: Hybrid Transactional/Analytical Processing (HTAP)“Because traditional data warehouse practices will be outdated by the end of 2018, data warehouse solution architects must evolve toward a broader data management solution for analytics.”

Reservation dogs, aka, “rez dogs” are the best

As computer scientists, we overlooked the last and critically important layer in the technology stack…The Data Layer

Three precipitating events led to the DOS concept

30

1. Our Enterprise Data Warehouse at Northwestern University Medicine, 2005-2009

Fast forward to 2016: New technology and designs Kappa architecture from Silicon Valley• One data stream for batch and real-time computations in the serving layer

• One code set

Kappa architectures can be implemented with a combination of open source tools like Apache Kafka, Apache HBase, Apache Hadoop (HDFS, MapReduce), Apache Spark, Apache Drill, Spark Streaming, Apache Storm, and Apache Samza.

Note of thanks to Julian Forgeat of Google

2. Realizing the breadth of the human health data ecosystem• What data do we need for research, personalized care, and community health?

And, by the way, we have barely any data on healthy patients

3. The ”Shark Tank” story

20+ Healthcare IT startups

Pitching great software applications and creative ideas

In my head: “We must give these great ideas and applications the data they need. They cannot possibly afford to build the data data infrastructure and skills that we have in Health Catalyst. They and the industry can’t afford it.”

For dramatic impact, let me quickly share with you the data content & sources in the Health Catalyst library… and it’s growing everyday

EMR Data Sources1. Affinity - ADT/Registration2. Allscripts - Ambulatory EMR Clinicals3. Allscripts Enterprise/Touchworks - Ambulatory EMR4. Allscripts Sunrise - Acute EMR Clinicals5. Aprima ERM6. Cerner - Acute EMR Clinicals7. Cerner - PowerWorks Ambulatory EMR8. Cerner HomeWorks - Other9. CPSI - Acute EMR Clinicals10.eClinicalWorks - Ambulatory EMR Clinicals11.Epic - Acute EMR Clinicals12.Epic - Ambulatory EMR Clinicals13.GE (IDX) Centricity - Ambulatory EMR Clinicals14.McKesson Horizon - Acute EMR Clinicals15.McKesson Horizon Enterprise Visibility16.Meditech 5.66 EHR w/DR17.NextGen - Ambulatory Practice Management18.Quality Systems (Next Gen) - Ambulatory EMR Clinicals19.Siemens Sorian Clinicals - Inpatient EMR

Finance/Costing Data Sources1. Affinity - Costing2. Allscripts (EPSi) - Budget3. Allscripts (EPSi) - Costing4. Allscripts (TSI) - Costing5. BOXI - GL6. Cost Flex - Costing7. Digimax Materials Management - Inventory

Management8. IOS ENVI - Costing9. Kaufman Hall Budget Advisor - Other10.Lawson - Accounts Payable11.Lawson - Accounts Receivable12.Lawson - GL13.Lawson - Supply Chain14.McKesson - Accounts Payable15.McKesson Enterprise Materials Management16.McKesson HPM - Costing

17.McKesson HPM - GL18.McKesson PFM - Accounts Payable19.McKesson PFM - GL20.McKesson Series - Accounts Receivable21.Meditech - GL22.Microsoft Great Plains - GL23.Oracle (Hyperion) - Costing24.Oracle (PeopleSoft) - GL25.Oracle (PeopleSoft) - Supply Chain26.PARExpress27.PPM - Costing28.Smartstream - GL29.StrataJazz - Costing

Billing Data Sources1. Affinity - Hospital Billing2. CHMB 360+ RCM - Hospital Billing3. CPSI - Hospital Billing4. Epic - Hospital Billing5. GE (IDX) Centricity - Hospital Billing6. GE (IDX) Centricity - Professional Billing7. HealthQuest - Patient Accounting8. Keane - Hospital Billing9. McKesson Series - Patient Billing10.McKesson STAR - Hospital Billing11.MD Associates - Professional Billing12.Siemens Sorian Financials - Inpatient

Registration and Billing

HR/ERP Data Sources1. API Healthcare - Time and Attendance2. iCIMS3. Kronos - HR4. Kronos - Time and Attendance5. Lawson - HR6. Lawson - Payroll7. Lawson - Time and Attendance8. Maestro9. MD People10.Now Solutions Empath - HR11.Oracle (PeopleSoft) - HR12.PeopleStrategy/Genesys - HR13.PeopleStrategy/Genesys - Payroll14.Ultimate Software Ultipro - HR15.WorkDay

Claims Data Sources1. 835 – Denials2. Adirondack ACO Medicare3. Aetna - Claims4. Anthem - Claims5. Aon Hewitt - Claims6. BCBS Illinois7. BCBS Vermont8. Children's Community Health Plan (CCHP) -

Payer9. Cigna - Claims10.CIT Custom - Claims11.Cone Health Employee Plan (United

Medicare) - Claims12.Discharge Abstract Data (DAD)13.Hawaii Medical Service Association (HMSA) -

Claims14.HealthNet - Claims15.Healthscope

16.Humana (PPO) - Claims17.Humana MA - Claims18.Kentucky Hospital Association (KHA) -

Claims19.Medicaid - Claims20.Medicaid - Claims - CCO21.Merit Cigna - Claims22.Merit SelectHealth - Claims23.MSSP (CMS) - Claims24.NextGen (CMS) - Claims25.Ohio Hospital Association (OHA) - Claims26.ProHealth - Claims27.PWHP Custom - Claims28.QXNT - Claims29.UMR Claims Source30.Wisconsin Health Information Organization

(WHIO) - Claims

40

Clinical Specialty Data Sources1. Allscripts - Case

Management2. Apollo - Lumed X Surgical

System3. Aspire - Cardiovascular

Registry4. Carestream - Other5. Cerner - Laboratory6. eClinicalWorks - Mountain

Kidney Data Extracts7. GE (IDX) Centricity Muse -

Cardiology8. HST Pathways - Other9. ImageTrend10. ImmTrac11.Lancet Trauma Registry12.MacLab (CathLab)

13.MIDAS - Infection Surveillance

14.MIDAS - Other15.MIDAS - Risk Management16.Navitus - Pharmacy17.NHSN18.NSQIPFlatFile19.OBIX - Perinatal20.OnCore CTMS21.Orchard Software Harvest -

Pathology22.PACSHealth - Radiology23.Pharmacy Benefits Manager24.PICIS (OPTUM)

Perioperative Suite25.Provation26.Quadramed Patient Acuity

Classification System - Other27.QXNT/Vital - Member28.RLSolutions29.SafeTrace30.Siemens RIS - Radiology31.SIS Surgical Services32.StatusScope - Clinical

Decisions33.Sunquest - Laboratory34.Sunrise Clinical Manager35.Surgical Information System36.TheraDoc37.TransChart - Other38.Varian Aria - Oncology39.Vigilanz - Infection Control

Health Information Exchange (HIE) Data1. Adirondack ACO Clinical Data from HIXNY (HIE)2. ADT HIE Patient Programs 3. Vermont HIE

Patient Satisfaction Data Sources1. Fazzi - Patient Satisfaction2. HealthStream - Patient Satisfaction3. NRC Picker - Patient Satisfaction4. PRC - Patient Satisfaction5. Press Ganey - Patient Satisfaction6. Sullivan Luallin - Patient Satisfaction

Master Reference & Terminology Data Content

1. AHRQ Clinical Classification Software (CCS)2. Charlson Deyo and Elixhauser Comorbidity3. Clinical Improvement Grouper (Care Process Hierarchy)4. CMS Hierarchical Condition Category5. CMS Place Of Service6. LOINC7. National Drug Codes (NDC)8. NPI Registry9. Provider Taxonomy10.Rx Norm11.CMS/NQF Value Set Authority Center

Wearables and Home Monitoring1. FitBit2. Garmin3. Apple4. Microsoft5. Precor6. Misfit7. Adidas8. Nokia9. Omron10.Polar11.TomTom12.LifeFitness13.And14. iHealth

15.Bayer16.BodyTrace17.AccuCheck18.Abbott19.Qardio20.ReliOn21.Trividia22.Nonin23.Strava24.myfitnesspal25. fatsecret26.Sony27.HealthKit28.HiGi

Other Sources of Healthcare-Related Data1. 2010 US Census Detail for

State of Colorado2. Affiliate Provider Database3. All Payer All Claims (certain

States) ---In process UT, CO, MA

4. Alliance Decision Support5. Allscripts - Ambulatory

Practice Management6. Allscripts - Patient Flow7. Allscripts EHRQIS - Quality8. Avaya9. Axis (MDX)10.Bed Ready - Other11.Cerner Signature12.CMS Standard Analytical Files13.Daptiv

14.Echo Credentialing - Provider Management

15.ePIMS16.First Click-Wellness17.FlightLink18.GE (IDX) Centricity - Practice

Management19.HCUP (NRD, NIS, NED

Sample sets)20.Health Trac21.HealtheIntent22.Hyperion23. InitiateEMPI24. Innotas25. IVR Outreach Detail26.MIDAS - Credentialing Module27.Morrisey Medical Staff Office

for Web (MSOW)28.National Ambulatory Care

Reporting System (NACRS)29.Nextgate EMPI30.Onbase31.PHC Legacy EDW32.QXNT/Cactus - Provider33.SMS Legacy - Other34.Truven Quality35.University HealthSystem

Consortium - Clinical and Operational Resource Database

36.University HealthSystem Consortium - Regulatory

• That’s the data that Health Catalyst manages and understands in the US healthcare ecosystem today, and the list is growing.

• Re-creating the technology and intellectual property is not scalable for the industry. We have to open it up and reuse it.

• We are barely getting started on the digitization of the industry.

The Data Operating SystemHealth Catalyst Applications

Client-BuiltApplications

RegistryBuilder

Leading Wisely

Care Management

CAFÉBenchmarks

ACO Financials

Choosing Wisely

Patient Safety

MeasureLibrary

Patient Engagement

Catalyst Analytics Platform

Data Ingest Data ExportData Pipelines

Source Connectors

Hadoop/ SparkData Lake

Fabric Real-Time Services

Real-Time Processing HL7

Real-Time Streaming

Machine Learning Pipelines

Marketplace

Atlas and more …SAMD & SMD

Fabric Application Services

Registries Terminology & Groupers

FHIREHR Integration

Security, Identity& Compliance

Patient & Provider Matching Measures

Fabric Data Services

Data Governance

Pattern Recognition NLP

Data QualityMetadata Standard Data Models

ML Models

3rd Party Apps

Reusable Content

What difference will DOS make?

50

Enable unprecedented software development• 10x – 100x faster software application development• 100x more options for software applications by enabling the start-up

brains in Matter Chicago, for example

Related impact at AmazonBetween 2001 and 2009, they implemented similar concepts to DOS as well as a “DevOps” culture in software development. The results were dramatic…

Rapidly accelerate the value of Mergers, Acquisitions, and Partnerships

• Your new company is not integrated until your data is integrated

• HIE’s are not sufficient for data integration… not even close

• Ripping and replacing EMRs and ERP systems with a single, common vendor is not an affordable or timely strategy

Thanks to Russ Tabet for the illustration

Enable a Personal Health RecordUpdated, integrated, shareable, downloadable, transportable

• A Personal Health Record is more than what’s in an EHR • Think of Mint.com and what it is to personal financial data

Scale home grown data warehouses• There are many of these in healthcare

• Home grown data warehouses are easy to start and build, but expensive to evolve and maintain

• But they are also hard to retire… what do you do?

• Rip and replace with a new vendor solution? Not attractive.

55

Enable Providers to become Payers• Current actuarial techniques inherently

inflate risk to the benefit of payers

• With DOS, providers are in a strong position to manage Total Cost of Care, risk, and margins

• Use the applications on top of DOS to further understand and lower risk, and manage margins

• With DOS, negotiate contracts from a position of data-strength

We Sagittarians could have turned out very differently

• The demand for EHRs was stretched by federal incentives. That’s over.

• The underlying software and database technology of EHRs was commoditized a long time ago.

• We can stretch the lifecycle and value of EHRs with DOS and open APIs, e.g. FHIR.

Extend the life and value of current EHR investments

Enable community health

• The BUILD Health Challenge in the US• Bold, Upstream, Integrated, Local, Data-driven

• Blue Zone Projects• National Geographic inspired

Community health is fundamentally a digital initiative

BUILD Communities

Blue Zone Communities

The Chargemaster of Evil

• Our digital journey of the future must include cost accounting and price transparency.

One last plea since I have the stage and you’re hostages…

• Let’s commit to making the chargemaster what it should be…True costs plus a reasonable, sustainable bottom line margin

Poll Question #2

a) Yesb) Noc) What’s a chargemaster?

Do you believe chargemasters are the root of many US healthcare evils and that it is within the scope of influence of healthcare executives to dramatically improve that situation?

60

Wrapping up• Why we need to change the digital trajectory

• We have a moral obligation to the country to raise our Digital Quotient in healthcare

• What is a Data Operating System and how did we get here?

• Making the data layer easier for application development to give us more choices

• What difference will DOS make?

• Better, faster, cheaper software for EHRs, M&A, PHRs, and more

For more on this general topic…

• Rob DeMichiei, CFO at UPMC (Thursday keynote)• Activity Based Cost accounting with 20% of the effort

• Health City Cayman Islands (Session 13)• A role model in healthcare quality, affordability, and access

• Imran Qureshi, Health Catalyst (Session 22)• Deeper dive on the Data Operating System

• John Moore, Chilmark (Session 23)• Convergence of payers and providers

• Jim Adams, The Advisory Board, annual IT National Meetings• September 13-14 in Marina del Rey• September 27-28 in Chicago• November 14-15 in Washington DC